It goes without saying that ankle mobility deficits are becoming more and more common these days. It may be because:
1. Modern footwear is atrocious, with elevated heels, high tops, and rigid sides
2. We carry our center of mass too far forward thanks to postural distortions that encompass anterior pelvic tilt and forward head posture (among other ramifications).
3. We never utilize extensive dorsiflexion in our daily lives, whether it's in a full squat or high-speed running.
Of course, it's usually a combination of all these factors. And, while we can try out minimalist sneakers to deal with problem #1 and tinker with our exercise program to work on problem #2, problem #3 is a bit more cumbersome, as many of these folks have anterior knee pain that is exacerbated with squatting, running, and ankle mobility exercises where the knee is driven in front of the toes, creating shear stress at the knee. In other words, this ankle mobility drill might be great for someone with healthy knees, but painful for someone with a history of knee pain.
Interestingly, if you consider the functional anatomy of the plantarflexors (calf muscles) while looking at this mobility exercise, you're really only putting the soleus on stretch. The gastrocnemius, actually crosses both the knee and ankle, working as a knee flexor and plantarflexor. So, while this drill may be "more functional" because it occurs in an upright position, it actually shortens the muscle at the knee as it lengthens it at the ankle. And, the more the knee tracks forward, the more symptoms those with knee pain will get.
To that end, if we think back to the functional anatomy lesson we just had, we can get the gastrocnemius to fully lengthen by combining knee extension with plantarflexion - which puts us in a great position that minimizes shear stress at the knee. Problem solved.
After someone has utilized this second drill for a while and minimized their symptoms, it can be progressed to a knee-break ankle mobilization, which still creates a bit of shear stress, but not nearly as much as the first video I showed. Because dorsiflexion is maxed out before knee flexion can occur, it seems - at least anecdotally - to reduce the discomfort that some folks feel.
Assuming you haven't been living under a rock for the past few years, you've surely learned that ankle mobility is imperative to long-term lower-extremity health in strength and conditioning programs and actual sport participation. If you need to learn why, check out this old post of mine: The Importance of Ankle Mobility.
While I think the industry has done a great job of highlighting the need for incorporating ankle mobility drills in one's warm-up, I'm not convinced that we've done a good job of "exhausting" our creativity when it comes to those drills, as most of them occur purely in the sagittal plane. While poor dorsiflexion is definitely the biggest issue at the ankle - and dorsiflexion does occur in the sagittal plane - I think we miss the boat when we only work on getting dorsiflexion in isolation. In reality, you need multi-planar ankle mobility to be prepared for life's events, so it's advantageous to train it a bit in your warm-ups.
So, I bring to you the wall ankle mobilization with adduction/abduction. It's just like a regular wall ankle mobilization, but when you get to end range, you gently rock back and forth between adduction and abduction (and internal rotation and external rotation, in the process) to make it more of a multi-directional movement that also challenges hip mobility a bit. A special thanks goes out to Kansas City Royals pitcher Tim Collins for helping with the demonstration here:
A few important coaching cues/notes:
1. Everyone always asks whether or not I care what the back foot/leg is doing, and I don't. Just focus on the front side.
2. The individual should feel a stretch in the posterior lower leg, not a pinching in the front. If there is pinching in the front, it's a good idea to refer out to a good manual therapist. In the meantime, you can train ankle mobility more conservatively with a rocking ankle mobilization:
3. If the individual's heel comes up off the ground, slide the foot closer to the wall to regress the exercise.
5. We usually perform this as three reps per leg, and each rep has a few glides toward adduction and abduction. You can use it during the warm-up, or as a filler between sets of compound movements. I like it between sets of deadlifts, since you're already barefoot or in minimalist sneaker.
6. If you're a heavy pronator (really flat feet and knock-knees), you probably don't need to do the adduction (rock in) portion of each rep.
I was introduced to the bowler squat originally by Dr. Stuart McGill at one of his seminars back around 2005. Beyond the endorsement from one of the world's premier spine experts, the fact that it's been a mainstay in our strength and conditioning programs for about seven years should prove just how valuable I think this combination mobility/activation exercise is.
Before describing it, though, I should mention that the name is a bit misleading. While it does look like a bowler's motion, the truth is that it's more of a "rotational deadlift" than it is a squat. There is some knee flexion involved, but the shin remains essentially vertical, and most of the motion occurs at the hips - and that's what makes it such a fantastic exercise. Have a look:
We talk all the time about how important glute activation is, but most folks simply think that a few sets of supine bridges will get the job done. The problem is that this exercise occurs purely in the sagittal plane, while the glutes - as demonstrated by their line of pull - are also extremely active in the frontal and transverse planes. The gluteus maximums isn't just a hip extensor; it is also a hip abductor and external rotator.
As such, the gluteus maximus is essential to properly eccentrically controlling hip flexion, adduction, and internal rotation that occurs with every step, landing, lunge, and change-of-direction. You can even think of it as an "anti-pronator."
A bowler squat effectively challenges the glutes to both lengthen and activate in a weight-bearing position in all three planes. And, for the tennis and baseball players out there, check out how closely the bowler squat replicates the finish position from a serve and pitch (I noted this in a recent article, Increasing Pitching Velocity: What Stride Length is and How to Improve It).
To perform the exercise, push the hips back as if attempting a 1-leg RDL, but reach across the body with the arm on the side of the non-support leg. The "hips back" cue will get the sagittal plane, while the reach across will get the frontal and transverse plane. Make sure to keep the spine in neutral to ensure that the range of motion comes from the hips and not the lower back. Keep the knee soft (not locked out), but not significantly flexed, either. Be sure to get the hips all the way through at the top, finishing with a glute squeeze.
A few additional cues we may use are:
1. Tell the athlete to pretend like he/she is trying to pick up a basketball with the support foot; it can help those who keep tipping over.
2. Provide a target - a medicine ball or dumbbell - that the athlete should reach for in the bottom position (this keeps folks from cutting the movement short, or making it too sagittal plane dominant).
3. Encourage the athlete to keep the chin tucked (to keep the cervical spine in neutral).
4. Put your hand a few inches in front of the kneecap and tell the athlete not to touch your hand with the knee; this keeps an athlete from squatting too much when he/she should be hip-hinging.
Typically, we'll perform this drill for one set of eight reps per side as part of the warm-up. However, in a less experienced population - or one with very poor balance - this may serve as a great unloaded challenge that can be included as part of the actual strength training program.
Anyone who has ever broken or burned a finger will tell you that you just don't appreciate how much you use your hands until you don't have access to one for a bit. Obviously, you partially lose your ability to do things - but what many folks might not appreciate is that you also lose some of your ability to sense things, as the hands contain a tremendously amount of sensory receptors relative to the rest of the body. In fact, the tiny folds in our skin on the fingertips that comprise the fingertip are there because they increase the surface area of the hands - which allows us to get more sensory receptors where we need them. Cool stuff, huh?
Why then, do we not give the hands any love when it comes to soft tissue work? We'll foam roll our hip flexors, lats, and other large muscle groups (which are certainly valuable), but we'll ignore one of the most sensory-rich parts of our body - and one that is constantly active (and overused, in some cases) throughout the day. We grip, type, and flip people the bird - but we never really pay attention to soft tissue quality in this region...until today, that is.
If you look at the structure of the hand, you'll see that it has a large fascial, the palmar aponeurosis (we'll call it the palmar fascia to keep things simple). This structure has an intimate relationship with the muscles/tendons and ligaments of the hand, and serves as a link between the forearm and fingers.
Based on the size alone, you can see that it has plantar-fascia-caliber importance even if it isn't weight bearing. You see, of the five muscles that attach via the common flexor tendon on the medial epicondyle at the elbow, four cross the wrist joint and palmar fascia on the way to the hand, where they work to flex and abduct or adduct the wrist, and flex the fingers.
Loads of people have tendinopathies going on up on the medial elbow (Golfer's Elbow), but they only work on this spot (called a zone of convergence). Meanwhile, the soft tissue quality might be just as bad further down at the wrist and hand, adding tension on an already over-burdended common flexor tendon. Think about it this way: if you had a pulled hamstring up by your glutes, would you only work to improve tissue quality at that spot, or would you work all the way down to the posterior knee to make sure that you'd improved some of the poor tissue quality further down as well?
Below, massage therapist and Cressey Performance coach Chris Howard talks you through two different ways to work out the kinks in the palmar fascia and surrounding regions, but keep in mind that it'll always be more effective to have a qualified manual therapist do the job - and that's certainly someone you should see if you have any symptoms whatsoever.
We've found that quite a few of our pitchers comment on how the ball seems to come out of their hand easier after this work. Usually, they're the guys who have the most stiffness along the forearm, particularly into wrist extension and supination.
Give it a shot at your desk at work and see how it feels.
Last summer, a college pitcher came up to Cressey Performance from the South to train for a month before his summer league got underway. He was seven months post-op on a shoulder surgery (Type 2 SLAP) and had been working his way back. Unfortunately, his arm was still bothering him a bit when he got up to see us.
After the first few days at CP, though, he told me that his arm felt as good as it’s felt in as long as he could remember. He’d been doing a comprehensive strength and conditioning program, but the “impact” stuff for him had been soft tissue work, some Postural Restoration Institute drills, an emphasis on thoracic mobility, and manual stretching into internal rotation, horizontal adduction, and shoulder flexion. From all the rehab, his cuff was strong and scapular stabilizers were functioning reasonably well – which led me to believe that his issues were largely due to tissue shortness and/or stiffness.
This realization made me immediately wonder what he’d been doing in the previous months for mobility work for his arm – so I asked. He then demonstrated the manual stretching series that every pitcher on his team went through every day on the table with their athletic trainer. Each stretch was done for 2x20s – and two of those stretches took him into extreme external rotation and horizontal abduction. I was pretty shocked.
Me: “You’re probably not the only guy on your team rehabbing right now, huh?”
Him: “No; there are actually too many to count.”
Me: “Elbows, too, I’m sure.”
Him: “Yep.”
Want to irritate a labrum, biceps tendon, or the undersurface of the rotator cuff? Stretch a thrower into extreme external rotation and simulate the peel-back mechanism. This also increases anterior capsular laxity and likely exacerbates the internal impingement mechanism over the long-term. To reiterate, this is a bad stretch!
Want to make an acromioclavicular joint unhappy? Stretch a thrower into horizontal abduction like this (again, this is a BAD stretch that is pictured):
Want to irritate an ulnar nerve or contribute to the rupture of an ulnar collateral ligament? Make sure to apply direct pressure to the forearm during these dangerous stretches to create some valgus stress. This is a sure-fire way to make a bad stretch even worse:
These stretches are very rarely indicated in a healthy population – especially pitchers who already have a tendency toward increased external rotation. The shoulder is a delicate joint that can’t just be manhandled – and when you’re dealing with shoulders that are usually also pretty loose (both from congenital and acquired factors), you’re waiting for a problem when you include such stretches. In fact, I devoted an entire article to this: The Right Way to Stretch the Pecs.
Everyone thinks that shoulder external rotation and horizontal abduction alone account for the lay-back in the extreme cocking position.
In reality, though, this position is derived from a bunch of factors:
1. Shoulder External Rotation Range-of-Motion – and this is the kind of freaky external rotation you’ll commonly see thanks to retroversion and anterior laxity:
2. Scapular Retraction/Posterior Tilt
3. Thoracic Spine Extension/Rotation
4. Valgus Carrying Angle
So, how do you improve lay-back without risking damage to the shoulder and elbow?
1. Soft tissue work on Pec minor/major and subscapularis – Ideally, this would be performed by a qualified manual therapist – especially since you’re not going to be able to get to subscapularis yourself. However, you can use this technique to attack the pecs:
2. Exercises to improve scapular retraction/depression/posterior tilt – This could include any of a number of horizontal pulling exercises or specific lower trap/serratus anterior exercises like the forearm wall slide with band.
3. Incorporate specific thoracic spine mobility drills – In most pitchers, you want to be careful about including thoracic spine mobility drills that also encourage a lot of glenohumeral external rotation. However, when we assess a pitcher and find that he’s really lacking in this regard, there are two drills that we use with them. The first is the side-lying extension-rotation, which is a good entry level progression because the floor actually limits external rotation range-of-motion, and it’s easy to coach. I tell athletes that they should think of thoracic spine extension/rotation driving scapular retraction/depression, which in turn drives humeral external rotation (and flexion/horizontal abduction). Usually, simply putting your hands on the shoulder girdle and guiding them through the motion is the best teaching tool.
A progression on the side-lying extension-rotation is the side-lying windmill, which requires a bit more attention to detail to ensure that the range-of-motion comes from the right place. The goal is to think of moving exclusively from the thoracic spine with an appropriate scapular retraction/posterior tilt. In other words, the arm just comes along for the ride. The eyes (and head) should follow the hand wherever it goes.
Again, these are only exercises we use with certain players who we’ve deemed deficient in external rotation. If you’re a thrower, don’t simply add these to your routine without a valid assessment from someone who is qualified to make that estimation. You could actually make the argument that this would apply to some folks in the general population who have congenital laxity as well (especially females).
4. Throw!!!!! – Pitchers gain a considerable amount of glenohumeral external rotation over the course of a competitive season simply from throwing. Sometimes, the best solution is to simply be patient. I really like long toss above all else for these folks.
In closing, there are three important things I should note:
1. You don’t want to do anything to increase valgus laxity.
2. You’re much more likely to get hurt from being “too loose” than you are from being “too tight.” When it comes to stretching the throwing shoulder, “gentle” is the name of the game – and all mobility programs should be as individualized as possible.
3. Maintaining internal rotation is a lot more important than whatever is going on with external rotation. In fact, this piece could have just as easily been named "The Two Stretches Pitchers Shouldn't Do, Plus a Few That Only Some of Them Need."
The other day, I received an email from a Show and Go customer who noticed that the scapular wall slide and the doorway slide were two similar, but not identical shoulder mobility drills included in the program. He asked if I could talk a bit more about the differences between the two - and when to use both.
First, let's have a look at the two exercises. Here's the scapular wall slide:
And, here's the doorway slide:
As the voice-over on the video above notes, the scapular wall slide is an acceptable fit for just about any workout routine. The only exceptions would be those who have upper extremity pain with overhead motions (rotator cuff tears, etc.).
However, we can utilize the doorway slide in certain folks to get to where we want to be a bit faster. More specifically, these folks are the ones who are REALLY immobile in their upper extremity and wouldn't even be able to get their arms back even close to the wall on the wall slides. So, in addition to not making them feel bad about their "tight shoulders", the doorway slide actually allows us to use the doorway as a stretching implement to get a gentle stretch across the anterior shoulder girdle (predominantly pec major and minor). There are three very important coaching points:
1. Don't let the head poke forward, as a forward head posture is simply a substitution for not retracting/depressing the scapulae or horizontally adducting the humerus.
2. Don't crank too aggressively on the shoulders; it should be a subtle stretch. And, it shouldn't be used with those (particularly overhead throwing athletes) who already have increased external rotation and, in turn, more anterior laxity.
3. Make sure to focus on pulling the shoulder blades down and back as the elbows are lowered. You shouldn't have movement of the humerus without movement of the scapula.
One of the most common issues we see in both athletes and our general population clients is a lack of ankle mobility - and more specifically, dorsiflexion range-of-motion.
For just about everything in life - from sprinting, to lunging, to squatting - we need a certain amount of dorsiflexion (think of how far the knees can go over the toes, or the positive shin angle one can create without lifting the heel). If we don't have it, we have to compensate.
One of the most common things we see in people with a lack of dorsiflexion ROM is an "out-toeing," as this opens up the ankle and allows for them to get to where they need to be - even if it isn't the most biomechanically correct way to do so.
This out-toeing may also be caused by hip internal rotation deficit (HIRD), so it's important to assess both. Check out this previous video blog for more information on how to assess for HIRD.
In a more "uncompensated" scenario, an athlete with poor ankle mobility may push through the toe instead of the heel - creating a quad-dominant propulsion in a scenario that should have signification contribution from the posterior chain musculature. In the pictures below, you'll see that Josh Beckett requires a considerable amount of dorsiflexion range-of-motion to get the job done (push-off without the heel leaving the ground).
This lack of ankle mobility may also negatively affect knee function. Research has shown that a lack of ankle mobility can increase rotational torque at the knee. This falls right in line with the joint-by-joint school of thought with respect to training; if you lock up a joint that should be mobile, the body will look elsewhere to create that range-of-motion.
This definitely applies to what happens to the lumbar spine during squatting in a person with an ankle (or hip) mobility deficit. If someone can't get sufficient dorsiflexion (or hip flexion and internal rotation), he'll look to the lumbar spine to get that range of motion by rounding (lumbar flexion). We know that combining lumbar flexion with compressive loading is a big-time no-no, so it's important to realize that folks with considerable ankle mobility restrictions may need to modify or eliminate squatting altogether.
Take, for example, Olympic lifters who wear traditional Olympic lifting shoes with big heel lifts. This artificially created ankle mobility allows them to squat deeper. While I'm not a huge fan of this footwear for regular folks for squatting, used sparingly, it's not a big deal.
Other individuals may be better served with hip dominant squat variations (e.g., box squats) that allow them to sit back and not squat quite as deep while they work to improve that ankle mobility and get closer to squatting deeper (with more dorsiflexion). With these individuals, we supplement the more hip dominant squatting with extra single-leg work and plenty of deadlift variations.
The take-home message is that ankle mobility has some far-reaching implications, and it's important to be able to assess it to determine if it's the factor that's limiting someone's safe and efficient movement.
For more information on how to evaluate and address ankle mobility, check out Assess and Correct.
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