Today is Part 2 of a detailed series on the thoracic spine from Eric Schoenberg.  If you missed it, be sure to check out Part 1. -EC

At this point, we need to quickly touch on the concept of “neutral.”  This is certainly a hot topic in the physical therapy and strength and conditioning worlds, as it should be.  For our purposes, we like to be clear that when someone is too flexed (i.e. fully slumped posture), our cue is to “extend back to neutral.”  In addition, when someone is too extended, the cue would be to “flex back to neutral.”  This holds true in all segments of the body and in all three planes of motion (e.g. pelvic tilt, genu valgus, etc.)  The problem that we tend to see is we don’t grade our correction and “overcorrect.”  This results in fixing one problem only to create a new one in the opposite direction.  

In Malcolm Gladwell’s new book, David and Goliath, he refers to this as the “inverted U curve.”  Its application here is that IF an athlete truly lacks T-spine mobility, then once we properly gain it, continued efforts to improve (rather than just maintain) this mobility will ultimately create a brand new problem (hypermobility).  This needs to be considered when we write new programs and lends itself nicely to the importance of thorough evaluation and re-evaluations.

To quickly recap part 1, for the purpose of this series, a cue to “extend the T-spine” is really a case of moving out of excessive flexion and learning to control flexion throughout the throwing motion.

In part 2 of this series, we will focus on the postural alignment and movement examination and its implications in developing an individualized exercise prescription for the athlete.  As a quick side note, it is of particular importance to recognize that the body segments don’t work in isolation.  This is a simple statement; however, when attempting to capture the role of a particular body segment or group of exercises, we are missing the big picture if we try to develop a concept without appreciating the kinetic chain.

In our opinion, the hallmark of an effective examination is the ability to properly identify the athlete’s unique postural alignment and movement tendencies.  These exams must be done with the shirt off to appreciate the bony and soft tissue anatomy. With respect to the thoracic spine, we first identify whether that athlete is in flexion, neutral, or extension.

Here's an example of an athlete with a flattened T-spine, and shoulder blades that have no idea what to do!

Additionally, we need to appreciate the position of the scapula and its impact on the appearance of perceived thoracic flexion.  An athlete that presents with scapular anterior tilt, abduction, and/or internal rotation can easily fool you into thinking that the athlete’s upper back is “rounded” or kyphotic. An athlete with a flat thoracic spine (hypokyphosis) will have a more prominent scapula due to lack of normal contour of the T-spine and ribcage.  In extreme cases, we will see the following:

1. Hypokyphosis (lack of T-spine flexion)

2. Scheurmann's Disease (greater than 60 degrees, and structural)

On x-ray, these cases will show a change in the normal vertebral “wedging.”  The intervention in this case is NOT to attempt to fix the mobility issue, but first determine if the issue is osseous/structural in nature.  Just like any other joint (the hip immediately comes to mind), you can’t stretch bone and any attempt to do so will result in an unhappy athlete!  These are extreme examples, but certainly something that warrants inclusion in this article.

However, more commonly in the physical therapy or strength and conditioning settings, we will see more “middle of the road” cases where there is too much or too little thoracic mobility. As you can see in the lateral view below, this athlete appears to be in excessive thoracic flexion, but it's really just anterior tilting of the scapulae.

However, in the posterior view, you'd be able to appreciate that the T-spine is relatively extended compared to accepted norms (40° flexion = normal curve). 

Moving forward, static alignment does not tell the whole story, so don’t test it alone and don’t let it fool you.  All too often, I hear people trying to prove a point about pitching mechanics or exercise technique and the only proof is a still photo.  This practice needs to stop because it is impossible to capture the complexity of human movement and make a conclusive statement from a screen shot. This concept is why the combination of the postural exam and movement analysis is so critical.

Athletes don’t get injured when they are standing still. They get injured moving (incorrectly!).  For that reason, watch your athlete’s move.  The concepts of FMS or whatever collection of multi-joint movements you like to combine to form a “movement examination” are great tools to collect data on your athlete’s preferred movement patterns.  However, it is also critical to watch the athlete perform the unique movements of their chosen sport. 

In our case, we like to talk to our athlete’s about pitching and we certainly like to watch them throw.  Asking questions like:  “What do you struggle with mechanically” or “where do you break down when you get tired” gives us valuable insight into movement tendencies and injury risk.  With respect to exercise, we observe closely to make sure we are achieving the desired result of the exercise.  In addition, we ask our athletes where they feel a particular exercise to help determine activation patterns and sequencing (motor control).

In addition to watching our athletes throw/pitch, swing, and/or run, we employ simple movement tests such as standing bilateral shoulder flexion (and abduction) to gather critical information about movement quality, timing, and relative stiffness. 

With respect to the video above, consider the excessive extension moment at the thoracic (and lumbar spine) due to increased relative flexibility resulting from poor anterior core stiffness.  This video brings up a lot of questions in my mind:

• Does this athlete need more mobility work into thoracic extension? 
• If he attempted these exercises, how can you be sure the motion will even come from the right place?
• If an athlete is truly “lax” congenitally, then why would they lack mobility at the T-Spine and nowhere else?  
• Are you sure his lack of shoulder flexion is due to decreased thoracic mobility? 
• Or, is he too flexible in his spine and too readily pulls into extension due to the stiffness of his lats? 

My point here is we need to consider the fact that improperly prescribed exercise will make the athlete worse than no exercise at all.  So, if you’re not sure, don’t guess.  Refer out or continue to re-assess until it becomes clear what the athlete needs.

Another simple movement test that we will have the athlete perform is standing thoracic flexion and extension.  Here we will assess the timing (quality), location, and amount of available range of motion that the athlete is working with.

It is also good practice to watch an athlete perform an exercise prior to putting it in his program. 

This athlete (also pictured above) demonstrates faulty movement by not getting out of extension at the top of his pushup prior to initiating the “pike” portion of the yoga push up.  When corrected, in the video below, he did a better job of getting his T-spine in position to allow his scapula to have a better platform to upwardly rotate and elevate as his hands moved overhead.  This was not a mobility issue; this was a patterning or motor control problem.

I should mention that in a full examination, we would consider movement testing of thoracic rotation and sidebending, ventilation, rib cage alignment, quadruped position/movement, etc.  But, for the purposes of this series, we again are choosing to focus primarily on the sagittal plane.  Pay attention to the way in which the athlete returns from flexion to get a good idea of his/her recruitment strategies.

In conclusion, the combination of static posture, movement testing, and unique athletic movement allows us to create a well-rounded profile of the athlete’s strengths and weaknesses.  Be sure that your examination a) identifies areas of limitation that need to be addressed and b) determines the reason why the athlete has these impairments.

In the third and final part of this series, we will discuss the concepts of relative flexibility and motor control as it relates to the topic of thoracic spine extension.

Also, if you’re interested in more information like this, we would love to see you at one of our Elite Baseball Mentorships, with the next one taking place in June. Click here to learn more.

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Today’s guest post comes from my friend and colleague, physical therapist Eric Schoenberg.  Eric is an integral part of our Elite Baseball Mentorships, and here, he kicks off a three-part series that I think you'll find very educational - even if it is a bit "geeky" along the way.  It'll test what you know and make you question some of the stuff you do with your training and work with clients. -EC

I’ll start by saying this is a classic case of giving an athlete what they need, not what we predict or assume they will need.  Let’s be clear up front: there are a lot of athletes that lack thoracic extension and rotation and certainly can benefit from T-spine mobility work.  This is especially true for your general population clients that live in flexion all day – although not every “average joe” is stuck in flexion; this is a wrong assumption!  However, for the purpose of this series, I am going to make a case for the following statement:

Not every individual - especially in baseball populations - needs thoracic extension and rotation mobility drills!  

In fact, to take it a step further, I would argue that in some cases, performing these types of exercises will actually make the athlete worse.

During our Elite Baseball Mentorship in August, I mentioned in passing during the postural examination portion of the breakout session that a lot of athletes present with flattened thoracic spines and some are actually relatively extended.  I followed this up by stating that some people don’t really need any T-Spine extension work.  This simple statement was met with a lot of surprise and follow up questions.

As a result, Eric and I thought it would be a good idea to explore this concept in greater detail.  As is often the case, a relatively benign statement takes on a life of its own and turns into a multi-part blog series.  As we develop these concepts, please feel free to share your thoughts and experiences in the comments section below.

The general assumption of the group was that everyone was kyphotic and T-spine extension was a default group of exercises that EVERY athlete needed.  This premise, however, does not take into account a host of key considerations, such as:

• Defining T-Spine Extension. (part 1)
• Anatomy and role of the Thoracic Spine, (part 1)
• Scapulothoracic joint kinematics, (part 1)
• Importance of a thorough static postural alignment and movement examination, (part 2)
• Scapular position/prominence, (part 2)
• Effect of the T-Spine on adjacent joints such as cervical spine, lumbar spine, pelvis, scapula, humerus, and ribcage, (part 2)
• Concept of relative stiffness, (part 3)
• Faulty motor control resulting in limited thoracic flexion (yes, lack of flexion!), (part 3)
• Timing and amount of relative T-spine extension and rotation in the pitching delivery. (covered in part recently by Matt Blake and Eric C. here and here.)

In an attempt to properly define thoracic spine extension with respect to the baseball player, we must first look at functional anatomy. The thoracic spine, with its rib attachments from T1-T10, is built for stability – most notably to protect the internal organs.  In addition, the T-spine has thinner intervertebral discs, a feature that adds to its relative inflexibility.  The sagittal alignment of the thoracic spine is kyphotic: 40 degrees in adults. (Neumann D.A. 2002).  With that said, we are not really talking about the T-spine being “extended”, but instead are talking about the relative amount of flexion that an athlete is in.  With that description, it’s important to appreciate that T-spine extension drills are working to put an athlete into an acceptable amount of flexion!  It is this flexion (or convexity) that provides a surface for the concave, ventral surface of the scapula to “float” on and create the scapulothoracic joint. (medial border of scapula and ribs 2-7).

For these reasons, we need to not just label an athlete as being “kyphotic” or having a “flat T-spine.”  Instead, we should attempt to define which segments of the T-spine have static or dynamic alignment issue and/or movement dysfunction and address them accordingly.

An important concept to look at is the T-spine is comprised of 12 vertebrae, so we will often find components of flexion, extension, and rotation within those 12 segments. Crosbie, et al. reports that the majority of T-spine extension occurs in the lower T-spine during overhead arm movement. This makes sense due to the thoracolumbar junction and the shape of the lower thoracic vertebrae.  The T10-T12 vertebrae are similar in size and function to the lumbar vertebrae.  T10 has a different rib articulation than T2-9 and T11/T12 have no facets on their transverse process for rib attachments (thus, increasing relative mobility).  So, more often than not, when we see anterior pelvic tilt, and lumbar extension compensation, we can assume that the lower T-spine is doing the same thing.  So what if, for the purposes of this article, we grouped the lumbar spine as T10-L5?

As a quick aside, it is recognized that the thoracic spine moves in three planes of motion.  More specifically, with respect to the frontal and transverse plane, with single arm elevation, the upper T-spine (T1-T5) has ipsilateral coupling of the lateral bending and rotation, whereas in the mid-lower T-spine T6-T12, we see contralateral coupling of lateral bending and rotation.  So in the frontal and transverse planes, the T-spine essentially works as two distinctly different subgroups.  This is important to consider when prescribing exercises to address a perceived movement impairment.  In addition, it is important to remember that the thoracic spine and hips (along with a stable lumbar spine) provide the rotational separation needed to excel in the game of baseball. However, for the purposes of this article, we will focus on the sagittal plane motion of flexion/extension.

As we continue to look at the sagittal plane, but shift our focus to T1, we see a smaller vertebrae (see picture above) that more resembles C7 (and other cervical vertebrae) than the caudal segments (T2-T9).  A case can be made that T1 (cervicothoracic junction) functions more like a cervical vertebrae than a thoracic vertebrae.

This leaves us with T2-T9: eight segments with an extreme mobility problem!  This is where we are really trying to mobilize “out of too much flexion” to get to an acceptable (neutral) position to allow for enough scapular (namely upward rotation and elevation) and glenohumeral motion to give us enough “space” to throw a baseball without causing an impingement.

So how can we be sure that we are following all these rules in three planes of motion when we are performing our T-spine mobility drills?  Are we in fact gaining motion in the correct segments within the context of their coupled motions?  Or, are we simply “mobilizing” what moves easiest and taking the “path of least resistance”?

Check back later in the week for part 2 of this series to read more about evaluation of static alignment and movement testing.  In addition, we will discuss how scapula position can fool us and (in part 3) how too many “abs” can be a bad thing.

In addition, if you’re interested in more information like this, we would love to see you at one of our Elite Baseball Mentorship, with the next one taking place in June. Click here to learn more.

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

Does training heavier lead to more hypertrophy? - This excellent review from Chris Beardsley summarizes the research to-date on the impact of various loads on muscle growth.

Heartburn, Reflux, and GERD: 10 Lifestyle and Nutrition Tips for Feeling Better Now - Precision Nutrition's Ryan Andrews wrote this great piece that will benefit anyone who's suffered from these common ailments.

7 Ways to Dominate the Pull-up - Nick Tumminello highlights seven strategies you can employ if you're struggling with pull-ups. Some of them are ones you may have heard, but as we've come to expect from Nick, there are also some innovative new exercises to try.

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It's been a while since we published an installment of Quick and Easy Ways to Feel and Move Better, but we're back at it today, thanks to CP coach Greg Robins, who has these five tips for you:

1. With deadlift technique, take tension out of the bar one hand at a time.

In my experience the single most difficult lesson to teach a newcomer to deadlifting is how to leverage their weight against the bar. This concept goes by many names, for example: taking the slack out, pulling the tension out, etc. Whatever your cue of choice, learning how to leverage is the “ah-ha” moment for many new lifters. In the following video, I demonstrate a drill that I find very helpful. It may just need to be done in the beginning stages of learning the lift, or it might be something you use for the rest of your life. Either way, it’s definitely worth a look:

2. Use this example to teach the difference between retraction and posterior tilting of the shoulder blades.

To piggy back off the video in point 1, check out this quick video on how to differentiate between retraction, and posterior tilting of the shoulder blades, and why it’s important to learn the latter when setting up for a deadlift.

3. Mimic a good standing posture with prone bridge variations.

The prone bridge, or “plank” exercise is probably the most popular core training exercise since the sit-up. It is an absolute go-to in our programming when teaching people how to resist extension and train the anterior core properly. Unfortunately, it’s also butchered more often than not.

A truly well done prone bridge is one that mimics correct alignment in a good standing posture. It is NOT just a position sans any low back extension. Let’s take a look at what I mean.

First, you need to position the shoulder blades correctly. Too often, people will excessively protract the scaps and embrace a more rounded over upper back position, seen here:

Instead, slightly tilt the shoulder blades back, and place them in a position more like the one seen here:

Next, do not allow excessive flexion of the spine from top to bottom:

In this last picture, we are allowing the person to completely dominate the movement with the rectus abdominis and are not promoting proper recruitment from the internal and external obliques or the transverse abdominis.

To bring this all together, here is a picture of good standing posture with 90 degrees of shoulder flexion; note the similarities to a properly executed prone bridge.

4. Try out this variation of the lower trap raise.

I like this variation for a few reasons:

• It allows some of the more extended populations to stay in a better spinal positioning.
• It promotes proper positioning of the shoulder blades in a back squat or overhead squat exercise.
• It takes away some of the resistance gravity places on us in a prone positioning.
• It helps develop a proper squat pattern and bottom position
• It’s efficient, allowing people to train multiple aspects of good movement at the same time.
• For more advanced populations you can get rid of the wall, and do it in a freestanding deep squat position.

5. Remember that not everything needs to be “difficult.”

Throughout a strength-training program, you will have exercises that are meant to be loaded up to their limit, and others that are there purely to practice a position or motor control pattern. As a client or athlete becomes more advanced, certain exercises will become less challenging. This doesn’t mean that you need to continually find ways to make a movement harder and harder. Too often, when we do so, we take away from the integrity of the movement.

Sure, you can load up your basic deadlift, squat, and lunge patterns until the cows come home, but exercises like the rollout, prone bridge, or side plank will eventually reach a limit in ways that you can productively make them “harder.” This by no means renders them useless, though. In fact, by loading them excessively, or adding an infinite amount of bells and whistles to them, you will mostly find ways to compensate and stray further from their intention. As they become easier to complete, it just changes their purpose from one of teaching the body, to one of reminding the body how to recruit properly.

Some exercises do have a ceiling, and once it’s reached, you don’t need to try and blast through it. Let them serve their purpose, and let the big movements account for your substantial progressions.

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It's time for the first 2014 installment of this weekly series.  Check out these recommended strength and conditioning reads:

Elite Training Mentorship - This month's update from me includes a presentation on the difference between anterior shoulder instability and laxity, and I talk about our approaches with athletes who may encounter these issues. There are also some great additions from Vaughn Bethell and Tyler English this month.

How to Hip Hinge Like a Boss - My buddy (and Cressey Performance co-founder) Tony Gentilcore did a great job with this piece.  If you struggle with hip hinging, this is a good place to start.

Perception, Threat, Pain, and Purple - Bill Hartman makes an awesome point about dealing with people with pain.  Hint: it's about much more than just having a good series of assessments and corrective drills!

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I really enjoying creating features with multiple installments because it really allows me to dig deep into a topic that interests both me and my readers. It’s like writing a short book, with each blog being a different chapter. That said, here were a few of my favorite features from 2013 at EricCressey.com:

1. Quick and Easy Ways to Feel and Move Better - This series is mostly CP coach Greg Robins' work, but I jump in here and there. Installments 28-52 ran this year.  Here were the most popular ones:

Installment 28
Installment 48
Installment 33
Installment 37
Installment 47

2. Coaching Cues to Make Your Strength and Conditioning Programs More Effective – I kicked off this (ongoing) feature in early 2012, and it was as huge a hit this year as it was last year.  My goal with this series is to feel like you have a coach right there with you. Here were the ones we ran this year:

Installment 5
Bench Press Edition
Installment 6
Installment 7

3. Pitching Performance: Understanding Trunk Position at Foot Strike - This was a three-part series co-authored with CP Pitching Coordinator, Matt Blake.

Part 1
Part 2
Part 3

4. Assessments You Might Be Overlooking - I just kicked off this series, but there are some important points covered in the first two installments:

Installment 1
Installment 2

We're close to wrapped up with the Best of 2013 series, but there's still more to come, so check back soon!

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Yesterday, I kicked off the "Best of 2013" series with my top articles of the year.  Today, we'll highlight the top five videos of the year:

1. Individualizing the Management of Overhead Athletes: How to Spot What Your Throwers Need - This is a free 47-minute presentation I made available to all my baseball-specific newsletter subscribers this year.  You can still access it at no charge.

2. Warm-ups for Sparing the Shoulders - This came as part of a post for Schwarzenegger.com.

3. Supine Alternating Shoulder Flexion on Doubled Tennis Ball - This upper back mobility/soft tissue drill was a big hit!

4. Fine-Tuning the Band Pullapart - This is a very popular exercise for shoulder health, but it's commonly performed incorrectly.  Try these modifications!

5. Standing External Rotation Hold to Wall - This is an awesome warm-up that requires no equipment.  We use it a lot with our throwers when they're on the field and don't have access to a table to do prone exercises.

As you can see, 2013 was the "Year of the Shoulder" at EricCressey.com!  I'll be back soon with the top guest posts of 2013.

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With the end of 2013 at hand, I’ll be devoting this week to the best content of the year, based on traffic volume at EricCressey.com. I’ll kick it off today with my five most popular articles from the past year.

1. Why You Struggle to Train Overhead – and What to Do About It - This article ran recently, and judging by the response, I should have written it up years ago!

2. 15 Static Stretching Mistakes - Do you need to stretch?  Maybe not! And, even if you do, you might be making some of these common mistakes.

3. 20 Ways to Prepare Athletes for Success in Sports and in Life - There are lots of valuable life lessons in this one, so it got a lot of love on social media.

4. 6 Tips for People Who Stand All Day - All the mobility and stability recommendations out there seem to be geared toward people who sit all the time - until now!

5. The Deficit Deadlift: A Strength Exercise You Can Do Without - Deadlifts are popular, and deficit deadlifting is controversial, so this webinar I did made for a popular post.

I'll be back soon with another "Best of 2013" feature.  Up next, the top videos of the year!

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

Squatting and Pulling with the Taller Lift - I always enjoy Charlie Weingroff's writing, even though it doesn't come frequently.  This was an excellent piece that reflects a lot of my own views on training taller athletes; just because a guy is taller doesn't mean you blindly contraindicate movements with him.

Is Post-Exercise Muscular Soreness a Valid Indicator of Muscular Adaptation - This is a great review in the Strength and Conditioning Journal from Brad Schoenfeld and Bret Contreras, and it covers a topic that has long been debated in training circles. 

9 Tips for Consistent Workouts - This is a solid article from Charles Staley, and it's timely, in light of how many New Year's Resolutions folks will fall off the bandwagon in the next 6-8 weeks.

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