Home 2008 January (Page 9)

Exclusive Interview with Dr. Jason Hodges

EricCressey.com Exclusive Interview with Dr. Jason Hodges

I am extremely fortunate to not only have a loyal group of newsletter subscribers, but also a very knowledgeable and passionate group of individuals who come from unique backgrounds. Collectively, you subscribers give me a ton of outstanding feedback that makes me better at what I do.

After Newsletter 95, I received a great email response from Dr. Jason Hodges:

Regarding the low back, I am a radiologist and I see MRIs every day describing what you said in the newsletter. Lots of people have bulging discs without symptoms. This is especially true of older patients who can have bulging discs at every level but without focal neurologic symptoms. In my experience, younger patients tend to have focal neurological signs with even mild disc bulges or disc herniations. But very often, the symptoms don't match up with the imaging findings. I have seen patients with symptoms down the right leg, but the disc herniation is on the left side, etc.

Needless to say, that “etc.” at the end of the last sentence got me intrigued, so I asked Dr. Hodges if he would be willing to do an interview for our subscribers. I think you’ll find it very enlightening – and forward-thinking.

EC: Thanks for joining us this week, Dr. Hodges. Could you please tell us a bit about both your professional background and health and human performance interests?

JH: Thanks for the opportunity, Eric. I did my undergrad at University of Kansas with a BA in biochemistry graduating in 1991, and received my MD degree from U. of Kansas School of Medicine in 1995. I finished my Radiology residency at U. of Missouri in 1999 and received my American Board of Radiology certification the same year. I am currently an executive partner in S and D Medical LLP in NYC. My interest in fitness really lies outside my professional duties although there is obviously some overlap. My Radiology training is not specific to fitness.

EC: In your reply to my newsletter last week, you not only confirmed some of the things I noted about MRI results in what we think are healthy lower backs, but also had some other very interesting experiences to share. Would you please fill our readers in?

JH: Often imaging findings do not correlate with clinical findings. Older patients often have very degenerative spines without symptoms. Whereas younger patients can have small bulging discs or herniated discs and have debilitating pain. The human body has a great reserve capacity. I see many “normal” kidneys that are in chronic renal failure

Medical imaging generally deals with anatomy: how organs “look”, not so much how they function. Obviously, they are linked, but function can decline long before anatomic changes occur. Symptoms can occur without imaging abnormalities. This leads doctors to conclude that nothing is wrong because the x-ray/CT scan/MRI looks normal. This is simply not the case.

Medical imaging is simply one piece of the clinical puzzle. An analogy can be made with astronomy. You can image the universe at visible light, x-ray, ultraviolet, infrared, etc. Each modality provides a vital, but incomplete picture of the universe. You have to put it all together to get the big picture.

EC: How about the knees? I know a lot of people are walking around with chronic ACL tears that aren’t symptomatic, but what else do you see?

JH: It is often easier to see acute injuries better than chronic images. We often see the secondary finding, such as edema or fluid collections rather than the direct injury itself. An acute ACL tear may show a gap in or fraying of the ACL, surrounding edema and joint effusion. A chronic ACL tear may show only a wavy appearance or abnormal signal as scar tissue has partially healed the injury. But it is important to recognize the chronic ACL tear because it alters the biomechanics of the knee, stressing other parts of the knee. This can lead to a higher risk of meniscal tear or premature arthritis. A common cluster of findings in acute knee injury is ACL tear, medial meniscal tear and medial collateral ligament sprain/tear and a joint effusion.

EC: Shoulders?

JH: The most common finding I see is tendinopathy of the supraspinatus tendon. It is the most likely to be impinged under the acromion and clavicle. The shape of the acromial hook can predispose to impingement, as can arthritic changes of the acromioclavicular joint. In radiology, we tend to use the term “tendinopathy” rather than “tendonitis”. “Tendonitis” implies white blood cell inflammation, which we cannot confirm on MRI. So we use the imaging term of “tendinopathy” which can certainly include tendonitis.

EC: So, what’s your take? Are we too heavily reliant on MRIs as a society? Certainly, it takes a lot more resources to get a MRI than x-rays, yet many people seem to request these at a moment’s notice to gain some peace of mind. What kind of accuracy are we talking?

JH: As I said, MRI is just a piece of the big picture. Some of the limitations include the fact that we image the joints in a static state, in one position. We image the lumbar spine with the patient lying down which is a whole different loading scheme than standing up. The tracking of the patella during extension is really best assessed by physical exam, not by MRI. It is a matter of putting too many eggs in the imaging basket, so to speak. MRI is the best imaging modality for the soft tissues, but it is not all-seeing/all-knowing.

EC: Let’s talk about lifters. What are you seeing in terms of chronic adaptations to lifting heavy stuff?

JH: To be honest, we don’t image many lifters except in the setting of acute injury. Lifters tend to be younger and healthier. Certainly, lifters have better bone density and have a lower risk of osteoporosis. Larger muscles and lower bodyfat are obviously the case.

EC: Aside from lifting, what other lifestyle habits have you found lead to less-than-stellar diagnostic imaging? Alcohol? Certain occupations?

JH: By far, the biggest limitation is obesity. All of the imaging modalities are limited by it, mostly for technical reasons. An ultrasound beam can only penetrate so far into the soft tissues. X-rays and CT scans are degraded by scattered radiation, which leads to a higher radiation dose and grainy images. Also, the time it takes to do the study increases, which gives a higher incidence of motion blur.

EC: So diagnostic imaging is less accurate with obese patients? One more reason to not get fat in the first place!

We often talk about how the best doctors are the ones who meet the lay population halfway. In other words, they’re the ones who can tell an injured patient what he CAN do, and not just what he CAN’T do. My experience has been that the best trainers and coaches are the ones that can meet the doctors halfway, and it’s something to which I attribute a lot of my success.

To that end, what resources would you recommend to trainers, coaches, and everyday weekend warriors looking to learn more in the direction of the clinical realm?

JH: Frankly, the mainstream media is not a great source of information. It is incumbent on us radiologists to let the primary care doctors know what we can image and, more importantly, what we can’t. Orthopedic surgeons tend to be the most knowledgeable regarding the musculoskeletal system, but don’t discount chiropractors. I am pretty open-minded to alternative medicine, unlike many of my fellow MDs. My chiropractor does a great job using ART on my trigger points in my traps. Also, never be afraid to get a second opinion.

My advice to all practitioners – be they doctors, chiropractors or trainers – is to learn as much as possible. Be confident in your knowledge and abilities, but don’t think that any one practitioner has all the answers. Medical knowledge is too vast for anyone to know everything about everything. I know my medical school training regarding fitness and nutrition was paltry. Sure, I learned about muscle fiber composition and the biochemistry of vitamins and minerals. But, most doctors just parrot the standard dogma of low-fat, high-carb diet, walk 20 minutes three times a week, etc. You and I both know that won’t lead to any significant body composition changes.

EC: Agreed. I actually know several doctors who have “seen the light” when they’ve started to read more of Dr. John Berardi’s work – not to mention the latest research of carbohydrate-restricted diets from the likes of Jeff Volek and Cassandra Forsythe. What else?

JH: Seek out those practitioners who aren’t afraid of the cutting edge. Just as you wouldn’t want a trainer who is a glorified rep counter, you don’t want a doctor who is simply going to give you the same old tired, old-school nutrition and fitness “advice,” if you can even call it that. That advice may promote health, but it won’t give the body composition changes most of your readers seek.

In addition to being confident in their abilities, practitioners need to know when to refer to other people. Some things need to be treated medically or surgically. They can’t be fixed in the gym or at the training table. Health and wellness should be a team effort with everybody working in their areas of expertise and not outside of it. Underconfidence and overconfidence in your abilities are equally bad for your client/patient.

Unfortunately, Western style medicine is very disease-oriented and body-part-oriented, often losing the big picture, especially regarding the whole kinetic chain of the musculoskeletal system. My opinion is that this is where trainers and chiropractors shine. I wish my fellow doctors would be more amenable to referring patients to trainers/chiropractors for problems that don’t need medical or surgical treatment. The human body has great ability to adapt and heal itself, if you give it a chance.

EC: Thanks again for taking the time to be with us!

JH: My pleasure. Thank you for inviting me. My kind gratitude to my colleague D. Dillon, RN, BSN for her assistance.

Two Quick Reminders

Upon my return, I’ll be headed to Pittsburgh for a seminar on March 29th. You can find details for the event on my Schedule page.

Also, I’ll be interviewed live for Vince DelMonte’s FREE Ultimate Muscle Advantage Teleseminar series on April 7th. You can sign up by heading HERE. All the best, EC.
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Five Tips from Mike Stare

Five More Tips from Mike Stare (SpectrumFit.net) 6. Perform thoracic mobilization before exercise, not after. There always seems to be controversy regarding when stretching should be performed to maximize function. Fortunately, the answer is clear regarding joint mobilization: perform exercise aimed solely at enhancing normal joint arthrokinematics prior to exercise. Studies have demonstrated that mobilization of the thoracic spine enhances voluntary force capacity of the lower trapezius, which is a muscle group that plays a pivotal role in ensuring optimal scapulohumeral mechanics. The foam roll has been used very successfully as a self-mobilization device for the thoracic spine, and will be a key exercise in the beginning of your routine.

7. Look to your daily life as the root of joint injuries. The more we learn about joint injuries, the more we learn that damage is more likely the consequence of repeated micro trauma, versus a one-time, acute macro-trauma. Joints respond very well to frequent, intermittent, and gradual loading, as opposed to infrequent, sustained, or sudden loading. Joints receive their nutrition from the passive diffusion of nutrients in the synovial fluid, facilitated by movement and intermittent loading. Prolonged sitting and standing can often rob the joints of the stimulus required for optimal health. When our minds are occupied, it is amazing how we can find ourselves enduring prolonged and awkward postures. Even worse, we may not feel the adverse affects of this in the short term, thus we don’t have an impetus to modify them. This is usually because many structures, such as disc, meniscus, and joints are aneural is areas, and often do dot relay noxious stimuli until a higher degree of damage occurs. Clinical experience and research shows that countless joint conditions, including osteoarthritis, shoulder impingement, low back, and neck pain are all correlated with prolonged sitting or repeated bending and twisting. It’s obvious to focus on technique, program design, corrective exercise, and nutrition for optimal performance. However, neglecting to address movement patterns and postures with daily tasks can subvert much of your hard work and often contribute to injury.

8. Use deloading to stimulate recovery. When we fracture a foot, it is well known that taking load of the bone for a limited time will facilitate healing. We should use the same logic regarding injuries to our weight bearing joints to various degrees. Vertical deloading through band or bar hangs are an example of removing loading upon the spine. This is often a welcomed break from the excessive loading we impose upon our spine through maximal strength workouts. The degree to which we perform our deloading should be proportionate to the degree to which we load our spine, be it chronic loading (sitting at our desk) or acute loading (heavy deadlifts), and proportionate to the severity of the symptoms (e.g. manual traction for acute back pain). Deloading can also be done with lower body exercises such as lunging when bodyweight is enough to irritate a flared up knee. Try taking a strong band suspend it from a rack, and loop it under your arms. The stronger the band, the greater the deload. This will allow you the benefits of facilitating the desired motor pattern and full joint excursion without reproducing the painful irritation of the joint.

9. Try the modified 1-leg squat to assess leg strength discrepancies. Strength discrepancies amongst the legs is very common, and often the cause of injury and decreased performance. A very simple technique to identify a unilateral strength deficit is as follows: perform a one leg squat or modified Bulgarian squat (non-stance leg moving backward). At the bottom of the movement, when the stance leg is at least 90 degrees and toes of the trail leg are in contact with the ground, lift the toes of the trail leg off the ground before ascending exclusively on the stance leg. Any strength discrepancy will be obvious based on the perceived difficulty from one leg to the other or the presence of compensation patterns.

10. Address your lumbar stability and position sense before overloading. Far too common is the failure to adequately master position sense and stability prior to overloading a joint. Doing so will lead to injury through structural damage and decreased performance through muscle inhibition. You cannot build the second floor before solidifying the foundation of a building. You cannot throw a punch with a limp wrist. Accordingly, you should not lift heavy before you can demonstrate proper joint position and stability.

New Blog Content

Correlating Pec Tears and Benching

Preventing Striking Injuries

Changing Parameters: Volume and Intensity

We'll be back next week with some all-new content. All the Best, EC
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Random Tips from Michael Stare

Random Tips from Michael Stare

Early in 2007, I interviewed physical therapist Michael Stare for one of our newsletters. As it turns out, that interview (featured HERE) was one of the more popular ones we’ve done – so I approached Mike about throwing a little more content our readers’ way. Here are five tips from Mike to get the ball rolling:

1. The sciatic nerve, not your hamstrings, is often the source of your chronic posterior thigh pain. It is alarming how often people are encouraged to stretch their hamstrings in response to an insidious onset of posterior thigh and buttock pain, often coupled with a nagging low back problem. In probably 90% of cases, the problem is not the hamstrings at all, but rather the sciatic nerve. So, if you have pain in the back of your leg and it wasn’t in the course of coming up lame after a sudden sprint, consider performing the following simple test before stretching your hamstrings:

Sit in a slouched position, head looking down to your lap. If this is pain-free, proceed to the next step. Dorsiflex the ankle on the side you are testing. Then, slowly extend your knee, stopping at the point where you first feel any symptoms, (stretch, pull, pain, tingling, etc). Next, while still holding this leg position, extend only your cervical spine. If this alleviates your symptoms, you are most likely dealing with an irritated sciatic nerve rather than your hamstrings. Why? Your hamstrings don’t connect to your head, so changing the cervical position shouldn’t influence the symptoms if the hamstrings are the source of the problem. Rather, the tension upon the sciatic nerve is alleviated with cervical extension as the dura of the spinal chord is connected with that of the sciatic nerve. So if your “chronic hamstring strain” isn’t healing, and your slump test is positive, you should stop stretching your hamstrings, and seek some professional advice.

2. Learn to posteriorly tilt your scapula. Poor control of the scapula is the root of most shoulder problems, as most informed conditioning and rehab experts will attest to. In fact, and anteriorly tilted scapula is the most common postural impairment found in those with shoulder pain. Posteriorly tilting the scapula removes a common mechanism of impinging the rotator cuff against the subacromial arch when elevating the arm. Furthermore, it helps to position the scapula to facilitate optimal length tension of the scapula and humeral musculature. So merely “pulling the shoulders back” doesn’t do the trick.

To practice scapular posterior tilt, lay supine on a firm surface, and attempt to bring the posterior aspect of the acromion to the table. If this is very difficult for you, you will likely require some activation work for your lower traps and stretching of your pec minor.

3. Stretch your psoas and your rectus femoris separately. Although it is common to hear recommendations to stretch your hip flexors, two major hip flexors, the psoas and the rectus femoris, should be stretched separately. This is due to the fact that they have separate origins and insertions. To stretch the psoas, ensure slight lumbar flexion via a posterior pelvic tilt, lumbar contra-lateral side bend, and hip extension. This can be done in standing or half kneeling. These motions can be quite tricky, so be sure to have a qualified coach or PT teach you. For the rectus femoris, posteriorly rotate the pelvis, flex the knee to about 120 degrees while placing the foot upon a stationary surface, and extend the hip. With both stretches, the most common mistake is to hyperextend the lumbar spine, which will reduce the effectiveness of the stretch and could contribute to back problems.

4. Train hip rotation rather than lumbar rotation. Tasks that involve powerful rotary force production, such as swinging, throwing, and kicking, mostly involve hip rotation versus lumbar rotation, at least when they are performed by skilled athletes. Emphasizing hip rotation makes sense from an anatomical perspective too. The hips are very stable joints, with a network of dense musculature designed to perform rotation. The lumbar spine is relatively more fragile. In fact, the annulus of the disc begins to experience failure at only 4% elongation, which usually occurs at only 3 degrees of rotation at each segment! Furthermore, the lumbar facets are orientated such that the joint surfaces are aligned in the sagittal plane, and are impacted at 3 degrees of rotation. Clearly, our training should reflect these biomechanical factors.

5. Try performing balance activities with your eyes closed. Balance is simply maintaining your center of mass within your base of support and is facilitated by many different sensory and motor qualities. Proprioception is a component of balance that is very important to athletes and fitness enthusiasts, as the training of it can reduce the incidence of some injuries, and the loss of it is the by-product of any joint injury. This is well researched with ankle injuries in particular. When performing single leg exercises, closing your eyes reduces the contribution of visual input towards the task of maintaining your center of mass over your base of support. Therefore, you must exclusively rely on feedback from the joint structures, and as a result enhance proprioceptive input.

About Michael Stare

Michael Stare is the Director and Co-owner of Spectrum Fitness Consulting, LLC, in Beverly, MA, where he trains young athletes and clients of various fitness levels. Mike received his BS in Kinesiology from the University of Illinois at Urbana-Champaign, his MS in Physical Therapy from Boston University, and his Doctorate of Physical Therapy from the Massachusetts General Hospital IHP. Mike recently completed Fellowship training in Orthopaedic Manual Therapy and currently practices with Orthopaedics Plus in Beverly, MA as a Physical Therapist. To learn more about Spectrum Fitness Consulting, go to www.SpectrumFit.net. Mike can be reached at mike@spectrumfit.net.

New Blog Content for the Week

Public Access: Not Just for Wayne and Garth

Inefficiency vs. Pathology

One More Reason I Love My Job

Active vs. Passive Restraints

Eating on the Road: Nutritional Travel Strategies

Seminars – Possibly in Your Neck of the Woods

A few buddies of mine are organizing events that are definitely going to be very solid. I’m only making it to the one here in Boston (June 6), but I’m sure that the rest will be excellent. Check ‘em out:

April 26: 2008 Georgia Strength Coaches Association Strength and Speed Coaching Clinic: More Info

May 17: 2008 Indianapolis Performance Enhancement Seminar with Bill Hartman and Mike Robertson: More Info

June 6, 2008: Second Annual Distinguished Lecture Series in Sports Medicine (Boston, MA): More Info

We’ll be back early next week with five more tips from Mike Stare and plenty of other new content.

All the Best,

EC

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Feedback on The Art of the Deload

Cressey on TV

Click the link below to view an hour-long interview I did on the Audrey Hall Show alongside Rich Gedman (former Red Sox catcher and current manager of the Worcester Tornadoes) and Bunky Smith (head coach of Framingham's American Legion Team) on the topic of youth baseball training.

http://link.brightcove.com/services/link/bcpid1137806189/bclid1408993191/bctid1424672868?src=rss

New Article(s)

I was a contributor on the T-Nation Strength and Size Roundtable:

Part 1

Part 2

Part 3

More Feedback on The Art of the Deload

“Eric Cressey has done it again! He's created another solid and easy to understand product with The Art of the Deload e-book. Deloading is more than just backing off on either volume or intensity during a training cycle and Eric gives great specifics about how to incorporate a number of different deload strategies. This is a must-have for anybody trying to write serious strength and conditioning programs.”

Brijesh Patel Associate Director of Strength and Conditioning - College of the Holy Cross Co-founder and partner of S B Coaches College, LLC: www.sbcoachescollege.com

The Art of the Deload

New Blog Content for the Week

From Old School to New School

Neutral Grip Multi-Purpose Bar Floor Press

Clarifying a Jaw-Dropping Study

Have a great weekend!

EC

PS - Don't forget that the FREE Ultimate Muscle Advantage Teleseminar Series starts this Monday.  Sign up

HERE so that you don't miss out.

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Newsletter #95

Inefficiency vs. Pathology

Q: I read with great interest your baseball interview at T-Nation, as I have two sons who play high school baseball. More interestingly to me, though, was this statement:

“Pathology (e.g., labral fraying) isn't as important as dysfunction; you can have a pathology, but not be symptomatic if you still move well and haven't hit "threshold" from a degenerative or traumatic standpoint.”

Is this something that can be applied to the rest of the body?

A: Great question – and the answer is a resounding “Absolutely!”

Many musculoskeletal issues are a function of cumulative trauma on a body with some degree of underlying inefficiency. People reach threshold when they do crazy stuff – or ignore inefficiencies – for long enough. Here are a few examples:

Lower Back Pain

As I touched on in a recent newsletter, we put a lot of compressive loading on our spines in the typical weight-training lifestyle – and you’d be surprised at how many people have spondylolysis (vertebral fractures) that aren’t symptomatic. But there’s more…

A 1994 study in the New England Journal of Medicine sent MRIs of 98 "healthy" backs to various doctors, and asked them to diagnose them. The doctors were not told that the patients felt fine and had no history of back pain.

80% of the MRI interpretations came back with disc herniations and bulges. In 38% of the patients, there was involvement of more than one disc.

It’s estimated that 85% of lower back pain patients don’t get a precise diagnosis.

Shoulders

You’d be amazed at how many people are walking around with labral fraying/SLAP lesions, partially torn rotator cuffs, and bone spurs. However, only a handful of people are in debilitating pain – and others just have a testy shoulder that acts up here and there. What’s the issue?

These individuals might have a fundamental defect in place, but they’ve likely improved scapular stability, rotator cuff strength/endurance, thoracic spine range-of-motion, soft tissue quality, cervical spine function, breathing patterns, mobility of the opposite hip/ankle, and a host of other contributing factors – to the point that their issues don’t become symptomatic.

Elbows

They do a lot of Tommy John surgeries and ulnar nerve transpositions for elbow issues that can often be resolved with improving internal rotation range-of-motion at the shoulder, or cleaning up soft tissue restrictions on flexor carpi ulnaris, flexor carpi radialis, pronator teres, etc.

According to Dr. Glenn Fleisig, during the throwing motion, at maximal external rotation during the cocking phase, there is roughly 64 Nm of varus torque at the elbow in elite pitchers. This is equivalent to having a 40-pound weight pulling the hand down.

The other day, I emailed back and forth with my good friend, physical therapist John Pallof about elbows in throwing athletes, and he said the following:

“Over the long term, bone changes just like any other connective tissue according to the stresses that are placed on it.  Most every pitcher I see has some structural and/or alignment abnormality – it’s just a question of whether it becomes symptomatic.  Many have significant valgus deformities.  Just disgusting forces put on a joint over and over and over again.”

Makes you wonder who is really "healthy," doesn't it? Carpal Tunnel

I can’t tell you how many carpal tunnel surgeries can be avoided when people get soft tissue work done on scalenes, pec minor, coracobrachialis, and several other upper extremity adhesion sites – or adjustments at the cervical spine – but I can tell you it’s a lot.

Knee Pain

Many ACL tears go completely undiagnosed; people never become symptomatic.

I know several people who have ruptured PCLs from car crashes or contact injuries – but they work around them.

Some athletes have big chunks of the menisci taken out, but they can function at 100% while other athletes are in worlds of pain with their entire menisci in place.

Many knee issues resolve when you clear up adhesions in glute medius, popliteus, rectus femoris, ITB/TFL, psoas, and the calves/peroneals; improve ankle and hip mobility; and get the glutes firing.

I’m of the belief that all stress on our systems is shared by the active restraints and passive restraints. Active restraints include muscles and tendons – the dynamic models of our bodies. Passive restraints include labrums, menisci, ligaments, and bone; some of them can get a bit stronger (particularly bone), but on the whole, they aren’t as dynamic as muscles and tendons.

Now, if the stress is shared between active and passive restraints, wouldn’t it make sense that strong and mobile active restraints would protect ligaments, menisci, and labrums? The conventional medical model – whether it’s because of watered-down physical therapy due to stingy insurance companies or just a desire to do more surgeries – fixes the passive restraints first. In some cases, this is good. In other cases, it does a disservice to the dynamic ability of the body to protect itself with adaptation.

I’m also of the belief that there are only a handful of exercises that are genuinely bad; upright rows, leg presses, and leg extensions are a few examples. The rest are just exercises that are bad for certain people – or exercises that are bad when performed with incorrect technique.

With these latter two issues in mind, find the inefficiency, fix it, and you'd be surprised at how well your body works when it moves efficiently.

Teleseminar Series Reminder

Just a reminder that this awesome FREE offer from Vince DelMonte starts next week, so don’t wait to sign up! My interview will be Monday, April 7.

Ultimate Muscle Advantage Teleseminar Series

All the Best, EC Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches used by Cressey Performance Pitchers after they Throw!
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Training Intensity

Subscriber-Only Q&A

Q: I purchased The Art of the Deload earlier in the week and I must say I'm very happy with the purchase.  There is very little info about deloading around – not even enough to scratch the surface of your option #1. So, having nine more alternatives is great! I was just curious about something mentioned in it.  You discussed your preference for a High/Med/Very high/low set-up.  I was wondering how you determine how much volume is a “high” week and so on.  Is it based on the primary lift (e.g., singles at >90%), or on total volume of a workout?

A: Thanks for your email and kind words.

I'm referring to overall training stress.  When I first started pulling these classifications together, I had a whole elaborate equation in place that took into account: 1. Total Reps 2. Intensity 3. Exercise Complexity (e.g., Deadlift vs. Curl) 4. Tempo 5. Range-of-Motion 6. Miscellaneous - everything from accommodating resistances to time under tension for isometric holds (and probably a dozen more things that escape my memory now) The end-result was a Microsoft Excel spreadsheet that was very colorful and elaborate - very pleasing to the eyes.   The problem was that it took me forever to write a program!  Fortunately, I started to get a "feel" for it over time, and ditched my system and went with my intuition.  So, now, I just "know" where total training stress is. For instance, I can tell you that 10 singles over 90% on front squats is going to be a LOT harder than 4x3 on that same exercise. Assume the ordinary Joe can do 4x3 with 87% of his 1RM (for ease of calculations, we'll call it 300 pounds).  He is using 261 for 12 reps, or a "tonnage" of 3,132 pounds.  If he hit a PR of 300, and then nine more singles at 270 (90%), he'd "only" accumulate 2,730 pounds of total work.  Density isn't everything. Normally, volume is a pretty good measure - but in situations like the one above, it doesn't hold true. Intensity can really beat you up. So, I guess the answer is that "stress" will be highest when there is a lot of volume, high intensity, compound lifts, longer eccentrics, full ROM, and accommodating resistances.  You learn to eyeball it. I generally "set the stage" for my total stress of 100% in week 1 (the high week).  Week 2 is set at 80%, as my goal is to take advantage of familiarity with the exercises in order to incorporate heavier loading.  In week 3, the stress is 120% for intentional overreaching; you're hoping to apply the strength gains you realized in week 2 in a higher volume scenario.  Week 4 is set at 60%, which gives you a chance to rebound before picking it up with a new program in week 5. All the Best, EC
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Newsletter #93

As I was driving to Cressey Performance on Saturday morning, a story about a drunk-driving incident in Bosnia came on the air. Apparently, some dude got picked up with a blood alcohol level of 0.6% - twenty times the legal limit (0.03%). Apparently, most people would have gone into a coma at a level of 0.4% - yet this guy was still going strong.

Now, you might be wondering, “What does this have to do with strength and conditioning, corrective exercise, or high-level performance?” It’s a reasonable question.

Truthfully, the answers exist all around you.

Go to your gym, and you’ll find the guy who has been doing full ROM leg presses and rounding his back under compressive loading for years – yet his back doesn’t hurt.

Then, glance across the room and you’ll see the guy benching with his elbows flared WAY out – just like he has three times a week for years – yet his shoulders don’t hurt.

Next to him, there’s that dude in the middle of his “abs circuit.” He’s done 400 hyperextensions and sit-ups – and is now looking to the seated oblique machine to see if he can completely annihilate his spine in one trip to the gym. The problem is, you’ve seen this every Tuesday since 1998 – and his back doesn’t hurt.

Look to the basketball court, and you’ll find some kid rocking the highest high-top sneakers you’ve ever seen; they look like cinderblocks on his feet. His ankles are taped, and his knees buckle in with every landing – yet his knees don’t hurt.

All these guys do crazy stuff that really isn’t good for the body, but they respond differently than the rest of us. They may just be waiting to reach threshold, or they might just be the lucky few that never become symptomatic – no matter how absurd what they do may seem.

The exception doesn’t make the rule. The rule is made from the research and anecdotal evidence from coaches who really know how to pick up on this stuff. They look at injuries, and then identify common causative trends they share.

Special Offer on Muscle Gaining Secrets

Last summer, I mentioned in newsletters 62 and 63 that I was impressed with Jason Ferruggia’s Muscle Gaining Secrets. In this resource, Jason does a great job of breaking down advanced concepts for the layman to apply to training and nutrition – and he provides a lot of solid bonuses from some bright guys like Keith Scott, Jim Wendler, and James Smith.

For the next three days, Jason is offering several extra bonuses alongside his original package at no additional charge. The entire package is very reasonably priced and well worth the investment.

Muscle Gaining Secrets

Blog Topics for the Week

Troubleshooting Shoulder Pain with Rows

Smith Machine Salaries

Feedback on "The Art of the Deload"

"The Art of the Deload is a great resource and reference for any strength coach, athlete, trainer, or everyday lifter.  Avoiding plateuing or hitting the wall in training can save coach and athlete alike days, weeks, and even months of frustration and backtracking.  Eric has done a wonderful job outlining a variety of ways to manipulate deloading to ensure continued progress and success in training."

Mike Kamal

Head Strength and Conditioning Coach – Merrimack College

Click HERE for more information.

All the Best,

EC

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7 Tips from Jonathan Fass

New Article I had a new article published at T-Nation last week; check out 4 Ways to Stay on Track. Seven Tips from Jonathan Fass I first got in touch with Jonathan Fass through some mutual friends, but it wasn't until I had a chance to chat with him in person here in Boston last winter that I realized how bright this guy was. Jon's a guy who flies under the radar, and his joking online personality sometimes masks how bright he really is. With that in mind, I asked him to quit cracking jokes for a few minutes and throw some knowledge my way for this week's newsletter. Check it out. 1. Performance enhancement is multi-faceted: approach it from every angle. Recognizing areas of musculoskeletal dysfunction is one of the best things that you can do for yourself in terms of improving performance, strength and overall health. However, simply spotting problems in movement, posture or muscle strength is only the beginning. Nothing in your body is a self-contained unit, and therefore a functional issue in one system, organ or muscle will result from and contribute to deficiencies in any number of areas, from proprioception and kinesthetic awareness to activation and motor control. Although your goal might be to “activate your gluteal muscles” to improve your squat performance, strength training alone won’t do the trick as efficiently as a mixture of strength training, neural activation drills, kinesthetic awareness training (the so-called “mind-muscle” connection), variable movement pattern training, and any number of other approaches could. Remember: There’s never only one cause to a physical problem, so don’t limit yourself to only one approach. 2. Don’t use a balanced routine if you want to become more balanced. Most of us realize that there is an inherent advantage in following a routine that is designed specifically for us, as opposed to a “generalized” cookie-cutter routine. Yet few people seem to actually understand what that really means, and feel that haphazardly throwing a few exercises together in a “balanced” routine is all it takes to suddenly make it an individualized routine. The problem is that almost no one is actually balanced in terms of muscle, posture, joint position or flexibility! Base your program design on your goals, but evaluate your exercise selection itself on your particular needs, whether those needs are postural improvements, muscle dysfunctions, weak points in your movement, strength and/or conditioning needs, or any combination that might be appropriate for you. A routine that would appear to be grossly imbalanced on paper is exactly what you need to become more balanced as a result. 3. Periodize everything. If you’re already using a form of periodization in your training, then you’re ahead of the game already (if you’re not, why not?!?). But while most trainees will immediately recognize the advantage in a periodized strength training program, they stop there and never think to apply this concept to their conditioning and diets as well. If your goal is to lose weight, planned fluctuations in your diet, from free meals, refeeds and diet breaks can help to disrupt the body’s attempt to establish energy homeostasis and help to limit or even reverse the affects of decreased leptin, testosterone, protein synthesis, thyroid hormone, and any other number of problems inherent with prolonged undereating. At the same time, periods of momentary decreases in calories during hypertrophy phases, such as carb cycles, can help to limit fat accumulation and maintain low body fat levels even when overfeeding. The same thought process should be used in your conditioning program, too: by mixing up the length, intensities, and even the methods with techniques such as barbell complexes and tabatas will encourage progression and avoid plateaus, whatever your ultimate goals may be. 4. “In the middle of every difficulty lies opportunity”-Albert Einstein. Dr. Einstein may not have been much of a muscle head, but it does seem that he knew a thing or two about working out. After all, some of my best strength and performance increases have come out of plateaus, injury, or missed workouts. Why? Because they gave me time to reflect on my techniques, form, and programming and to evaluate what had gone wrong. Sometimes, that’s far more important than knowing what’s going right. After all, Plato wrote that “necessity is the mother of invention.” So use your setbacks to reinvent yourself, whether that means taking a step back to improve your form, evaluate weak-points, allow injuries to heal, alter your sleeping or eating habits, or change your workouts altogether for an entirely new stimulus. Something went wrong to put you in that position: fix the problem and take the opportunity to learn and improve so that it doesn’t happen again. 5. Postural improvements occur outside of the gym, not in it. If your goal is to improve humeral positioning, for instance (the so-called “Neanderthal Shoulder”), chances are that you are performing a few additional exercises, mobility drills and stretches in the gym to try and undo your imbalance. While that’s the usual approach towards fixing a problem, the truth is that it’s hardly going to be affective alone. While you might be dedicating five, ten or even fifteen minutes every other day in the gym in corrective exercise, that leaves somewhere over 6200 minutes each week, give or take a few hundred minutes, for you to undo your hard work by not being aware of your posture, positioning and movement outside of the gym! If you want to make a lasting, permanent change in yourself, you have to make it a habit, not just an exercise. One more thing: Lasting change in posture and motor control will take, on average, three weeks to occur. That’s a lot of time to either help or hurt your own cause…the choice is yours. 6. Performing wrist extension exercises might actually be making your grip weaker. The functional role of the wrist extensors is to maintain an optimal length-tension relationship for the wrist and finger flexors to exert the greatest amount of torque when gripping and holding an object. Therefore, you can train the extensors to become stronger just by carrying objects, and not by performing active dumbbell or barbell wrist extensions. In fact, if you create a strength imbalance at the wrist in an attempt to get your forearms stronger for the sake of appearance, you could actually impact the ability of your flexors to grip strongly, impacting your weights on more important strength building exercises such as deadlifts, rows and pull-ups or chin-ups, which naturally and functionally train the wrist extensors, anyway. 7. Practice your form: it’s all in your head. Motor learning occurs through a phenomenon known as “cortical plasticity” and “reorganization,” which describe the adaptive capabilities of the brain’s motor centers, specifically populations of cortical neurons in the primary motor cortex. In other words, we learn by making physical changes in our brains as we practice movement, and practice makes perfect. What this also tells us, however, is that imperfect practice will lead to imperfect learning and motor control. And after it is learned, it has to go through further physical change in order to alter that motor pattern. By putting the time in to learn and practice proper form and technique, you will save yourself a lot of wasted time in terms of poor and less efficient movement, as well as the time that it will take to retrain your movements later on. Form should always follow function; when function follows poor form, injuries can and will occur. About Jonathan Fass Jonathan Fass is an Active Release-certified NSCA Certified Strength and Conditioning Specialist (NSCA), ACSM Certified Health & Fitness Instructor, and USA Weightlifting Level-1 Club Coach. He is currently a doctoral student in the City University of New York's Physical Therapy Program. Jonathan designs and implements exercise programs for Rutgers students, student athletes, and faculty/staff at Rutgers University, NJ. He is also an instructor for Rutgers Recreation, an adjunct lecturer in the Exercise Science department, and the Conditioning Coach for both the Rutgers Men's and Women's Rugby teams, Rutgers Women's Club Soccer, and Rutgers Water Polo team. You can find his articles in numerous print and online magazines, including Men's Fitness magazine. Check out his website at www.AcceleratedStrength.com. That does it for this week's installment. We'll be back early next week with our next newsletter - and an announcement on a new product that you won't want to miss. Have a great weekend! EC
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To Squat or Not to Squat

To Squat or Not to Squat?

I’m going to let you in on a little secret: not all our athletes squat, and the older and more banged up they get, the less they squat.

We’ve all been told that “squats are king” when it comes to leg development, and the carryover of squat variations to athletic performance cannot be overstated. Squats even have a place in corrective exercise settings; I’ve frequently used box squats to help iron out quad-dominant vs. hip dominant imbalances. And, the eccentric strength attained from squatting is of undeniable importance in active deceleration in sports – thus taking the stress off of the passive restraints like menisci, ligaments, and discs. The list of benefits goes on and on.

As with anything in life, though, there’s a downside: you get some pretty crazy compressive loads on the spine when you get stronger:

Cappozzo et al. found that squatting to parallel with 1.6 times body weight (what I’d call “average” for an ordinary weekend warrior who lifts recreationally) led to compressive loads of ten times body weight at L3-L4 (1). That’s 7000N for a guy who weighs about about 150.

Meanwhile, in a study of 57 Olympic lifters, Cholewicki et al. found that L4-L5 compressive loads were greater than 17,000N (2). It’s no wonder that retired weightlifters have reduced intervertebral disc heights under MRI.

The spine doesn’t buckle until 12,000-15,000N of pressure is applied in compression (or 1,800-2,800N in shear) – so it goes without saying that we’re playing with fire, to a degree.

Fortunately, our body can adapt reasonable well – but not if you train like an idiot and ignore marked inefficiencies. Think of it this way:

Roughly 3/4 of all athletes have disc bulges/herniations that go completely undiagnosed.

It’s estimated that 4.4% of six-year olds have spondylolysis (lumbar fracture[s] (3)).

Presence of spondylolyis is estimated at 15-63% in ordinary athletes (highest is among weightlifters) – yet only 50-60% of those diagnosed under imaging actually report lower back pain (4).

This isn’t the only place in the body where this happens. If you’re a pitcher, you’re going to have a ripped up shoulder labrum – but that doesn’t mean that you’re symptomatic. If you’re a pitcher with a junk labrum AND a lack of internal rotation range-of-motion, though, chances are that you’re hurtin’.

What does this tell us? Inefficiency is as important – and possibly MORE important – than pathology.

So, let’s assume for a second that everyone in the world had spondylolysis, disc bulges, and explosive diarrhea (just for shits and giggles – pun intended, if you’d like). To take it a step further, though, let’s say that everyone insisted that they squat and we didn’t have the option of saying “no.” What would I do, in this instance?

1. Avoid Lumbar Flexion. The aforementioned Cappozzo et al. study demonstrated that as lumbar flexion increased under load, compressive load also increased (1). In other words, if you aren’t mobile enough to squat deep, you need to squat a little higher. I’ll use light “tap and go” (to a box) variations in my strength training programs to teach proper depth to those who lack flexibility.

2. Optimize hip range-of-motion. If your hips are stiffer than your lumbar spine, you’ll move at your spine first. Those who move at the lumbar spine get hurt; spine range of motion and power are highly correlated with injury risk. Some schmucks named Cressey and Robertson made a DVD called Assess and Correct that seems to help on this front… I incorporate these in all of my weight lifting programs.

3. Optimize ankle range-of-motion. Those with poor ankle mobility will turn the toes out considerable when they squat in order to make up for a lack of dorsiflexion ROM. When they can’t externally rotate any more, they’ll start to flex at the lumbar spine (mostly because their hip mobility is also atrocious).

4. Optimize thoracic spine range-of-motion. Look at the guys who are lifting the biggest weights injury-free, and examine the way their erector musculature is “allocated.” You’ll notice that the meat is in the upper lumbar and thoracic regions – not the “true” lower back.  Why?  They subconsciously know to avoid motion in those segments most predisposed to injury, and the extra meat a bit higher up works to buttress the shearing stress that may come from any flexion that might occur higher up.  Novice lifters, on the other hand, tend to get flexion at those segments – L5-S1, L4-L5, L3-L4, L2-L3 – at which you want to avoid flexion at all costs.  Our body is great at adapting to protect itself - especially as we become better athletes and can impose that much more loading on our bodies. Just ask Olexsandr Kutcher, who’s pulling close to 800 and squatting close to 900 at sub-200 body weights.

5. Stabilize the @#*$_@^ out of your lumbar spine. This does not mean sit-ups, crunches, sidebends, hyperextensions, or the majority of what you’ll encounter in yoga (although some variations are sufficient). Lumbar rotation, flexion, and hyperextension serve to make the spine less stiff relative to the hips. Your back may feel tight, but stretching it is quite possibly the silliest thing you can do, as you’d be encouraging more problems long-term in the process. Tony Gentilcore likes to talk about how it’s like picking a scab; it feels good in the meantime, but only hurts you in the long-run. Yeah, I think Tony is odd, too.

If I can get my act together, I’ll have a full detailed progression ready for you in a few weeks.

6. Deload the spine once-a-month if you’ve been at this a while. There’s nothing wrong with dropping squatting for a week each month to focus on extra single-leg work, movement training, pull-throughs…you name it. I know of a lot of powerlifters who do it for 3-4 weeks at a time, so one week won’t kill you. Having a balanced workout routine is key to healthy lifting.

7. Avoid training first thing in the morning. Because we’ve decompressed overnight, our spines are “superhydrated” when we first wake up in the morning; this places more stress on the ligaments and discs and less on the supporting musculature. As a little frame of reference, full flexion reduces buttressing strength against shear by 23-43% depending on the time of day – meaning that your spine might be 20% safer later in the day even if exercise selection is held constant. Give the spine a bit of time to “dehydrate” and you’ll be much better off.

8. Get Lean. Ever wonder why pregnant women are always having lower back pain?  Could it be that they're hyperextending (overusing the lumbar erectors) to offset the new weight they're carrying in the abdomen?  Beer bellies work the same way.

9. Keep moving throughout the day. It takes about 20 minutes for "creep" to kick in with your muscles - and the less you let that happen, the better.  The best posture is the one that is constantly changing.

10. Fix asymmetries. Okay, so we know that compression is probably a necessary evil. And, we know that flexion + compression is even worse. And, wouldn’t you know? We can actually make things worse by adding in an element of lumbar rotation. Who rotates at the lumbar spine? Usually, it’s those with asymmetries in mobility or strength at the ankle, hip, or thoracic spine. Compare ROM side-to-side and check side bridge endurance time; fix what’s out of whack.

Obviously, a lot of this requires some more involved functional tests, a solid background in functional anatomy, and an understanding of how to fix what’s wrong. In my most recent product, The High Performance Handbook, I've outlined a Four Phase System that incorporates a self-assessment, proper strength routine, mobility exercises, and de-loading phases for healthy, rapid results. If you're ready to take a good hard look at your routine, you can find more information here.

HPH-main

References:

1. Cappozzo A, Felici F, Figura F, Gazzani F. Lumbar spine loading during half-squat exercises. Med Sci Sports Exerc.1985; 17:613 -20.

2. Cholewicki J, McGill SM, Norman RW. Lumbar spine loads during the lifting of extremely heavy weights. Med Sci Sports Exerc.1991; 23:1179 -86.

3. Morita T, Ikata T, Katoh S, Miyake R. Lumbar spondylolysis in children and adolescents. J Bone Joint Surg Br. Jul 1995;77(4):620-5.

4. Soler T, Calderon C: The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med 2000 Jan-Feb; 28(1):57-62.

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Strength Coach Podcast

Strength Coach Podcast

I was recently interviewed by Anthony Renna for Strength Coach Podcast #6 – and there is also some good Q&A with Mike Boyle, Gray Cook, and Jamie Harvie of Perform Better. Check it out HERE.

New Article

I had a new article published at T-Nation last week. For those who missed it:

What I Learned in 2007

Q&A

Q: Are partial deadlifts (rack pulls) supposed to work your lower back harder than regular deadlifts? The reason I ask is that my lower back tends to be more sore when I do rack pulls; does it necessarily mean that my form is bad? Or, could it be that my lower back is weak?

A: No; they don’t hit the lower back harder in a relative (to the glutes and hamstrings) sense, but absolutely, sure. Assuming a pin setting close to the knees, rack pulls allow you to use more weight – so they’ll definitely hit the upper back and grip harder.  Like a regular deadlift, you still need to transfer force from the lower to upper body. However, the fact that your form falters with added load even with a reduction in range of motion tells me that the force transfer side of things is where you falter.

In reality, lower backs are rarely weak; most guys overuse them.  Research has shown that lower back injury risk is positively associated with lumbar spine range of motion. The more your lower back moves, the more likely it is to get hurt.

My sense is that it's multidirectional lumbar spine instability that only gets better with:

a) avoiding lumbar flexion and rotation, especially under load

b) training under PROGRESSIVELY heavier loads, meaning that you don't attempt a weight you can't lift in perfect form

c) keep focusing on anti-rotator/anti-sagittal-plane-motion training - side bridges, pallof presses, kneeling cable chops, bar rollouts, etc

d) optimizing range of motion at the hips and thoracic spine

Mike Robertson, Bill Hartman, Mike Boyle, and I have written quite a bit about strategies “C” and “D.”

“B,” however, might be the one issue that nobody seems to cover, so I thought I’d toss out an analogy in this regard. Just think of what I’m doing with my pro pitchers right now. Most report to spring training at the end of February or early March.

Right now, they're all throwing bullpens (2x/week) at 75-80% intensity with only 30-35 throws a session (mostly fastballs, just a few change-ups, and no breaking pitches).  Meanwhile, they’re just doing some long tossing on three “off-days” per week to help get their arms back in shape gradually and facilitate recovery.

During these bullpens, they take their time between pitches. The idea is technical perfection and precision.The guys won’t hesitate to talk mechanics (or watch videos of the previous pitches) for a minute or two between throws.  Apparently, they sometimes spend this time conspiring on how to throw fastballs at their strength coach while he tries to get videos for them, too.

How do you think their mechanics would improve with going out there and throwing 90mph+ every day from the get-go? It probably wouldn’t do much, and chances are that they’d chew up a shoulder, elbow, lower back, or knee in the process – either from faulty mechanics, excessive loading of tissues too early, or a combination of the two.

Now, why should improving deadlift technique be any different? As your “bullpen,” you do some technique work in the 75-80% range and keep it picture-perfect, adding 5-10 pounds a week.

Meanwhile, as your “long tossing sessions,” you do your assistance work (outlined above) and possibly some very light technique work to groove the movement pattern and facilitate blood flow.  Over time, these strategies bump that lift up.  Grinding against circa-maximal weights every week with poor technique won't get you anywhere except injured.

See you next week.

EC

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