Home Posts tagged "Laxity"

4 Ways Hypermobile Clients Can Improve Their Training

Today's guest post comes from Cressey Sports Performance coach, Laura Canteri.

From super tight to super loose, people can fall at any point on the laxity continuum. Most women fall under the more hypermobile side of things, but there are a surprising amount of women who are nonetheless unaware of their extreme laxity. As a hypermobile female who learned the hard way, I want to share my knowledge and experiences with you to help improve your training and long-term health in four simple steps. While I'll focus my attention on females in particular, the overwhelming majority of these lessons hold true for hypermobile males as well.

1. Create Self Awareness.

What is Hypermobility?

Each joint has a certain amount of laxity and can be either congenital (you were born with it; thanks, Mom and Dad) or as a consequence of repetitive activities (e.g., swimming).  It shouldn't be confused with instability, which would result from an injury that leads to excessive, uncontrolled range-of-motion. With that said, hypermobility is excessive laxity at a joint. If you often feel “tight” and don’t think that this article pertains to you, I encourage you to keep reading.

How Do I Know If I’m Hypermobile?

At Cressey Sports Performance, we like to use the Beighton scale to assess joint laxity and hypermobility. The screen is scored out of nine points in which there are five tests (see below). Unilateral tests should be scored on both sides with each positive test counting as one point. The higher the score, the higher the laxity.

1. Extend the pinky to >90° angle with the rest of the hand (left and right sides)
2. Flex the thumb to contact with the forearm (left and right sides)
3. Elbow hyperextension > 10° (left and right sides)
4. Knee hyperextension > 10° (left and right sides)
5. Toe touch with knees straight, touch the palms flat on the floor

Beighton_Score

2. Remove Static Stretching From Your Routine.

From youth to college basketball, I had my fair share of injuries - from sprained ankles to dislocated shoulders -but despite having such loose joints, I would always feel “tight.” I couldn’t touch my toes, clasp my hands behind my back, or do any “cool” tricks. So, I incorporated static stretching before and after every game/practice to decrease my risk for injuries. Good news: I was eventually able to touch my toes and clasp my hands behind my back. Bad news: I continued to have even more shoulder instability issues, which resulted in surgery.

So, what gives? I wouldn’t feel “tight” if I was hypermobile, right? Wrong. Let me explain. When other structures aren’t working properly (i.e. your ligaments and tendons) to support a joint, the surrounding muscles work overtime to stabilize and protect it. This mechanism is known as "protective tension" and is the reason why someone who is hypermobile may feel “tight.”  Our body creates trigger points as a strategy to create stability where we don't have it. It may feel good to stretch in the moment, but stretching muscles around an already lax joint capsule will only lead to more instability and greater risk for injury.  It's like picking a scab; you feel better in the short-term, but wind up with longer term problems.

Long story short, if you're looking for a quick reduction in tightness, get rid of the static stretching and grab yourself a foam roller instead - and then follow that work up with some good stability exercises.

3. Stay Away From End Ranges.

Women who have a lot of joint laxity tend to stand, sit, and train in extreme end ranges (see pictures below). When joints are constantly loaded beyond normal range, the ligaments will continue to become more lax and the joint will experience more wear and tear overtime. Here are a few examples:

Hyperextended Elbows During a Push-up

elbowhyperextension 

Hyperflexed Lumbar Spine and Hyperextended Cervical Spine During Sitting

IMG_4273

Hyperextended Knees During Standing

IMG_4274

Hyperextended Knees and Right Hip Shift During Standing

IMG_4275

Whether you are sitting behind a desk at work, attending a yoga class, or lifting weight, it is important to be aware of your body position and stop just short of end range.

4. Improve Motor Control.

Generally speaking, women have greater Q-angles (measured from hip to patella along femur) and a higher predisposition to joint laxity compared to men. Looser joints require more stability and motor control; therefore, learning better movement patterns is critical for improving long-term health and joint integrity.

For example, if you are experiencing discomfort in the front of your shoulder, one exercise you could incorporate is the standing external rotation. This is a great exercise for hypermobile individuals to increase posterior rotator cuff strength, increase shoulder stability, and improve motor control by learning how to keep the ball centered in the socket.

Regardless of what exercise you perform, in order to improve motor control you must:

a. Be present:  Eliminate distractions (e.g. texting, Facebook, etc.). If you are not focused, you will naturally fall back to your compensatory movement patterns

b. Maintain a neutral spine: It is common for hypermobile women to overextend their lower back and rely on bony stability; therefore, learning how to execute and maintain a neutral spine is important in every exercise in order to set a foundation for better alignment

c. Slow down: Perform each rep in a controlled manner, and emphasize quality over quantity.

d. Train in non-fatigued state: Be aware of how you feel, as fatigue will negatively affect your ability to learn new movement patterns

Conclusion

My personal experiences have led me to believe that hypermobility, especially for women, is more common than one might think. Creating awareness for yourself or your clients is the first step in the right direction. As Eric always says, “Assess, don’t guess.”

Happy training to all my hypermobile readers out there!

About the Author

Laura Canteri (@LC_Canteri) heads up strength camps (group training) at Cressey Sports Performance – Florida. She completed her master’s degree in exercise physiology at Florida Atlantic University, and also is Precision Nutrition certified. In addition to her work at CSP, Laura works with folks from all walks of life through her distance-based consulting. You can reach her at l.c.canteri@gmail.com. 

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Random Thoughts on Sports Performance Training: Installment 4

In light of the recent launch of The Specialization Success Guide, I feel like there have been a lot of posts on the site lately on the topic of powerlifting. With that in mind, I thought I'd shuffle things up with a bit more discussion about training in a broader sense, so let's talk some general athletic development.

1. We don't any regular barbell bench pressing with our baseball guys, and it's even pretty rare for us to use dumbbell bench pressing in their programs. This is, in part, because we want to utilize movements where the scapulae can move freely, as opposed to having them pinned down on a bench. In light of this exclusion, we're often ask: what do you do instead?

The answer, as many of you know, is landmine presses, push-up variations, and cable press variations. However, what a lot of people might not realize is that another good option is to simply replace a press with some kind of overhead hold variation, whether it's a Turkish get-up or bottoms-up carry.

One other variation I really like is the kneeling overhead hold to stand. I'll often use this with beginners who might need a little stepping stone before they get to the Turkish get-up. In addition to getting some great reflexive rotator cuff work, we're driving scapular upward rotation in a population that really needs it. Still, that doesn't mean that everyone is ready for it. Watch the video to learn more:

2. It's not uncommon at all to see medial (inside) elbow pain in lifter.s This usually comes from the tremendous amount of grip work one does in combination with lots of loaded elbow flexion. Usually, when these issues pop up, cutting back on lifting volume and modifying exercise selection is imperative.

However, what a lot of folks fail to appreciate is the impact that supplemental conditioning work can have on the overuse pattern. Just imagine how much abuse your common flexor tendon is taking when you hop on the rowing machine for 20 minutes to log a few thousand meters, or add in some barbell or kettlebell complexes. These are very grip-intensive approaches and need to be incorporated carefully - and certainly not all the time. Cycle them in, and then cycle them out.

As an example, I'm someone who deals with medial elbow irritation here and there, and most of the time, it's when I'm doing more work on the rower. As such, I've learned that one rowing session a week is really all I can handle if I'm doing my normal upper body training workload.

3. Having a good hip hinge is a huge contributor to athletic success, and to that end, we include toe touch progressions with a lot of our athletes. Without a doubt, the biggest mistake I see with athletes doing a toe touch is the substitution of knee hyperextension for hip flexion. Here's what that looks like:

photo-68

You'll notice that there really is absolutely no posterior shift of the center of mass, and he stays in plantarflexion (calves don't stretch). This is something you'll see really commonly in athletes with very hypermobile joints. I've demonstrated it before with the following video; you'll notice that this loose-jointed athlete can actually get a crazy toe touch without any sort of hip hinge, as he's blocked by the wall. Hypermobile athletes will always try to trick you!

Every time you allow them to use a faulty hip hinge pattern, you're giving them two opportunities to work themselves closer to an ACL injury. First, you're putting them in a position where the glutes can't control the femur, and where the hamstrings are too overstretched to really help stabilize the knee effectively. Second, knee hyperextension is commonly a part of the typical ACL injury mechanism (especially in contact injuries where an opponent tackles an athlete low); do we really want to be going to this dangerous end-range over and over again in our training? With that in mind, when coaching the hip hinge, you want to ensure that the athlete establishes and maintains a slight bend in the knee; the "soft knees" cue usually works well.

4. I've often heard people talk about how prone bridges (front planks) are useless if you can already do quality push-ups. While I can certainly appreciate this line of reasoning, I think it overlooks two things.

First, most people rattle through push-ups pretty quickly, so the time under tension may actually be considerably lower than what one would get on a prone bridge.

Second, you can make a prone bridge considerably more difficult via a number of different means, and my favorite is adding full exhalations on each breath. This is something that's very difficult to "sync up" with push-ups, but the benefits are excellent: more serratus anterior recruitment, better posterior tilting of the pelvis, better anterior core engagement, and relaxation of overused supplemental respiratory muscles.

So, don't rule out bridges just yet! I love them as a low-level motor control exercise at the end of a training session - and after the loaded core work (chops, lifts, etc) have been completed.

Have a random thought of your own from the past week? Feel free to post it below; I'm all ears!

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Functional Stability Training of the Upper Body: Why Do You Feel “Tight?”

When Mike Reinold and I released Functional Stability Training of the Upper Body, it quickly became our most popular product of all time. In light of this week's big sale, I thought you might like a little teaser of what to expect.  Here is an excerpt from one of my webinars, "Understanding and Managing Joint Hypermobility:"

Remember, FST-Upper - as well as Lower, Core, and the bundle package - are all on sale for 25% off this week. Just enter coupon code MLB2020EC at checkout to get the discount at www.FunctionalStability.com.

fstupper

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15 Static Stretching Mistakes

One of the most debated topics in the strength and conditioning world in recent years has been whether or not static stretching is necessary and, if so, when it should be implemented.  While I don't think everyone needs it, and that there are certainly are times when it is a bad idea to utilize, I'm still of the mindset that it can have some solid benefits when implemented properly. 

Unfortunately, like all training initiatives, some people do it all wrong. To that end, I wanted to devote today's article to covering the top 15 static stretching mistakes I encounter.

Mistake #1: Stretching through extreme laxity.

This is the most important and prevalent one of all, so it comes first.  When I see someone doing this, this is pretty much how I feel:

We're all have a different amount of congenital laxity.  Basically, this refers to how much "give" our ligaments have.  Some folks have naturally stiff joints, and others have very loose joints.  This excessively joint laxity is obviously much higher in females and younger populations, but, as Leon Chaitow and Judith DeLany discuss in Clinical Applications of Neuromuscular Techniques: Volume 1, it is also much higher in folks of African, Asian, and Arab origin.

When you take someone who is really lax and implement aggressive static stretching, it's on par with having someone with a headache bang his/her head against a wall.  It makes things worse.

This is a tricky thing to understand, though, because many of these "loose" individuals will comment on how they feel "tight."  Usually that tightness is just them laying down trigger points as a way for the body to create stability in areas where they are chronically unstable.  They'd be better off working on stability training to get back to efficient movement.

I think yoga has a tremendous amount of applications and we borrow from the discipline all the time, but I think this is where many modern yoga classes fall short; they have everyone in the class go to the same end-range on certain exercises. Folks with serious joint laxity should not only contraindicate certain yoga poses, but also modify others so that they're training stability short of the true end-range of their joints. Unfortunately, most of the people you'll see in yoga classes are hypermobile women; you see, they like to do the things they're good at doing, not necessarily what they need to do.

How do you know if you're lax, though? I like to use the Beighton hypermobility scale to assess for both generalized congenital laxity and specific laxity at a joint. The screen consists of five tests (four of which are unilateral), and is scored out of 9:

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

Beighton_Score

One of the biggest problems I see in today's strength and conditioning world is that we assume all "big, strong" athletes are tight and need aggressive stretching.  As an example, take a look at this high Beighton score in a 6-3, 240-pound athlete.  We do very little static stretching with him - and absolutely none in the upper body.

If someone is really lax, nix the static stretching and instead spend more time on stabilization work.  If they still feel like they need to "loosen up," tell them to do some extra foam rolling.  They'll transiently reduce some of the stiffness they're feeling, but they won't be working through harmful end-range joint range-of-motion in the process.

Mistake #2. Substituting knee hyperextension for hip flexion in hamstrings stretches.

This comment piggybacks a little bit on mistake #1, as lax individuals (who probably shouldn't be stretching their hamstrings, anyway) are the most likely to have problems with this.  Because the hamstrings are two-joint muscles (knee and hip), folks will often allow the knee to "give" extra because they are subconsciously trying to avoid an uncomfortable stretch at the hip - or they simply aren't paying attention.  These are the same folks who have terrible hip hinges on toe touch tests, yet can touch their toes without a problem; they just go to knee hyperextension to make it happen.  As an example, this particular athlete scores really high on the Beighton hypermobility score, and he can actually put his palms flat on the floor with little to no posterior weight shift (the wall blocks him). 

How does he do it? Knee hyperextension. 

We'd much rather get a good hip hinge without resorting to excessive joint range of motion at the knee. You get good at what you train, so if you're always doing your static stretching in a bad position, you're going to be more likely to wind up in knee hyperextension on the field - and that's where ACL injuries occur.

Mistake #3: Not creating stiffness at adjacent joints.

In a previous post, I talked about why stiffness can be a good thing, in spite of the negative connotation of the word.  Stiffness is a crucial part of keeping us healthy and enhancing athleticism.  "Good" stiffness allows us to overpower "bad" stiffness that's occurring in the wrong places, and it helps to transfer force as part of the kinetic chain.  Static stretching can either be an opportunity to foster good stiffness or develop bad habits.

You see, we static stretch to transiently reduce stiffness (or true tissue shortness).  However, if we don't stabilize (stiffen up) adjacent joints, it defeats the purpose. Let me give you an example.

Let's say that I want to stretch my hamstrings in the supine position with not just a neutral position (center), but also a bias toward internal rotation/adduction (left) and external rotation/abduction (right).


 



 

 

Now, let's see what happens to these stretches if one doesn't engage the lateral core to prevent the pelvis from rolling toward the direction of the stretch on the ones that go out to the sides.

Mistake #4: Irritating the medial aspect of the knee with 90/90 hip stretches.

Most folks are familiar with doing 90/90 hip stretches or cradle walks as a way to improve hip external rotation in a position of hip flexion.  This is the position I commonly see people using at the point of maximal stretch:

The problem is that many folks crank excessively on the medial aspect of the knee by rotating the tibia (lower leg) instead of the femur (upper leg).  This actually parallels what happens during a McMurray's Test for medial meniscus pathology:

It's a pretty safe bet that static stretching into a position that replicates a provocative test is never a good idea - and it's one reason we use 90/90 stretches very sparingly.  If you are going to use this stretch, however, I recommend that individuals grab the quadriceps on the stretching side to ensure that the majority of the pull into external rotation and flexion comes from the femur and not the tibia.  The opposite hand is simply there to support the weight of the lower leg.

Mistake #5: Substituting valgus stress at the knee for hip adduction/internal rotation stretching.

It's really important than folks have adequate hip internal rotation, as a loss of hip internal rotation has been correlated with low back pain, and it can certainly predispose individuals to hip and knee issues as well. The knee-to-knee stretch is a popular approach for maintaining and improving hip internal rotation, and it's also my chosen method for demonstrating how incomplete my goatee was at the time of this picture.  

lyingkneetoknee

As you can see from the picture, this position can also impose some valgus stress at the knees if it isn't coached/cued properly.  So, instead of thinking of letting the knees fall in, I tell athletes to actively internally rotate the femurs (upper leg).  The stretch should occur at the hips, not the knees.

In folks with a history of medial knee issues, we won't use this static stretch.  Rather, we'll use a kneeling glute stretch, which still gets a bit of stretch into adduction, which will still stretch several of the hip external rotators indirectly.

Lastly, keep in mind that the knee-to-knee isn't a stretch most females will ever have to utilize because of their tendency toward a knock-knee posture (wider hips = greater Q-angle) at rest.

Mistake #6: Not monitoring neutral spine during hip stretching.

This point really works hand-in-hand with #3 from above, which talked about establishing stiffness at adjacent joints.  Certainly, maintaining neutral spine falls under the category of "good stiffness," but because it's such a common mistake, it deserves attention of its own.  When the hip flexes, you shouldn't go through lumbar flexion. For this split-stance kneeling adductor stretch, notice the correct on the left and the incorrect on the right:

And, when it extends, you shouldn't go through lumbar extension.  Again, the correct is on the left, and incorrect (hyperextended) is on the right:

Mistake #7: Not monitoring neutral spine during standing stretches.

Again, this is another point that piggybacks off of establishing good stiffness, but I see a lot of people doing upper extremity stretches - overhead triceps, lats, pecs - in terrible spine posture.  Perhaps the best example is the overhead triceps stretch with the lumbar spine in hyperextension, plus forward head posture further up.

Mistake #8: Stretching your lower back.

There may be times when a qualified manual therapist might want to do some mobilizations on your lower back. The rest of you really shouldn't be stretching your spine out. Stretch your hips, and mobilize your thoracic spine (upper back), where it's much safer for you to move. Focus on building up some core stability.

Mistake #9: Stretching your calves – and then wearing high heels the rest of the day.

There's nothing wrong with the "stretching your calves" part; it's the high heels part that makes me want to bang my head against the wall. Talk about a dog chasing its tail!

Mistake #10: Stretching a throwing shoulder into extension and/or external rotation (and creating valgus stress at the elbow in the process).

I devoted an entire video to this topic last week in my baseball-specific newsletter:

Mistake #11: Stretching through pain or neurological symptoms.

I honestly can't think of a single reason why anyone should ever stretch oneself through pain. Sure, there may be times when physical therapists may push a post-operative joint through some uncomfortable ranges of motion, but that's a trained professional making a educated decision.  You stretching yourself through pain is just throwing a bunch of s**t on the wall to see what sticks.  Don't do it.

Sometimes, an indirect approach is better.  As an example, there is research demonstrating that core stability exercises can transiently and chronically improve hip internal rotation - even without stretching the joint.  If you're hurting while stretching, see a qualified medical professional to help you devise a plan to work around the issue while reducing your symptoms.

On the topic of neurological symptoms, as an example, intervertebral disc issues with radicular symptoms into the legs may be exacerbated by stretching the hamstrings.  Similar issues can come about if folks with thoracic outlet syndrome perform aggressive upper body stretching. If nerves aren't gliding the way that they need to be, the last thing you want to do is yank on them.

Mistake #12: Not tightening the glutes during hip flexor stretches.

I've written previously at length about how anterior (front) hip irritation is often caused the head of the femur (ball) gliding forward in the acetabulum (socket) during hip extension.  This femoral anterior glide syndrome (described in detail here), was originally introduced by physical therapist Shirley Sahrmann.  Effectively, the hamstrings have a "gross" hip extension pull - meaning that they don't have a whole lot of control over the head of the femur.  Therefore, we need to have great gluteus maximus contribution to hip extension, as the glute max posteriorly pulls the femoral head back during hip extension so that the anterior hip capsule doesn't get irritated.

What we don't consider, however, is that if we stretch a hip into hip extension (osteokinematics), we also need that glute contribution to control the glide (arthrokinematics) of the femoral head.  This is a definite parallel to what I described earlier with respect to stretching a throwing shoulder into extension or external rotation; you don't just want to do it carelessly. As such, whenever you stretch the hip into extension, make sure that you tighten up the glute:

Mistake #13: Stretching into a bony block.

There are a lot of things that may limit range of motion at a joint.  It could be muscular shortness/stiffness, capsular tightness, muscular bulk, swelling, or guarding due to injury.  In many cases, though, it simply has to do with the congruency of the bones (or lack thereof) at a joint.

In the case of a "fresh" bone spur or loose body at the posterior aspect of the elbow, aggressively stretching into extension could easily provoke symptoms.  Conversely, I've seen some elbows with flexion contractures that are a combination of bony blocks and subsequent tissue shortening and capsular tightening that can be stretched until the cows come home with no problem. 

Each case is unique - but at the end of the day, remember that you're better off being too tight than too loose.  In other words, if you're unsure about something, don't stretch it.

Beyond just reactive changes like bone spurs and loose bodies, we also have folks who simply have different congenital or acquired bone structures.  Many individuals have retroverted (externally rotated) or anteverted (internally rotated) femoral carrying angles.  Those in retroversion will lack hip internal rotation no matter how much you stretch them, and those in anteversion aren't going to be gaining external rotation no matter what you do.  Trying to power through these bony blocks will likely create hip discomfort as well.

We also see retroversion as an adaptation in throwing shoulders, where bones "warp" to allow for more lay-back during the extreme cocking phase of throwing.  This is why most throwers will have significantly less internal rotation on the throwing shoulder than on the non-throwing shoulder in-spite of the fact that they have symmetrical total motion (IR + ER) from side to side; they simply shift their arc.

Before you stretch, you better find out if it's bone or soft tissue that is limiting you at end-range.  If it's bone, you're better off leaving things alone.

Mistake #14: Putting the band behind your head during hamstrings stretching.

This one drives me bonkers.  It screams "I know stretching isn't hard to do, but I'm still too lazy to put any semblance of effort into doing it correctly."  Why create forward head posture and neck stress when stretching the hamstrings?

Mistake #15: Not monitoring your breathing.

Nowadays, I'd say that we do just as much "positional breathing drills" as we do actual stretches. The more I learn (particularly from the Postural Restoration Institute school of thought), the more I realize that breathing in specific positions can have a dramatic effect on reducing tissue stiffness. For instance, here is one that many of our right-handed pitchers do. 

The left femur is internally rotated and adducted, the left rib flare is "tucked," right thoracic rotation is encouraged, the lumbar spine is flat, and the right shoulder blade is fully upwardly rotated with a bit of upper trap activation. We cue the athlete to inhale through the nose without allowing the rib cage to "fly up," and then encourage him to exhale fully, allowing the ribs to "come down."

We stretch to reduce tone, not increase it - and most athletes are in a constant state of inhalation, which corresponds to a big anterior pelvic tilt and lordotic curve. 

APT-250x300

When the rib cage flies up like this, we lose our Zone of Apposition (ZOA), a term the PRI folks have coined to describe the region into which our diaphragm must expand to function.

Zone-of-Apposition-300x220

In this extended posture, rather than effectively use their diaphragm, athletes will overuse supplemental respiratory muscles like lats, sternocleidomastoid, scalenes, and pec minor - and these are all areas where we're always trying to reduce tone.

Teaching athletes how to control their breathing during stretching - and paying particular attention to fully exhaling on each breath - goes a long way to help reduce sympathetic nervous system stimulation, get rid of unwanted tone in the wrong places, effective favorable changes to posture, and make the most of the stretches you're prescribing.  I think the folks in the yoga and Pilates worlds have done a good job of drawing attention to the importance of breathing, and we should appreciate that with respect to how static stretching and dynamic flexibility drills are implemented.

Conclusion

There are really only 15 mistakes that were right on the tip of my tongue - to the tune of 2,800 words!  To reiterate, I have a lot of clients/athletes who do absolutely no static stretching, but that's not to say that it can't be of benefit to a good chunk of the population.  Just remember that each body is unique, so no two static stretching programs should be alike in terms of exercise selection and coaching cues. 

If you benefited from this article, please share it via Facebook or Twitter, as this is a very misunderstood topic in the world of health and human performance.  Thanks for your support!

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