What an Elbow Alone Can Tell You About Strength and Conditioning Program Design

About the Author: Eric Cressey

On Tuesday, we had our first ever “Night with the Pros” at Cressey Performance.  At the event, 15 of the professional baseball players who train at Cressey Performance in the off-season sat in on a roundtable, answering questions about their careers, long-term developmental approach, college recruiting processes, weekly routines during the season, and a host of other topics.   Marlins closer Steve Cishek discussed how he dealt with pressure as a rookie; Indians pitcher Corey Kluber explained why he wound up selecting a smaller D1 program over the baseball “powerhouses;” Royals reliever Tim Collins threw a live bullpen for the crowd and talked about his rise to the big leagues against all odds, and New Balance Baseball was there to provide some sweet prizes and showcase some of their great products.

Even with 15 players on the panel, no two stories were alike; everyone has had a different path to success.  Accordingly, when it came time to do my live demonstration, I wanted to emphasize the unique nature of every arm – and how a quick elbow assessment can provide quite a bit of information about what you need to do for a whole-body strength and conditioning program.  More than anything, for a bit of “shock value,” I used the elbow of one of our pro guys who came to use following a Tommy John surgery where he didn’t get all his extension back during his rehabilitation.  In speaking with a few of the young attendees the following day, seeing a 25-degree elbow flexion contracture with a “zipper” scar along the medial side was a big eye opener that they needed to be serious about arm care.

We can use the Beighton scale to assess for both generalized congenital laxity and specific laxity at a joint.  The screen consists of five tests, four of which are unilateral:

1. Elbow hyperextension > 10° (left and right sides)
2. Knee hyperextension > 10° (left and right sides)
3. Flex the thumb to contact with the forearm (left and right sides)
4. Extend the pinky to >90° angle with the rest of the hand (left and right sides)
5. Place both palms flat on the floor without flexing the knees

So, at the end of the day, you can score up to nine points on the screen if you are ultra-lax.  This would be something you’d certainly find more often in women than in men, and the incidence of laxity is going to be higher in sports like swimming, baseball, gymnastics, and tennis (that can benefit from increased range of motion) than it is in football, hockey, etc; it’s just natural selection at work, to some degree.

That said, I mentioned earlier that the elbow assessment alone – which, in my eyes, is the quickest and easiest of the bunch – can tell you a ton about what your priorities are going to be when writing a strength and conditioning program.  There are really four scenarios that I come across on a weekly basis.  For the record, describing joint end-feel in the rehabilitation community is much more elaborate (and specific to each joint) than I make it out in these examples; I just want them to be user-friendly for the lay population.  I’ll describe the first scenario, Elbow Hyperextension, in today’s piece, and come back tomorrow to cover the rest.

Usually, elbow hyperextension has a very soft or “empty” end-feel – as if the forearm could just pop off if it was pulled into further hyperextension.  When I see this, I know that there is a very good chance that this individual will have a high Beighton score and I won’t have to do much (if any) stretching for him whatsoever – especially in the upper body (you can expect to see upwards ot 200° of total motion at the shoulders, too).  Of course, I’ll follow up with additional specific and general screens to determine whether this hypermobility characterizes the elbow, upper extremity, or entire body.

Generally, these individuals need more stabilization exercises – so a hearty dose of strength training is in order. Unfortunately, many people like to stick to what they are good at doing, so it’s not uncommon at all to see folks with raging congenital laxity going to yoga class after yoga class, wondering why their backs still hurt.  It’s simply because they’re taking an unstable body into end-ranges of motion over and over again.  I think specific yoga exercises have outstanding benefits for specific people, but those with congenital laxity need to approach them with caution.  And, certainly, trying to turn young gymnasts into human pretzels probably isn’t a great idea for long-term health; for every Olympian, there are 10,000 kids with stress fractures in their spines.

That said, if you have someone who presents with a high Beighton score, but still doesn’t move well, there are four likely scenarios, in my opinion.

First, and most obviously, there can be an injury that doesn’t become symptomatic until they weight bear.  Refer out if that is the case.

Second, they can be “grossly” unstable and simply need familiarization and strengthening in the movements you’re teaching them.  Just because someone is lax enough to be put in the bottom position of a lunge doesn’t mean that they’ll have adequate joint stabilization to hold that position.  As I’ve written previously, you need adequate stiffness at adjacent joints to allow each joint to move optimally.

Third, they can have breathing issues (those who live in anterior pelvic tilt and rib flair are examples) or soft tissue restrictions (not as likely, but it does happen).  These issues might not present with a Beighton score alone, because people can “fake” joint ROM in a passive sense when they are relaxed enough.  As an example, I’ve seen folks with outstanding abduction range-of-motion who are fibrotic soft tissue messes where the adductors insert on the pubis.  I’ll always go to breathing and soft tissue work well before I go to stretching with these folks.

Fourth, I’ve seen quite a few folks with hypermobility everywhere except their ankles.  It could be because we have absolutely destroyed feet and ankles over the years with high-top sneakers, high-heel shoes, and ankle taping.   It could also be protective spasming from a previous ankle sprain that wasn’t rehabilitated properly.  Or, it could be that folks have shifted their center of gravity so far forward (due to the aforementioned postural distortions) that they simply can’t shut off their plantarflexors.  So, it’s up to you to determine if things are short (measure passive dorsiflexion or do a wall ankle mobility test) or stiff (provide a counterbalance – such as a goblet squat – to see if dorsiflexion increases).

As I mentioned earlier, this is just one of four scenarios that I commonly see when I first look at an elbow.  Be sure to check out Part 2, where I introduce the other three and outline the implications of your findings on strength and conditioning program design.

In the meantime, for more information on assessing and managing the elbow, I’d encourage you to check out the Everything Elbow In-Service.  In this 32-minute in-service, I cover everything from functional anatomy, to injuries, to injury mechanisms, to strength training program modifications.  There are valuable lessons for both those in the baseball world as well as those who don’t have any interest in baseball.  It’s affordably priced at just $12.99 – and half of all proceeds go to charity.

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