Home Posts tagged "AC joint"

How Lower Body Exercises Can Impact Upper Body Function

A while back, I published a blog called Making the Case for Training in the Post-Surgery Period. In short, it discussed how we are almost always dealing with athletes who are training during their rehabilitation periods. In many cases, this is strictly working around the issues while they're going through physical therapy.

In writing these programs, one recognizes that it's actually far easier to write a program for a post-op lower body issue than it is for a post-op upper body scenario. Very simply, because most strength and conditioning exercise selections work "from the ground up," there are many more ways that lower extremity exercises can impact upper body drills than vice versa. Today, I'll outline some examples.

1. Grip work.

There is grip involvement in deadlifts, various dumbbell single-leg exercises, and even squatting exercises that require an athlete to grasp the bar. Particularly in the case of elbow issues, too much grip work can become a real problem. For example, in the 4-8 month period after Tommy John surgery, it's not uncommon for athletes to experience discomfort in the common flexor tendon region - and it usually has to do with the cumulative stress of gripping during strength training and rehab work on top of the intensification of the throwing program. Some doctors have surgical approaches that are a bit "rougher" on the flexor tendon, too. In these scenarios, you're best off working predominately with lower body drills that don't involve a lot of grip work.

2. Front rack position with acromioclavicular (AC) joint issues. 

When you want an AC joint issue to calm down, there are really three big rules: 

a. Avoid reaching across the body (horizontal adduction, like a cross-body stretch)

b. Avoid reaching behind the body (full extension, like in a dip)

c. Avoid direct pressure to the area (particularly because it has very little muscle mass to cushion it)

Gray326-4

With respect to "C," the front squat set-up is an absolute no-no. The pressure on the bar across the shoulder girdle can really take an upset AC joint and make it markedly worse. And, since this is in many cases an injury that we’re just “waiting out,” simply training through it will only makes things worse long-term.

HandsFreeRack

Therefore, deadlift variations, single-leg variations, and back squats (assuming no other related problems) are likely better bets. That said, we generally use the safety squat bar and giant cambered bar exclusively with those who present with AC joint problems.

3. Back squat position with internal impingement.

Internal impingement (also known as posterosuperior impingement) is a broad diagnosis most common in overhead throwing athletes. In the late cocking phase of throwing (or swimming, tennis, etc.) - which involves external rotation and abduction - the humeral head tends to translate superiorly (up) and anteriorly (forward) relative to the scapula.

layback

These issues are magnified by poor scapular control, weakness of the rotator cuff, insufficient thoracic mobility, loss of tissue extensibility around the shoulder girdle, and in some cases, structural changes. The end result is that the biceps tendon, labrum, rotator cuff, glenohumeral ligaments, or nerves that pass the anterior aspect of the shoulder get irritated. The term "internal impingement" really just explains the pain-provoking position, not the specific diagnosis. Generally speaking, the pain is purely mechanical in nature; it won’t bother an athlete unless the “apprehension” position (full external rotation at 90+ degrees of abduction) is created.

Just about every overhead athlete is constantly "flirting" with internal impingement problems, so my feeling is that it's best to just avoid this "at-risk" position in the weight room - and that's why we don't back squat any of our overhead throwing athletes. And, we certainly wouldn't use a back squat with anyone with symptomatic internal impingement.

backsquat

4. Giant cambered bar with scapular anterior tilt, humeral anterior glide, and forward head posture.

The giant cambered bar is an awesome option for avoiding the "at-risk" abducted, externally rotated position that often gives overhead athletes problems, but it can create a problem with athletes who are prone to scapular anterior tilt, humeral anterior glide, and/or forward head posture. Because of the positioning of the hands, the elbows are driven a bit behind the body, which can cause the shoulder blade to dump forward and "ball" to glide forward on the socket. You may also see the head shoot forward.

That said, these faults can be easily minimized with good cueing. However, I wouldn't recommend using this bar with an athlete who has a big predisposition toward any of the three issues.

5. Scapular depression from holding heavy weights in the hands.

The deadlift can be an awesome exercise for improving poor posture - but not in all cases. Specifically, whenever we have an athlete who sits in too much scapular depression and downward rotation (more info on that HERE), we'll avoid holding really heavy weights in the hands for lower body training.

ScapularDownwardRotation-300x225-2

Our goal is to teach the shoulder blades to sit a little higher at rest, and functionally get higher when the arms need to go overhead. We don't want all our lower body work competing against that. During this time period, it's best to go with squatting variations, barbell supine bridges/hip thrusts, DB/KB goblet set-ups, sled work, the front squat grip, glute-ham raises, and anything else your imagination yields - as long as it doesn't tug the shoulder blades down.

There are many more considerations for how lower body work impacts upper body function, but these are definitely the five I most frequently encounter that you should keep in mind. If you're interested in learning more, I'd encourage you to check out my newest resource, Sturdy Shoulder Solutions.

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Strength and Conditioning Stuff You Should Read: 5/9/12

Here's this week's list of recommended strength and conditioning reading:

Elite Training Mentorship - I just had some new content loaded here for one of our twice-a-month updates.  My two in-services, Progression and Regression and Understanding and Managing Acromioclavicular Joint Issues will be of particular interest.

Trunk Stability for Young Athletes - Mike Robertson did a great job with this post on preparing today's young athletes without skipping steps.

Understanding USA Hockey's American Development Model (ADM) - This is an excellent post from my friend (and former CP intern) Kevin Neeld.  I love how Kevin has sought out to be "the guy" when it comes to hockey much like we have done so in our work with baseball players.  I also really enjoyed this post, because I think we can learn a lot on long-term development models by looking to the successes and failures encountered in other sports.  In particularly, I loved his quote, "We're winning the race to the wrong finish line."

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Weight Training Programs: Assess, Don’t Assume

Late last week, my buddy Nick Tumminello made the follow comment that some folks, unfortunately, took out of context:

“Everyone is talking about assessments (and that's cool). But, no one seems to talking about simply not allowing poor form in training. If you can't keep good form in a certain exercise (movement pattern), simply don't do that exercise until you've improved the movement or decided that you're simply not built for it to begin with. Not sure why things need be any more complicated than that!”

For the record, I agree 100% with Nick and understood what he meant, but it would have been easy to assume that he was referring to “trainers train, and therapists assess.”  In other words, many folks assume that as long as you aren’t symptomatic in some way, then you’re safe to start exercising because you can simply “feel” things out as you go and, if something hurts, you don’t do it.

While you obviously shouldn’t do something if it hurts, just because something doesn’t hurt doesn’t mean that it’s not harmful long-term – and to me, that’s the difference between “working someone out” and provided them with an optimal training experience.  As physical therapist Mike Reinold has said, “Assess; don’t assume.”

To illustrate my point, here are a few examples.

Let’s say you have someone with a chronically cranky acromioclavicular joint or osteolysis of the distal clavicle that might only be apparent upon reviewing a health history, palpating the area, or taking someone into full horizontal adduction at the shoulder.  While direct over-pressure on the area (as in a front squat) would surely elicit symptoms, my experience is that most folks won’t notice a significant amount of pain until the next day if the strength exercise selection is inappropriate (e.g., dips, full range-of-motion bench pressing).  You might have avoided what “hurt” during the session (presumably because the individual was warmed up), but you find out after the fact that you just set an individual back weeks in their recovery and fitness program.

How about right scapular winging?  It’s not easily observed if a client has a shirt on, and if you simply throw that individual into a bootcamp with hundreds of push-ups each week, you’re bound to run into trouble.  Here’s the thing, though: even if you observed that winging and wanted to address it in your training, you really have to consider that it can come from one or more of several factors: weak scapular stabilizers, a stiff posterior cuff, insufficient right thoracic rotation, faulty breathing patterns, or poor tissue quality of pec minor, rhomboids, levator scapulae (or any of a number of other muscles/tendons).  Just doing some rows and YTWL circuits will not work.

Also at the shoulder, a baseball pitcher with crazy congenital and acquired shoulder external rotation may have a ton of anterior instability in the “cocking” position of throwing (90 degrees of abduction and external rotation), but be completely asymptomatic.  Back squatting this athlete would exacerbate the problem over the long haul even if he didn’t notice any symptoms acutely.

Finally, in my recent article, Corrective Exercise: Why Stiffness Can Be a Good Thing, I spoke about how someone can have crazy short hip flexors and still manage a perfect squat pattern because his stiffness at adjacent joints is outstanding.  If I don’t assess him in the first place and just assume that he squats well, I’m just waiting for him to strain a rectus femoris during sprinting or any of a number of other activities.  Gross movement in a strength and conditioning program wouldn’t tell me anything about this individual, but targeted assessments would.

The point is that while Nick’s statement is absolutely true – demanding perfect form is corrective in itself – you’ve still got to assess to have a clear picture of where you’re starting.  Otherwise, many cases like this will slip through the cracks.

To that end, I’m happy to announce that my long-time friend and colleague, Mike Robertson, recently released his Bulletproof Knees and Back Seminar DVD Set.  This comprehensive product covers anatomy, assessments, program design, and coaching.  In fact, almost the entire second day is focused on coaching, and that’s an area in which most trainers really do need to improve.  All in all, this isn’t a collection of bits and pieces; it’s Mike’s entire philosophy on training someone who is suffering from knee or low back pain (and how to prevent it in the first place).  Effectively, Mike covers what both Nick and I are getting at in the paragraphs you just read.

This is tremendously valuable information that fitness professionals need to hear, so be sure to check it out.

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AC Joint Impingement vs. “Regular” Shoulder Impingement

I've seen a few acromioclavicular (AC) joint impingement cases at our facility in the last couple of weeks and thought it'd be good to do a quick blog to talk about how different they are from "regular" (external) shoulder impingement cases.  And, it is a very important differentiation to make. I've already written at length about AC joint issues in Getting Geeky with AC Joint Injuries: Part 1 and Part 2.  And, I kicked out a two-part series called The Truth About Shoulder Impingement; here are Part 1 and Part 2. While I talk a lot about the symptoms for both, several provocative tests for these issues, and training modifications to avoid exacerbating pain under these conditions, there was one important "differential assessment that I missed."  Mike Reinold actually taught me it as we were planning the Optimal Shoulder Performance DVD set.

shoulder-performance-dvdcover

Just paying close attention to (and asking about) where folks have their pain during overhead motion can tell you quite a bit.  In an external impingement - where we're talking about the rotator cuff tendons and bursa rubbing up against the undersurface of the acromion - you'll usually get pain as folks approach 90 degrees of abduction (arm directly out to the side).  That pain will persist as they go further overhead, and in my experience, start to die off as they get to the top.

externalimpingementvsacjoint

Conversely, for those with AC joint impingement - what is essentially bone rubbing up against bone - you see a "painful arc" only at the last portion of abduction:

painfularc-for-acj

You can usually confirm your suspicions on this front with direct palpation of the AC joint and checking to see if folks have pain when reaching across the chest.

Much of the training modifications will be the same for these two conditions, but there are also going to be several key things that should be managed completely differently.  For instance, front squatting someone with an AC joint issue would not be a good idea due to the direct pressure of the bar on the AC joint; it would, however, be just fine for most cases of external shoulder impingement.  In another example, some serious AC joint issues are exacerbated even by just doing the end-range of a rowing motion (to much shoulder extension/horizontal abduction) - whereas even folks with full-blown rotator cuff tears can generally do rows pain-free.

Assess, don't assume!

For more information - including loads more assessments like these - check out the Optimal Shoulder Performance DVD set.

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Getting Geeky with AC Joints: Part 2

Getting Geeky with AC Joints: Part 2 In my last newsletter, I went into great detail on the types of acromioclavicular (AC) joint injuries we see, and some of the common inefficiencies that cause some folks to become symptomatic.  I also outlined some corrective exercise strategies to expedite recovery time.  This week, though, I discuss a very important - yet often-overlooked - piece of the puzzle: how to maintain a training effect in spite of these injuries. Ask anyone who has ever had an AC joint injury, and they'll tell you three things to avoid if you don't want to irritate it: 1. Avoid direct pressure to the area (particularly because it has very little muscle mass to cushion it) 2. Avoid reaching across the body (horizontal adduction) 3. Avoid reaching behind the body (full extension) We can use these three guidelines to get moving in the right direction with respect to maintaining a training effect in spite of the AC joint injury. With respect to #1 from above, front squats are an absolute no-no.  The pressure on the bar across the shoulder girdle can really take an upset AC joint and make it markedly worse.  And, since this is in many cases an injury that we're just "waiting out," simply training through it will only makes things worse long-term.  So, deadlift variations, single-leg variations, and back squats (assuming no other related problems) are likely better bets.  That said, we generally use the safety squat bar and giant cambered bar exclusively with those who present with AC joint problems.

Another important consideration in this regard is overhead pressing.  Believe it or not, many individuals with AC joint problems will actually tolerate overhead pressing quite well, as direct trauma to the AC joint won't really compromise scapulohumeral rhythm very much.  However, you have to consider two things. First, as I mentioned in my previous newsletter, some folks might have developed the AC joint issue over time due to a scapular anterior tilt causing the acromion and clavicle to sit differently.  This dyskinesis would also make overhead work less safe - so the individual would actually be training through a faulty movement pattern, and potentially injuring the rotator cuff, biceps tendon, bursa, and labrum. Second, if the individual is okay to overhead press from a movement standpoint, one needs to make sure that the bar, dumbbell, or kettlebell does not come down directly on the AC joint in the bottom position. With respect to #2 from above, obviously, dumbbell flyes and cable crossovers are out (not sure why they'd be "in" in the first place, but that's a whole different newsletter).  However, close-grip bench pressing variations will generally cause pain as well.  You also have to be careful with cable and medicine ball variations that may position the arm across the body. Moving on to #3, full extension of the humerus will light up an AC joint pretty quickly.  So, dips are out - and, honestly, I generally tell folks they're out for good after one has experienced any kind of AC joint issue.  Full range-of-motion (ROM) bench pressing and push-ups are generally issues as well, so I tend to start folks with more partial ROM work.  Examples would include dumbbell and barbell floor presses and board presses.  Here's a 3-board press:

As the shoulder starts to feel better, one can move down to 2-board, 1-board, and eventually full ROM bench press.  Remember, a medium or wide grip will generally be tolerated better than a close grip.

I also really like push-up iso holds at a pain-free ROM for these individuals because closed-chain exercises are always going to be a bit more shoulder friendly than open-chain variations.  This is really quite simple: set up as if you are going to do a push-up, and go down as far as you can with no pain.  When you reach your pain-free end-range, hold there while bracing the core, locking the shoulder blades down and back, and tightening the glutes; do not let the elbows flare out or hips sag!  We'll hold for anywhere from 10-60s, depending on fitness levels.  Over the course of time, increase the ROM as your symptoms reduce.

There you have it: acromioclavicular joints - from onset to corrective exercise - in a nutshell.  Obviously, make sure you seek out a qualified professional if you think you may have these issues, but keep this progression in mind as you return to (or just try to stay in) the iron game. Feedback on Building the Efficient Athlete "In my ten years in the fitness industry, I have been to many seminars and conferences - but the Building the Efficient Athlete Seminar was by far the most informative and comprehensive event I have attended in as long as I can remember.  The amount of knowledge you get when you combine Eric Cressey and Mike Robertson is unparalleled.  The seminar was filled with great classroom information, hands-on assessments, and on-site training tips.  I highly recommend this DVD set to any coach, trainer, or athlete who is looking to get a leg up on the competition." Mike Hanley, USAW, RKC Morganville, NJ www.HanleyStrength.com

Pick up your copy of Building the Efficient Athlete today!

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New Blog Content Exercise of the Week Stuff You Should Read Jays Prospect Collins a Surprising Strikeout Machine Random Friday Thoughts How to Progress Back to Deadlifting After a Back Injury Have a great week! EC

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Getting Geeky with AC Joint Injuries

Getting Geeky with AC Joint Injuries Lately, I've gotten quite a few in-person evaluations and emails relating to acromioclavicular (AC) joint issues.  As such, I figured I'd devote a newsletter to talking about why these injuries are such a pain in the butt, what to do to train around them, and how to prevent them in the first place (or address the issue once it's in place). First off, there is a little bit about the joint that you ought to know.  While the glenohumeral joint (ball-and-socket) is stabilized by a combination of ligamentous and muscular (rotator cuff) restraints, the AC joint doesn't really have the benefit of muscles directly crossing the joint to stabilize it.  As such, it has to rely on ligaments almost exclusively to prevent against "shifting."

ac-joint

As you can imagine, then, a traumatic injury or a significant dysfunction that affects clavicle positioning can easily make that joint chronically hypermobile.  This is why many significant traumatic injuries may require surgery.  While almost all Grade 4-6 separations are treated surgically, Grades 1-2 separations are generally left alone to heal - with Grade 3 surgeries going in either direction. In many cases, you'll actually see a "piano key sign," which occurs when the separation allows the clavicle to ride up higher relative to the acromion.  Here's one I saw last year that was completely asymptomatic after conservative treatment.  It won't win him any beauty contests, and it may become arthritic way down the road, but for now, it's no problem.

pianokeysign

Now that I've grossed you out, let's talk about how an AC joint gets injured.  First, we've got traumatic (contact) injuries, and we can also see it in people who bench like this:

Actually, that's probably a fractured sternum, but you can probably get the takeaway point: don't bounce the bar off your chest, you weenie.  But I digress... Insidious (gradual) onset injuries occur just as frequently, and even moreso in a lifting population.  Most of the insidious onset AC joint problems I've encountered have been individuals with glaring scapular instability.  With lower trapezius and serratus anterior weakness in combination with shortness of pec minor, the scapula anteriorly tilts and abducts (wings out) - and you'll see that this leads to a more inferior (lower) resting posture.

scapanteriortilt

In the process, the interaction between the acromion (part of the scapula) and clavicle can go a little haywire.  The acromion and clavicle can get pulled apart slightly, or the entire complex can get pulled downward a bit.  In this latter situation, you can also see thoracic outlet syndrome (several important nerves track under the clavicle) and sternoclavicular joint issues in addition to the AC joint problems we're discussing. As such, regardless of whether we're dealing with a chronic or insidious onset AC joint issue, it's imperative to implement a good scapular stabilization program focusing on lower trapezius and serratus anterior to get the acromion "back in line" with the clavicle.  Likewise, soft tissue and flexibility work for the pec minor can also help the cause tremendously. Anecdotally, a good chunk of the insidious onset AC joint problems I've seen have been individuals with significant glenohumeral internal rotation deficits (GIRD).  The images below demonstrate a 34-degree GIRD on the right side.

gird1gird2

It isn't hard to understand why, either; if you lack internal rotation, you'll substitute scapular anterior tilt and abduction as a compensation pattern - whether you're lifting heavy stuff or just reaching for something.  And, as I discussed in the paragraph above, a scapular dyskinesis can definitely have a negative effect on the AC joint. Lastly, you can't ever overlook the role of thoracic spine mobility.  If your thoracic spine doesn't move, you'll get hypermobile at the scapulae as a compensation - and we already know that's not good.  And, as Bill Hartman discussed previously, simply mobilizing the thoracic spine can actually improve glenohumeral rotation range-of-motion, particularly in internal rotation.  Inside-Out is a fantastic resource in this regard - and is on sale this week, conveniently! So, as you can see, everything is interconnected!  In part 2 of this series, I'll discuss training modifications to work around acromioclavicular joint problems and progress back to more "normal" training programs. New Blog Content Birddogs, Continuing Education, and Terrible Journalism Stuff You Should Read Exercise of the Week: Dumbbell Reverse Lunge Random Friday Thoughts It's All About Specialization 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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Pain with Horizontal or Vertical Pushing?

Last week, I published a post on shoulder issues with overhead pressing, and got two good comments as replies: 1. In HS I separated my AC joint during the first game of junior year. I played the rest of the year with out letting it heal, and to this day I have still have shoulder issues (college ball didn't help the issue much either). It seems my shoulder allows me to overhead press/push press/jerk and incline press, but flat bench is out of the question unless I'm using DBs. Is this typical of this type of shoulder injury, or am I an outlier and most individuals show the same symptoms as yourself? Granted we each have different injuries but same local area. 2. I have pain doing flat bench presses with barbell and upright rows. Decline barbell press is also sometimes uncomfortable, but incline press and overhead press is working fine. This is actually pretty typical of acromioclavicular (AC) joint problems.  Folks will have problems with exercises like full-ROM bench presses and dips, as they force full humeral extension. Decline bench pressing requires less humeral extension on the eccentric than regular bench pressing and dips, so that would explain the decrease in symptoms. That said, overhead pressing will usually be okay because it doesn't require so much humeral extension (nothing past neutral).  However, some folks will have other related problems (e.g., rotator cuff injury during the AC injury), so both horizontal and vertical pushing movements may become problems. So, obviously, not all shoulder problems are created equal.  However, a lot of the time, they can be treated with similar means: good scapular stabilization movements, a focus on thoracic spine mobility, and dedication to strengthening the rotator cuff and improving soft tissue quality.

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