As I mentioned last week, this past weekend was Ron Wolforth's Ultimate Pitching Coaches Bootcamp just outside of Houston, TX.  To say that it was an awesome experience would be an understatement.  I considered myself really lucky to be presenting alongside the likes of Brent Strom (St. Louis Cardinals), Phil Donley (Philadelphia Phillies consultant who has rehabbed loads of million-dollar arms), Perry Husband (Downright Filthy Pitching), and Ron himself.  These guys are not only getting important information out there for coaches, but also getting their hands dirty in the trenches to take athletes and coaches to the next level with new information.

I also tried to get folks to think about what they already are doing with respect to distance running, "core" training, upper and lower body lifting, assessments, warm-ups (check out the Monster Mobility Pack for ideas), and post-throwing flexibility work.  I discussed the difference between inefficiency and pathology and how your can have a terrible-looking MRI and/or x-ray and still be pain free.

2.  I can't believe Joe Dirt didn't win an Oscar.

(for the record, it isn't Tony that drives me nuts; it's the universal acceptance of the stability ball as training implement for everybody) 7. If you Google "medial deltoid," you get 7,710 results.  You know what?  There is no such thing as a medial deltoid!  It's the middle deltoid - and yes, it is a pretty big difference anatomically (the medial deltoid would technically be the anterior deltoid, if you really think about it).  You don't get Google search results for rhombazoids or upper trapezoids - and medial deltoid isn't much better. 8. In my article series on running programs for pitchers, I alluded to how I dislike it when pitchers run to get fit.  Rather, I feel that they need to get fit to run.  Truth be told, this doesn't just apply to pitchers; it applies to everyone, endurance athletes included.  Taking up running to lose weight is a recipe for disaster for a lot of people.  These people may include: dentists, professional wrestlers, eskimos, Starbucks employees, politicians, elves, laywers, and even superheroes.  Yes, the only thing worse for Superman than kryptonite is distance-running-induced plantar fasciitis. If you're a marathoner or triathlete, have at it - but be sure you're prepared to start it in the first place. 9. Can somebody tell me why we're just arresting this guy now?  He should have been incarcerated for that hairstyle the seconds the 1980s were over!

10. The only thing worse than a close-talker is a close-coacher.  This may include standing on top of an athlete, or shouting as many cues as possible during a set.  Step off, dude. 11. Inside-Out doesn't get much love, but it is the single-best upper extremity injury prevention product out there.  If you have shoulder or elbow issues, you should have bought this over a year ago!

Give Bill and Mike (and your rotator cuffs) some love. 12.  I really could use about 28 hours in the day.  I'd even settle for 27 - but 24 just doesn't seem to be cutting it.

13. It drives me nuts that I really couldn't come up with #13, but then I realized that I could just go back to my mainstay.  Good Lord, this is atrocious.  I don't even know where to begin...

You probably noticed that the newsletter is a day late this week. I have been absolutely swamped with the goings-on at Cressey Performance on top of heading to a big baseball seminar in Houston this weekend (fly out Thursday night). Fortunately, though, this full schedule provided me with the idea for this newsletter.

With the chaos of the past week, I didn't have time to do my normal cooking and food prep for the week on Sunday night. So, Tuesday morning (had already had a normal breakfast), with about twenty minutes left before I needed to head out to work, I looked in the fridge in hopes of pulling together a few meals from a stir fry or casserole. Nothing was there.

As a result, I just wound up grabbing a half-empty tub of cottage cheese and added a tablespoon of psyllium husk powder for fiber. Later in the day, I'd add some Superfood and a scoop of low-carb Metabolic Drive, and had that concoction with a handful of almonds from the stash in the top drawer of the desk in my office. Another meal was a Metabolic Drive bar, and a third was simply a shake with Superfood and some Flameout (fish oil) and almonds. Obviously, it wasn't an ideal daytime meal plan - and it certainly wasn't an aesthetically-pleasing culinary masterpiece like you'd see in John Berardi's Gourmet Nutrition Cookbook, but it got me through the 8-10 hours.

I had a shake with my evening training session, and then came home to cook up a legitimate, whole food meal.

This certainly wasn't optimal, but it was a nutritional "out" for me: it got calories in, kept my energy levels up, and did so without blowing my diet with unhealthy convenience foods. Having good food easily accessible to me is huge when things get busy; I'll roll with mixed nuts, protein powders, protein bars (homemade and Biotest ones), Superfood, and beef jerky. We're also lucky to have a cafeteria in our building, and a good take-out place with awesome salads just about three miles down the road. So, in my eyes, there is never a reason for me to eat garbage - even if I haven't had time to cook up good stuff for myself.

Obviously, this can be applied to diet, but it also has applications in other facets of your healthy lifestyle.

From a training logistics standpoint, what happens if you walk in to your gym to squat, and find that the only squat rack is occupied and there is a long line waiting to use it. Do you stand in line, or do you go to trap bar deadlifts (option A) or walking dumbbell lunges (option B)?

Also along the training lines, but with more of injury perspective, what do you do if your shoulder starts acting up when you go to barbell bench press? Do you try to push through it, skip it altogether, or move to neutral grip dumbbell bench presses (option A) or a push-up variation (option B)? (As an aside, I just wrote an article covering these situations; check it out HERE)

How about professionally? If you're a trainer or a strength coach, if something stumped you, who do you contact? Have you built a good network of health care professionals with both general expertise and specializations? Case in point, one of my current clients started up with me in December of 2006, and he came to me with a C5-C6 disc hernation that had left him with numbness in the tip of his middle finger for the previous ten years - and none of the neurologists and physical therapists he'd seen could do anything about it. I introduced him to John Pallof, PT, COMT, and John had complete feeling back in his finger within two sessions from a combination of manual therapy and neural flossing.

Nowadays, John sees every neck issue that comes to Cressey Performance. Likewise, Dr. Bill Morgan sees all our significant wrist and elbow issues - and the list goes on and on. So, it's not just about having a network; it's about having a network of great people, some of whom specialize in certain areas. I had dinner with Dave Tate a while back, and I recall him saying that he was less concerned with knowing everything and more concerned with knowing who to call to find out everything. Dave was right on the money.

What about easily accessible resources? What books, DVDs, journals, and newsletters do you consult on a regular basis to stay on top of things and research new issues that cross your path? Improving your own abilities is just as important as expanding your network. If you haven't seen it already, a while back, I compiled a Recommended Resources page outlining my recommendations for both free websites and products you can use to stay ahead of the game.

At risk of sounding overconfident, I think that the Building the Efficient Athlete DVD set is something that every trainer and strength coach should watch, as it covers everything from functional anatomy, to static and dynamic assessments, to troubleshooting common resistance training technique mistakes.

Food for thought - and hopefully a little something for everyone.

New Blog Content

Random Friday Thoughts
Training the Baseball Catcher
Relative Strength Improvements on Maximum Strength

Have a great week!

EC

4. For some good reading - particularly with respect to nutrition - check out Brian St. Pierre's blog. 5. I'm going with Joseph Addai over LenDale White this weekend.  Thanks to everyone for the feedback from Tuesday.  Fingers crossed... 6. Happy Birthday to Cassandra Forsythe-Pribanic!  Cass and I go way back, and she's been a great friend and resource for me all along the way.  If you're looking for top-notch female-specific nutrition and fitness resources, you definitely ought to check out The New Rules of Lifting for Women and the Women's Health Perfect Body Diet, both of which Cass or co-authored.

In Part I, I went into some detail on why I really didn’t like the catch-all term “shoulder impingement.” This week, I’m going to talk about the different kinds of shoulder impingement: external and internal.

External impingement, also known as outlet impingement, is the one we hear about the most. Here, we’re dealing with compression of the rotator cuff – usually the supraspinatus, and over time, the infraspinatus (and biceps tendon) – by the undersurface of the acromion. This impingement can lead to bursal-sided rotator cuff tears - and happens a lot more with ordinary weekend warriors and very common in lifters (not to mention much more prevalent in older populations.

External impingement can be further subdivided into primary and secondary classifications. In primary impingement, the cause is related to the acromion – either due to bone spurring or congenital shape. As you can see in the photo below, hook (II) and beak (III) are worst than flat (I), as there are marked difference in “clearance” under the acromion.

Secondary impingement, on the other hand, is usually related to poor scapular stability (related to both tightness and weakness, as described in last week’s newsletter), which alters the position of the scapula. In both cases, pain is at the front and/or side of the shoulder and is irritated with overhead activity, scapular protraction, and several other activities (depending on the severity of the tissue problems). You’ll also generally see a lack of external rotation range-of-motion, as these are folks who do too much bench pressing and computer work (both of which shorten the internal rotators).

Conversely, internal impingement, also known as posterosuperior impingement, really wasn’t proposed until the early 1990s. This form of impingement is more common in younger individuals who are involved in overhead sports, making it more of an “athletic impingement.” Adaptive shortening and scarring of the posterior rotator cuff in these athletes causes a loss of internal rotation and an upward translation of the humeral head during the late cocking phase of throwing (or swimming): external rotation and abduction.  These issues are magnified by poor scapular control, insufficient thoracic rotation, and weakness of the rotator cuff.

When the humeral head translates superiorly excessively in this position, it impinges on the posterior labrum and glenoid (socket), irritating the rotator cuff and biceps tendon along the way. So, pain usually starts in the back of the shoulder, as you are seeing irritation of the posterior fibers of the supraspinatus and anterior fibers of the infraspinatus tendons. Gradually, this pain may “shift” toward the front as the biceps tendon, and that implies labral involvement.  At least initially, 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.

We often hear about SLAP lesions in the news. This refers to a superior labrum, anterior-posterior injury. In reality, when we are talking about labral injuries in overhead athletes as they relate to internal impingement, it’s mostly just posterior (although serious cases can eventually affect the anterior labrum, too). There are different kinds of SLAP lesions (1-4). Every baseball pitcher you’ll meet has a SLAP 1, which is just fraying. SLAP 2 lesions are far more serious and often require surgical intervention. SLAP 1 issues become SLAP 2 lesions when poor mobility and dynamic stability aren't established.

So, just to bring you up to speed, we’ve got two different kinds of impingement, one of which (external) has two subcategories that mandate different treatment strategies (primary = surgery, secondary = corrective exercise). We also have two separate areas where pain presents (external = front/side, internal = back). That’s just the tip of the iceberg, though, as we have two more considerations…

First, symptomatic internal impingement tends to be "mechanical pain." Unless you’re dealing with a more advanced case, athletes with symptomatic internal impingement only have pain when they get into the late cocking phase (and sometimes follow-through). It usually isn’t present when they’re just sitting around – and for this reason, they can usually be more aggressive in the weight room with upper body training. Keep in mind that I use the term “symptomatic” because I think that internal impingement is a physiological norm, just like I observed last week with external impingement.  You're essentially just going to go out of your way to avoid this "apprehension" position in the weight room by omitting exercises like back squats.  An apprehension test - illustrated in the most enthusiastic video in internet history - is a quick and easy assessment many doctors and rehabilitation specialists use to check for symptomatic internal impingement, as it reproduces the injury mechanism.

Second, and perhaps more importantly, you are dealing with two rotator cuff tears that are fundamentally different. It’s these differences that make me think doctors need to get rid of the term “impingement.” Here’s the scoop:

Let’s say that we have two guys with partial thickness tears of the supraspinatus – one from external impingement and one from internal impingement.

With external impingement, we’re usually dealing with a bursal-sided tear, as the rubbing comes from the top (acromion). These issues will generally heal more quickly because the bursa actually has a decent blood supply.

With internal impingement, on the other hand, we’ve got an articular-sided tear, meaning that the wear on the tendon comes from underneath (glenoid). The tear is more interstitial in nature. Blood supply isn’t quite as good in this area, so healing is slower (or non-existent).

Traditionally, articular has been an athletic injury, and bursal has been a general population issue. This is not always the case, though.

Factor in the activity demands of overhead throwers, and they have more challenging tears and greater functional demands. Fortunately, they also typically have age and tissue quality on their sides, so things tend to even out.

With all these factors in mind, if a doctor ever tells you that you have "shoulder impingement," ask:

1. Internal or external?

2. If external, is it primary or secondary? (It’ll probably be both)

3. If internal, is there labral involvement? Biceps tendon?

4. If internal, what is the internal rotation deficit? (They should measure it, as this will begin to dictate the rehabilitation plan)

5. Given my age, activity level, and the nature of the tear, do you feel that surgical or conservative treatment is best?

Click here to purchase the most comprehensive shoulder resource available today: Sturdy Shoulder Solutions.

Sign-up Today for our FREE Baseball Newsletter and Receive Instant Access to a 47-minute Presentation from Eric Cressey on Individualizing the Management of Overhead Athletes!

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.

New Blog Content

The Mainstream Media Lag Why Wait to Repair an ACL? (Abbreviated) Random Friday Thoughts

1. This is my first post on the new blog, so apologies in advance if:

a) the font style or color is out-of-whack

b) it comes up in Portuguese (meaning that you’d have no idea what I am saying, anyway)

c) your computer freezes up on account of the complete and utter awesomeness that you’re beholding with the new site

Kidding aside, it’s been a royal pain in the butt thus far and I’m just anxious to have it done so that I can just go back to writing.

2. Believe it or not, as some of you probably have noticed, I haven’t blogged for a full week. There was just a ton of stuff to get gone for the new site as well as loads of other projects on my plate.

Interestingly, though, it was by far my best week of training since the spring. I had a great front squatting session on Tuesday, and although Wednesday was supposed to be a day off, I got antsy later in the day. So, I did a little sprint work – and it felt great. So, I figured what the heck: I might as well test my vertical jump and broad jump. I wound up jumping a personal best of 34.7 inches and then tying a personal best on the broad jump with 114 inches. As a cooldown, I wrestled a grizzly bear and then did walking lunges in the parking lot with an intern over each shoulder. Those whippersnappers will learn!

Random digressions aside, it’s very clear that this blog is completely counterproductive for my strength, power, and physique goals. In fact, I’d say that is roughly on-par with distance running as a competing demand for my attention and physiological recuperation. I’m going to take one for the team and keep writing, though; winners persevere.

(and in case you folks didn’t pick up on it, that was a joke)

3. Here is a cool study:

Rotator Cuff Tendinopathy: Is there a Role for Polyunsatured Fatty Acids and Antioxidants?

Essentially, this is a survey of all the available research on the topic, and here is what they determined: “Only one trial was found that investigated the efficacy of PUFAs and antioxidants on tendinopathies. The findings suggest that some (low level) evidence exists to support the supplementation in the management of tendinopathies. Any conclusions based on this one article should be reached with caution. Subsequently, there is a distinct and clear need for well-planned randomized controlled trials that aim to investigate the efficacy of supplements in the management of tendinopathies including those of the rotator cuff.”

Meanwhile, we spend BILLIONS on NSAIDs, cortisone shots, and surgeries. Don’t you just love the medical model? While these options are certainly warranted in some situations, we’re studying for the wrong test by ignoring the role of PUFAs and antioxidants in the treatment of tendinopathies.

Chances are that the NIH won’t soon fund anything to look at this, though, as they are too busy doing the 38,736^th study in history on creatine.

4. A good cartoon, in light of the week ahead:

5. Speaking of turducken, is anyone looking forward to listening to John Madden on Thanksgiving as much as I am?  I mean, this is quite possibly the greatest broadcasting spectacle in football history, as Madden will be bouncing off the walls try to slip in as many Brett Favre references as possible - even if Favre and the Jets don't play until the following Sunday.

6. Another interesting study that ought to make you think:

Lumbar Intervertebral Disk Degeneration in Athletes

Basically, the researchers found that college baseball players and swimmers were 3.23 and 2.95 times more likely (respectively) than their non-athlete counterparts to have disk degeneration. And, there was a clear association between disk degeneration and lower back pain.

Now, here is something to consider…I would be willing to bet that if you took these athletes and actually trained their “cores” the right way, they would be better off long-term than the nonathletes – in spite of the amount of disc degeneration that’s present already. I feel very strongly that multidirectional lumbar stability goes a long way in overcoming any structural flaws – from vertebral fractures (spondylolysis) to disc issues; there are a lot of structurally jacked up backs out there that are completely asymptomatic.

To me, it’s the folks who do nothing that are most at-risk of debilitating back pain long-term. When s**t hits the fan for them, they are playing behind the 8-ball, as they’re older and completely untrained. So, they are starting from scratch when it’s the hardest to start from scratch. Food for thought.

In the meantime, pick up a copy of Combat Core and save yourself. It’s the best “core training” program out there.

7. That last thought was pretty heavy with techy stuff, huh? Did it blow your mind? You know, kind of like it blew your mind when David Hasselhoff talked to that car – and the car actually talked back?

Yeah, that was crazy.

Anyway, that's all for this week.  Did you miss me?

Have a good weekend...