This past weekend, I attended a great seminar here in Boston with Dr. William Brady.  In fact, it was among the best I've seen.  I was the only non-chiropractor/manual therapist in attendance, but walked away from the seminar with some tremendously valuable insights that'll help me with each and every one of my clients moving forward.

The first lesson of the day is that those of you who have an opportunity to see Dr. Brady speak should absolutely, positively check him out: Integrated Diagnosis.  Diagnostically, he's among the best I've ever seen - and that includes his ability to teach others.

The second lesson of the day revolves around an important concept Dr. Brady extended - and my take on how you can modify this message to accommodate your role as a coach, trainer, or fitness enthusiast/athlete.  There is a reason that almost any doctor or physical therapist gets results - and it resolves around understanding where symptom threshold occurs.  To illustrate this, let's examine a shoulder problem purely from a soft tissue perspective.

Dr. Brady talked about how you have building blocks to threshold.  Let's say that after an accurate physical examination, this particular shoulder problem (supraspinatus tendinosis, for example) presents with soft tissue restrictions at the infraspinatus, teres minor, subscapularis, inferior capsule, and pec minor.  So, symptom threshold (the dotted line) might look like this relative to baseline (straight line):

Pec Minor - - - - - - - - - - - Inferior Capsule Subscapularis Teres Minor Infraspinatus BASELINE - NO SYMPTOMS

So, imagine a therapist who just addresses pec minor.  He gets that patient below threshold, but doesn't necessarily "fix" him; he might be back in with the same problem weeks later.  This is confounded by the fact that "overuse" is actually one of the building blocks, too.  So, even if you leave all the soft tissue restrictions alone, simply resting will get someone below threshold - even if the therapist has done ZERO to address the underlying problems.

This is one reason why a MRI might not tell you much at all about someone's problem.  With this problem, the MRI would probably just say "supraspinatus tendinopathy" and recommend physical therapy and rest from painful activities.  So, in the "full picture" - where soft tissue work is one of several components (assume they are equal contributors, for the sake of our argument) - the building blocks to threshold might look something like this:

Overuse Rotator Cuff Weakness Scapular Stability Poor Glenohumeral (Ball-and-Socket) Range of Motion - - - - - - - - - - - - - - - - Soft Tissue Restrictions Poor Thoracic Spine Mobility Type 3 Acromion (non-modifiable, without surgery) Poor Exercise Technique Poor Cervical Spine Function Opposite Hip/Ankle Restrictions (baseball pitchers are great examples) Inappropriate Structural Balance in Programming (e.g., pressing more than pulling) Faulty Breathing Patterns BASELINE - NO SYMPTOMS

So, what do we do in an ideal scenario (not always possible with today's insurance plans)?

1. More time with patient education (exercise technique, programming strategies - or just outsource it to a qualified professional or good book/article or DVD). 2. Address Thoracic Mobility (Assess and Correct is a great resource for this)

3. When present, address Hip and Ankle Mobility 4. Retrain some breathing patterns with initial instructions home exercises 5. Provide some take-home neck drills and get people out of chronic forward head posture

All told, I think this could be as simple as 4-5 extra drills in each shoulder rehab program plus a brief sit-down conversation with each patient on exercise program modifications; it really is that simple.  Unfortunately, it rarely happens - and that's when things become chronic.

So, fitness professionals and coaches need to step up as advocates for their clients and athletes, respectively, and fitness enthusiasts need to be relatively informed "consumers" to look out for themselves.

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EricCressey.com Subscriber-only Q&A

Q: Could you please explain the rationale for the wall triceps stretch you used in a previous blog post? A: Here’s a photo of that stretch, for those who missed it:

Most throwers with shoulder problems will have the most pain at:

a. maximal external rotation/late cocking phase (usually the worst type of problems, SLAP 2 lesions, that warrant a great consideration of surgery)

or

b. follow-through/deceleration (usually something that’s more easily fixed with good posterior cuff/capsule stretching and good scapular stability work, so conservative treatment is the name of the game)

Of course, all this depends on symptoms, degree of mechanical pain, and what the MRI says. Sometimes, though, if the stiffness isn't present posteriorly, but you're still seeing these kind of symptoms, you have to look to the inferior capsule. The shoulder capsule is large and relatively “loose” to allow for the wide range of shoulder movements present. When tightness kicks in somewhere, you can see some noteworthy problems. So, the roundabout answer to your question is that the truth is that this is as much an inferior capsular mobilization/stretch as it is a triceps stretch. As a general rule of thumb, you always migrate opposite capsular tightness. Inferior tightness leads to superior migration. Inferior tightness is the big problem in regular ol' weekend warriors, and definitely moreso in those who have had surgery and been immobilized with the arm at the side As an aside to this, rarely will someone need JUST inferior capsule mobilizations; they usually need other attention to areas such as

thoracic spine mobility work.

Feedback on The Truth About Unstable Surface Training

Here’s a quote from Leigh Peele of avidityfitness.com on my new e-book,

The Truth About Unstable Surface Training:

“This e-book, regardless of if they have to break out a dictionary, is for every trainer/coach/physical therapist out there. Period. If you are a trainer or if you plan on being a trainer or physical therapist, then you need to own this manual. This isn’t just about doing things “right,” either; this puts you ahead of the pack. Your teams, clients, and patients will thank you for the increase of knowledge.

“I also feel that this e-book is for those who are really serious about training and applying the best methods to their program. If you don’t have a good coach and you need one, sometimes yourself is all you have. If that is the case, go to the education. Coach yourself. “In short, if you design programming, be it for yourself or for others, you should get this e-book for a learning resource.”

Click here to purchase The Truth About Unstable Surface Training.

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Detailed Feedback on Maximum Strength Random Friday Thoughts A Little Monday Update Random Friday Thoughts 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!

Mike Robertson flew up from Indianapolis to check out a seminar up here in Boston this past weekend. We really enjoyed watching Kevin Wilk, Bob Mangine, and Mark Comerford, three fantastic rehabilitation specialists. Additionally, I enjoyed catching up with Mike just as much, as he’s a wealth of information, particularly with respect to the knees. From just talking with Mike this weekend, I picked up some really good stuff – in addition to the entire day the presenters spent on the knee this weekend.

With that in mind, on Sunday, I wrote down five things that caught my attention this weekend. Then, I handed them to Mike and asked him to elaborate on them on his laptop on the plane ride home for a “guest spot” in my newsletter. Here’s what you’ve got:

5 Keys to Bulletproofing Your Knees

1. VMO specific work is currently poo-poo in the strength and conditioning industry. While I agree that we need to focus on strengthening the hip abductors/external rotators (especially glute max and posterior glute med), current literature leads us to believe that there’s more to the VMO than we might have expected.

Several studies in the past two years have indicated that there is a definite change in fiber pennation between the vastus medialis longus (VML) and the vastus medialis obliquus (VMO). Beyond that, while your other quad muscles like rectus femoris and vastus lateralis only have one motor point, the entire vastus medialis actually has THREE motor points! We may not totally understand the VMO yet, but I’m not willing to write off its importance with regards to knee health.

2. When looking at the body as a functional unit, we can’t overlook the core with regards to knee health. More specifically, we know the rectus abdominus and external obliques work to keep us in pelvic neutral and out of anterior pelvic tilt. Lack of strength in these core muscles increases anterior pelvic tilt, which drives internal rotation of the hip and valgus of the knee. Getting and keeping these muscles strong could go a long way to preventing knee injuries, especially in female athletes.

3. Are accelerated ACL rehab programs what we need? I’m not so sure, and I think making young athletes follow the accelerated programs the pros use may do more harm than good. Unlike the pros that are getting paid to play, we need to focus on the long-term outcomes of our young athletes, not simply getting them back on the field ASAP. Many have done an excellent job of rehabbing patients and getting them back on the field quickly, and quantifying strength and power production/absorption is critical.  Many of the leading PT’s and orthos, however, are moving back to a slightly more conservative approach to allow the graft itself more time to heal. The properties of a tendon graft slowly take on the properties of a ligament over time; this is called ligamentization. However, ligamentous changes can still be seen as late as 12-18 months post-surgery.

5. When an athlete tears their ACL, proprioceptive deficits are seen as quickly as 24 hours post-injury. What’s really intriguing, however, is that we often see this same deficit carried over to the healthy knee as well! Even after reconstruction this deficit can be seen for up to six years. To counteract this, don’t forget to include basic proprioceptive training (barefoot warm-ups, single-leg stance work, etc.), and train that “off” leg in the interim. For more tips, tricks, and programming recommendations on knees, check out Mike Robertson’s Bulletproof Knees manual. It’s by far the best resource I’ve seen on preventing and addressing knee pain.

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All the Best,

EC

Yesterday, I asked some readers for some feedback on Maximum Strength, and I received dozens of emails. This one definitely stood out in my mind, as it goes to show you how versatile the program really is:

Hi Eric,

Sacramento, CA

Here, in part three of a series on why distance running is terrible for pitchers, I put the final nails in the coffin.

Reason #7: Nobody likes to babysit.

Simply put, running is babysitting. Catcher is actually the position that requires the most endurance in baseball, but we don’t run catchers extra, do we? Nope – and it’s because we have bullpens for them to catch, batting practice for them to take, and all the other responsibilities associated with handling a pitching staff and being a pseudo coach on the field.

My business partner actually was a division 1 pitcher almost ten years ago, and when I brought up this argument, he smiled and nodded, replying with, “When I was a pitcher, all we did was shag fly balls and run poles.” Meanwhile, 57% of pitchers suffer a shoulder injury during a competitive season (5) – and that doesn’t even include elbow, lower back, or lower-extremity injuries! At the major league level, pitchers are 49% of the players, but they account for 68% of the time on the disabled list league-wide (6). Running isn’t going to prevent these problems; it’s going to exacerbate them.

Strike 1.

Reason #8: Distance running ignores existing imbalances.

Baseball is an at-risk sport for a number of reasons. You’ve got an extremely long competitive season, overhead throwing, and – possibly most significantly – unilateral dominance. Switch hitters and guys who bat right and throw left (or vice versa) tend to be a bit more symmetrical, but the guys who bat and throw on the same side tend to have the most glaring issues. Many really smart dudes – most notably, Gray Cook – note that asymmetry is quite possibly the best predictor of injury. When we get pitchers after a long season, our first goals are to address range of motion deficits, particularly in:

1. lead leg hip extension (tight hip flexors)

2. lead leg hip internal rotation (tight external rotators)

3. lead leg knee flexion (tight quads)

4. Throwing arm shoulder internal rotation (tight posterior rotator cuff and capsule)

5. Scapular posterior tilt (tight pec minor and levator scapulae)

6. Throwing arm elbow extension (tight elbow flexors)

I knocked back some caffeine, splashed some water on my face, and really put my thinking cap on to see if I could come up with a rationale for how distance running addresses any of these issues. In the end, I had nothing. I came to the realization that jogging negatively affects the majority of them – and pitchers would be better off just shagging fly balls instead of splitting time between that and long runs. At least they move side-to-side when they’re chasing fly balls.

Strike 2.

I am a firm believer that the best coaches are the ones who engage their athletes. The best coaches I had in my athletic career were the ones who made me look forward to each training session. With that said, the only people who look forward to distance running are – you guessed it – distance runners!

Most of the ballplayers you’re coaching have always seen running as a form of punishment for doing something wrong; they hate it as much as I do (okay, maybe not that much). And, truth be told, they’d hate it even more if they realized it is limiting their development as athletes.

I have always disliked it when people criticize the status quo, but fail to offer solutions of their own. With that in mind, the next installment of this series will outline my personal perspective on how to attack the time between pitching outings.

1. Gleeson, M. Immune systems adaptation in elite athletes. Curr Opin Clin Nutr Metab Care. 2006 Nov;9(6):659-65.

2. Komi, P.V. Stretch-shortening cycle. In: Strength and Power in Sport (2^nd Ed.) P.V. Komi, ed. Oxford: Blackwell, 2003. pp. 184-202.

3. Hennessy L, Kilty J. Relationship of the stretch-shortening cycle to sprint performance in trained female athletes. J Strength Cond Res. 2001 Aug;15(3):326-31.

4. McCarthy JP, Agre JC, Graf BK, Pozniak MA, Vailas AC. Compatibility of adaptive responses with combining strength and endurance training. Med Sci Sports Exerc. 1995 Mar;27(3):429-36.

5. Ouelette, H, Labis J, Bredella M, Palmer WE, Sheah K, Torriani M. Spectrum of shoulder injuries in the baseball pitcher. Skeletal Radiol. 2007 Oct 3.

6. Fleisig, GS. The Biomechanics of Baseball Pitching. Spring 2008 Southeast ACSM Conference.

Maximum Strength Four-Month Mailer

Nearly four months ago, we first released Maximum Strength, and many of you purchased it. Now, we’d love to hear what you think.

In particular, we know that if you performed your “Packing Day” shortly after you received the book, chances are that you’re gearing up for “Moving Day,” when you get to put all the past four months’ hard work and dedication to the test. This is the time when you get to see some specific quantifiable results.

To that end, as I noted above, we’d love your feedback – whether it’s in the form of your pre- or post-testing numbers, subjective assessments, likes/dislikes, or even before/after pictures. A lot of work went in to preparing this book and program, and assuming that similar projects will be taking place in the months and years to come, feedback from the target audience can only help to make those projects even more successful – and in an efficient manner.

A New Model for Training Between Starts: Part 2

Yesterday, in Newsletter 121, I got the ball rolling on a series I’ve been meaning to write for quite some time. The focus is why distance running is counterproductive for pitchers – and today, here are three more reasons it’s bad news.

Here, I need to get a bit geeky for a second so that I can explain the stretch-shortening cycle (SSC). The easiest analogy I can use is that when you want to shoot a rubber band at someone, you pre-stretch it before you release your shot. Muscles work the same way; pre-stretching them (eccentric action) prior to shortening them (concentric action) stores elastic energy and helps that muscle generate more force. Anecdotally, I’ve heard estimates that as much as 25-30% of pitching velocity is attributed to elastic energy – or how effectively someone makes use of the stretch-shortening cycle.

Where we’re different from rubber bands is that we can actually train those elastic qualities to make our tendons more efficient at collecting, temporarily storing, and releasing that elastic energy to help us run faster, jump higher, and throw harder. It’s why doing plyos, sprinting, and throwing medicine balls can do wonders for a player’s performance.

With the stretch-shortening cycle, we need three things, according to Komi (2):

1. a well-timed muscle preactivation before the eccentric phase

2. a short, fast eccentric component

3. immediate transition (minimal delay) between stretch (eccentric) and shortening (concentric) phases. This period is known as the amortization phase, and the shorter it is, the less elastic energy we lose (as heat).

To be honest, #1 takes care of itself. For #2 and #3, though, we are definitely working against ourselves with distance running, as the importance of the SSC rapidly diminishes as exercise duration continues. In fact, the vertical jump only predicts sprinting performance up to 300m (3).

In other words, the longer exercise goes, the more we “muscle” it instead of being relaxed. What do we know about guys who try to muscle the ball to the plate? They don’t throw hard because it impairs pitching specific mobility and they don’t let the arm whip through.

I will take a guy with a good vertical jump over a guy with a high VO_2max anyday. Distance running conditions guys to plod instead of bounce – and this definitely has implications in terms of chronic overuse conditions.

Strike 1.

As just one example of how stressful the pitching motion is on the body, the humerus internally rotates at 7,500°/second during the acceleration phase of throwing. It takes a lot of strength and power to generate this kind of velocity, but just as importantly, it takes a lot of strength and power – and in a timely fashion – to decelerate it. We need to not only be able to generate enough force to resist and control this acceleration at end-range, but also be able to generate this force quickly (power). To that end, you would think that conditioning for pitchers would be similar to that of strength and power athletes, who avoid distance running altogether.

Instead, most pitchers run several times a week. When was the last time you saw a marathoner throw 95mph?

Additionally, in many cases, coaches encounter Latin American players who have never had access to weight-training equipment – and this is a huge window of untapped potential. Using distance running when these athletes could be devoting more time to getting stronger is a huge hindrance to these players’ development, as it conditions them to go longer instead of faster. At some point, you have to put more horsepower in the engine instead of just changing the oil.

We know that when we first get young athletes started with weight training, there is a huge transformation to make them more athletic in the 8-10 weeks that follow. You would be surprised at what good training can do for many advanced pitchers in the initial phases, too. The reason is that, unlike position players, many pitchers are (to be blunt) one-trick ponies. They know how to throw a nasty cutter, a crazy 12-to-6 curveball, or a slider with a funny arm-slot. So, it’s always been “okay” for them to be completely unathletic outside of their delivery. They might get guys out, but they’re long-term gambles teams because of their increased risk of injury; weak, immobile bodies break down the fastest – just like distance runners.

Strike 2.

In what was – at least in my eyes – a landmark study, McCarthy et al. (1995) looked at “compatibility” of concurrent strength training and endurance training. Traditionally, the attenuation of strength and power gains has been a big issue when endurance exercise is added to a strength training program. As I noted in Cardio Confusion, these researchers found that strength and power loss was only an issue when the intensity of the endurance exercise was greater than 75% of heart-rate reserve (HRR) (4). I can guarantee you that the majority of pitchers who are running distances are doing so at well over 75% HRR.

As I’ll note in my recommendations at the conclusion of this article, I strongly feel that the secret is to stay well above (circa-maximal sprinting, in other words) or below (70% HRR, to play it safe) when implementing any kind of running. The secret is to avoid that middle area where you don't go slow and don't go fast; that's where athletes get SLOW!  And, ideally, the lower-intensity exercise would be some modality that provides more mobility benefits.

Strike 3. The batter’s out!

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