By Eric Cressey

Although each of the four muscles of the rotator cuff contributes to humeral motion, their primary function is stabilization of the humeral head in the glenoid fossa of the scapula during this humeral motion. Ligaments provide the static restraints to excessive movement, while the rotator cuff provides the dynamic restraint. It's important to note, however, that even if your rotator cuff is completely healthy and functioning optimally, you may experience scapular dyskinesis, shoulder, upper back, and neck problems because of inadequate strength and poor tonus of the muscles that stabilize the scapula. After all, how can the rotator cuff be effective at stabilizing the humeral head when its foundation (the scapula) isn't stable itself? Therefore, if you're looking to eliminate weak links at the shoulder girdle, your best bet is to perform both rotator cuff and scapular stabilizer specific work. In my experience, the ideal means of ensuring long-term rotator cuff health is to incorporate two external rotation movements per week to strengthen the infraspinatus and teres minor (and the posterior deltoid, another external rotator that isn't a part of the rotator cuff). On one movement, the humerus should be abducted (e.g. elbow supported DB external rotations, Cuban presses) and on the other, the humerus should be adducted (e.g. low pulley external rotations, side-lying external rotations). Granted, these movements are quite basic, but they'll do the job if injury prevention is all you seek. Then again, I like to integrate the movements into more complex schemes (some of which are based on PNF patterns) to keep things interesting and get a little more sport-specific by involving more of the kinetic chain (i.e. leg, hip, and trunk movement). On this front, reverse cable crossovers (single-arm, usually) and dumbbell swings are good choices. Lastly, for some individuals, direct internal rotation training for the subscapularis is warranted, as it's a commonly injured muscle in bench press fanatics. Over time, the subscapularis will often become dormant – and therefore less effective as a stabilizer of the humeral head - due to all the abuse it takes.

Last week, I was fortunate enough to get a free copy of Mike Robertson and Bill Hartman’s 2008 Indianapolis Performance Enhancement Seminar DVD Set. To be honest, the word “fortunate” doesn’t even begin to do the product justice; it was the best industry product I’ve watched all year.

The DVD set is broken up into six separate presentations:

1. Introduction and 21^st Century Core Training

2. Creating a More Effective Assessment

3. Optimizing Upper Extremity Biomechanics

4. Building Bulletproof Knees

5. Selecting the Optimal Method for Effective Flexibility Training

6. Program Design and Conclusion

To be honest, I’ve already seen Mike Robertson deliver the presentations on DVDs 1 and 4 a few times during seminars at which we’ve both presented, so more of my focus in this review will be on Bill’s presentations because they were more “new” to me. That said, I can tell you that each time I’ve seen Mike deliver there presentations, he’s really impressed the audience and put them in a position to view training from a new (and better) paradigm, debunking old myths along the way. A lot of the principles in his core training presentation mirror what we do with our clients – and particularly with those involved in rotational sports.

Bill’s presentation on assessments is excellent. I think I liked it the most because it really demonstrated Bill’s versatility in that he knows how to assess both on the clinical (physical therapy) and asymptomatic (ordinary client/athlete) sides of the things. A few quick notes from Bill’s presentation that I really liked:

a. Roughly 40% of athletes have a leg length discrepancy – but that’s not to say that 40% of athletes are injured or even symptomatic. As such, we need to understand that some asymmetry is normal in many cases – and determining what is an acceptable amount of asymmetry is an important task. As an example, in my daily work, a throwing shoulder internal rotation deficit (relative to the non-throwing shoulder) of 15 degrees or less is acceptable – but if a guy goes over 15°, he really needs to buckle down on his flexibility work and cut back on throwing temporarily. If he is 17-18° or more, he shouldn’t be throwing – period.

b. It’s important to consider not only a client/patient/athlete looks like on a “regular” test, but also under conditions of fatigue. There’s a reason athletes get hurt more later in games: fatigue changes movement efficiency and safety! This is why many tests should include several reps – and we should always be looking to evaluate players “on the fly” under conditions of fatigue.

c. Bill made a great point on “functional training” during this presentation as well – and outlined the importance difference between kinetics (incorporates forces) and kinematics (movement independent of forces). Most functional training zealots only look at kinematics, and in the process, ignore the amount of forces in a dynamic activity. For example, being able to execute a body weight lateral lunge with good technique doesn’t guarantee that you’ll be “equipped” to handle change-of-direction challenges at game speed. In reality, this force consideration is one reason why there are times that bilateral exercise is actually more function than unilateral movements!

d. Bill also outlined a multi-faceted scoring system he uses to evaluate athletes in the context of their sports. It’s definitely a useful system for those who want a quantifiable scheme through which to score athletes on overall strength, speed, and flexibility qualities to determine areas that warrant prioritization.

DVD #3 is an excellent look at preventing and correcting shoulder problems – and in terms of quality, this presentation with Mike is right on par with their excellent Inside-Out DVD. Mike goes into depth on what causes most shoulder problems and how we can work backward from pathology to see what movement deficiency – particularly scapular downward rotation syndrome – caused the problem. There is a great focus on lower trapezius and serratus anterior strengthening exercises and appropriate flexibility drills for the pec minor, levator scapulae, and thoracic spine – as well as a focus on the effects of hip immobility and rectus abdominus length on upper body function.

To be honest, I think that DVD #4 alone is worth far more than the price of the entire set. It actually came at an ideal time for me, as I’m preparing our off-season training templates for our pro baseball guys – and flexibility training is a huge component of this. Whenever I see something and it really gets me thinking about what I’m doing, I know it’s great. Bill’s short vs. stiff discussion really did that for me.

Bill does far more justice to the discussion than I can, but the basic gist of the topic is that the word “tight” doesn’t tell us much at all. A short muscle actually has lost sarcomeres because it’s been in a shortened state for an extended period of time; this would be consistent with someone who had been immobilized post-surgery or a guy who has just spent way too long at a computer. These situations mandate some longer duration static stretching to really get after the plastic portion of connective tissue – and this can be uncomfortable, but highly effective.

Conversely, a stiff muscle is one that can be relatively easily lengthened acutely as long as you stabilize the less stiff segment. An example would be to stabilize the scapula when stretching someone into humeral internal or external rotation. If the scapular stabilizers are weak (i.e., not stiff), manually fixing the scapula allows us to effectively stretch the muscles acting at the humeral head. If we don’t stabilize the less-stiff joint, folks will just substitute range of motion there instead of where we actually want to create it. In situations like this, in addition to good soft tissue work, Bill recommends 30s static stretches for up to four rounds (this is not to be performed pre-exercise, though; that’s the ideal time for dynamic flexibility drills.

DVD #5 is where Mike is at his best: talking knees. This is a great presentation not only because of the quality of his information, but also because of his frame of reference; Mike has overcome some pretty significant knee issues, including a surgery to repair a torn meniscus. Mike details the role of ankle and hip restrictions in knee issues, covers the VMO isolation mindset, and outlines some of the research surrounding resistance training and rehabilitation of knee injuries in light of some of the myths that are abundant in the weight-training world.

DVD #6 brings all these ideas together with respect to program design.

I should also mention that each DVD also includes the audience Q&A, which is a nice bonus to the presentations themselves. The production quality is excellent, with “back-and-forths” between the slideshow and presenters themselves. Bill and Mike include several video demonstrations in their presentations to break up the talking and help out the visual learners in the crowd, too.

All in all, this is a fantastic DVD set that encompasses much more than I could ever review here. In fact, if it’s any indicator of how great I think it is, I’m actually going to have all our staff members watch it. If you train athletes or clients, definitely get it. Or, if you’re just someone who wants to know how to keep knees, shoulders, and lower backs healthy while optimizing flexibility, it’s worth every penny. You can find out more at the Indianapolis Performance Enhancement Seminar website.

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Random Friday Thoughts: 7/25/08

Training around Knee Pain

Willing and Abele

All the Best,

EC

On Monday night, Josh Hamilton put on an amazing show with 28 homeruns in the first round of the MLB Homerun Derby. While he went on to lose to Justin Morneau in the finals of the contest, Hamilton did smash four 500+ ft. shots - and stole the hearts of a lot of New York fans. It's an incredible story; Hamilton has bounced back from eight trips to rehabilitation for drugs and alcohol to get to where he is today.

Geek that I am, though, I spent much of the time focusing on the incredible hip rotation and power these guys display on every swing. According to previous research, the rotational position of the lead leg changes a ton from foot off to ball contact. After hitting a maximal external rotation of 28° during the foot off “coiling” that takes place, those hips go through some violent internal rotation as the front leg gets stiff to serve as a “block” over which crazy rotational velocities are applied.

How crazy are we talking? How about 714°/s at the hips? This research on minor leaguers also showed that stride length averaged 85cm - or roughly 380% of hip width. So, you need some pretty crazy abduction and internal rotation range-of-motion (ROM) to stay healthy. And, of course, you need some awesome deceleration strength – and plenty of ROM in which to apply it – to finish like this.

Meanwhile, players are dealing with a maximum shoulder and arm segment rotational velocities of 937°/s and 1160°/s, respectively. All of this happens within a matter of 0.57 seconds. Yes, about a half a second.

These numbers in themselves are pretty astounding – and probably rivaled only by the crazy stuff that pitchers encounter on each throw. All these athletes face comparable demands, though, in the sense that these motions take a tremendous timing to sequence optimally. In particular, in both the hitting and pitching motions, the hip segment begins counterclockwise (forward) movement before the shoulder segment (which is still in the cocking/coiling phase). Check out this photo of Tim Hudson (more on this later):

Many of you have probably heard about a “new” injury in major league baseball – oblique strains – which have left a lot of people looking for answers. In fact, the USA Today published a great article on this exact topic earlier this season. Guys like Hudson, Chris Young, Manny Ramirez, Albert Pujols, Chipper Jones and Carlos Beltran (among others) have dealt with this painful injury in recent years. You know the best line in this entire article? With respect to Hudson:

“After the 2005 season, he stopped doing core work and hasn't had a problem. Could that be the solution?”

I happen to agree with the mindset that some core work actually contributes to the dysfunction – and the answer (to me, at least) rests with where the injury is occurring: “always on the opposite side of their throwing arm and often with the muscle detaching from the 11th rib.” If I’m a right-handed pitcher (or hitter) and my left hip is already going into counter-clockwise movement as my upper body is still cocking/coiling in clockwise motion – both with some crazy rotational velocities – it makes sense that the area that is stretched the most is going to be affected if I’m lacking in ROM at the hips or thoracic spine.

I touched on the need for hip rotation ROM, but the thoracic spine component ties right into the “core work” issue. Think about it this way: if I do thousands of crunches and/or sit-ups over the course of my career – and the attachment points of the rectus abdominus (“abs”) are on the rib cage and pelvis – won’t I just be pulling that rib cage down with chronic shortening of the rectus, thus reducing my thoracic spine ROM in the process?

Go take another look at the picture of Tim Hudson above. If he lacks thoracic spine ROM, he’s either going to jack his lower back into lumbar hyperextension and rotation as he tries to “lay back” during the late cocking phase, or he’s just going to strain an oblique. It’s going to be even worse if he has poor hip mobility and poor rotary stability – or the ability to resist rotation where you don’t want it.

Now, I’m going to take another bold statement – but first some quick background information:

1. Approximately 50-55% of pitching velocity comes from the lower extremity.

2. Upper extremity EMG activity during the baseball swing is nothing compared to what goes on in the lower body. In fact, Shaffer et al. commented, “The relatively low level of activity in the four scapulohumeral muscles tested indicated that emphasis should be placed on the trunk and hip muscles for a batter's strengthening program.”

So, the legs are really important; that 714°/s at the hips has to come from somewhere. And, more importantly, it’s my firm belief that it has to stay within a reasonable range of the shoulder and arm segment rotational velocities of 937°/s and 1160°/s (respectively). So, what happens when we give a professional baseball player a foo-foo training program that does little to build or even maintain lower-body strength and power? And, what happens when we have that player run miles at a time to “build up leg strength?” How many marathoners do you know who throw 95mph and need those kind of rotational velocities or ranges of motion? Apparently, bigger contracts equate to weaker, tighter legs…

Meanwhile, guys receive elaborate throwing programs to condition their arms – and they obviously never miss an upper-body day (also known as a “beach workout"). However, the lower-body is never brought up to snuff – and it lags off even more in-season when lifting frequency is lower and guys do all sorts of running to “flush their muscles.” The end result is that the difference between 714°/s (hips) and 937°/s and 1160°/s (shoulders and arms) gets bigger and bigger. Guys also lose lead-leg hip internal rotation over the course of the season if they aren’t diligent with their hip mobility work.

So, in my opinion, here’s what we need to do avoid these issues:

1. Optimize hip mobility – particularly with respect to hip internal rotation and extension. It is also extremely important to realize the effect that poor ankle mobility has on hip mobility; you need to have both, so don’t just stretch your hip muscles and then walk around in giant high-tops with big heel-lifts all day.

2. Improve thoracic spine range of motion into extension and rotation.

3. Get rid of the conventional “ab training/core work” and any yoga or stretching positions that involve lumbar rotation or hyperextension and instead focus exclusively on optimizing rotary stability and the ability to isometrically resist lumbar hyperextension.

4. Get guys strong in the lower body, not just the upper body.

5. Don’t overlook the importance of reactive work both in the lower and upper-body. I’ve read estimates that approximately 25-30% of velocity comes from elastic energy. So, sprint, jump, and throw the medicine balls.

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I’ll be making my Fenway Park debut on Saturday. I know it’s hard to believe, but it won’t be for my catching abilities, base-stealing prowess, or 95-mph two-seam fastball. Rather, I’ll be speaking on a panel at the annual Fenway Park Fantasy Day to benefit The Jimmy Fund. And, if people don’t give a hoot about listening to me, they’ve got a skills zone with batting cages, a fast-pitch challenge, and accuracy challenge on top of loads of contests and tours. I’ll be sure to snap some photos for you.

This is an absolutely great cause, and while I know most of you won’t be in attendance, I’d highly encourage you to support the cause with a donation to the Jimmy Fund. What they are doing is something very special, and I’m honored to be a part of it.

A: Thanks for the email.  It really depends on whether you're dealing with someone who just has an accentuated kyphotic curve or someone who actually has some sort of clinical pathology (e.g. osteoporosis, ankylosing spondylitis, Cushing’s Syndrome) that's causing the "hump."  In the latter case, you obviously need to be very careful with exercise modalities and leave the “correction” to those qualified to deal with the pathologies in question.

In the former case, however, there’s quite a bit that you can do. You mentioned using a foam roller as a “prop” around which you can do thoracic extensions:

Thoracic Extensions on Foam Roller

While some people think that tractioning the thoracic spine in this position is a bad idea, I don’t really agree. We’ve used the movement with great success and absolutely zero negative feedback or outcomes.

With most of these exercises, you’re using motion of the humerus to drive scapular movement and, in turn, thoracic spine movement.

The importance of t-spine rotation again rang true earlier this week when I had lunch with Neil Rampe, director of corrective exercise and manual therapy for the Arizona Diamondbacks. Neil is a very skilled and intuitive manual therapist, and he had studied extensively (and observed) the effect of respiration. He made some great points about how we can’t get too caught up in symmetry. Neil noted that we’ve got a heart in the upper left quadrant, and a liver in the lower right. The left lung has two lobes, and the right lung has three – and there’s some evidence to suggest that folks can usually fill their left lung easier than their right. The right diaphragm is bigger than the left –and it can use the liver for “leverage.” The end result is that the right rib winds up with a subtle internally rotated position, which in turns affects t-spine and scapular positioning. Needless to say, Neil is a smart dude – and once I got over how stupid I felt – I started scribbling notes. I’m going to be looking a lot more at breathing patterns as a result of this lunch.

Additionally, it’s very important to look at the effects of hypomobility and hypermobility elsewhere on thoracic spine posture. If you’re stuck in anterior pelvic tilt with a lordotic spine, your t-spine will have to compensate by rounding in order to keep you erect. And, if you’ve shortened your pecs and pulled the scapulae into anterior tilt and protraction, you’ll have a t-spine that’s been pulled into flexion. Or, if you’ve done thousands and thousands of crunches, chances are that you’ve shortened your rectus abdominus so much that your rib cage is depressed to the point of pulling you into a kyphotic position.

On the hypermobility front, poor rotary stability at the lumbar spine can lead to excessive movement at a region of the spine that really isn’t designed to move. It’s one reason why I like Jim Smith’s Combat Core product so much; he really emphasize rotary stability with a lot of his exercises. Lock up the lumbar spine a bit, and you’ll get more bang for your buck on the t-spine mobilizations.

As valuable as all the t-spine extension and rotation drills can be, they are – when it really comes down to it – just mobility drills. And, to me, mobility drills yield transient effects that must be sustained and complemented by appropriate strength and endurance of surrounding musculature. Above all else, strength of the appropriate scapular retractors (lower and middle trapezius) is important. You can be very strong in horizontal pulling – but have terrible posture and shoulder pain – if you don’t row correctly.

Not being cognizant of head and neck position can lead to a faulty neck pattern:

Cervical hyperextension (Chin Protrusion) Pattern

Here, little to no scapular retraction takes place. And, whatever work is done by the scapular retractors comes from the upper traps and rhomboids – not what we want to hit.

Then, every gym has this guy. He just uses his hip and lumbar extensors to exaggerate his lordotic posture and avoid using his scapular retractors at all costs.

Another more common, but subtle technical flaw is the humeral extension with scapular elevation. Basically, by leaning back a bit more, an individual can substitute humeral extension for much of the scapular retraction that takes place – so basically, the lats and upper traps are doing all the work. This can be particularly stressful on the anterior shoulder capsule in someone with a scapula that sits in anterior tilt because of restrictions on pec minor, coracobrachialis, or short head of the biceps. Here is what that issue looks like when someone is upright like they should be. A good seated row would like like this last one – but with the shoulder blades pulled back AND down. We go over a lot of common flaws like these in our Building the Efficient Athlete DVD series.

Finally, don’t overlook the role that soft tissue quality plays with all of this. Any muscle – pec minor, coracobrachialis, short head of the biceps – that anteriorly tilts the scapulae can lead to these posture issues. Likewise, levator scapulae, scalenes, subclavius, and some of the big muscles like pec major, lats, and teres major can play into the problem as well. I’ve always looked at soft tissue work as the gateway to corrective exercise; it opens things up so that you can get more out of your mobility/activation/resistance exercise.

Hopefully, this gives you some direction.

I had a new article published on Tuesday at T-Nation; be sure to check out The Prehab Deload.

You can never get enough Hartman…

Earlier this week, Bill Hartman provided us with seven great tips; here are eight more than certainly won’t disappoint!

8. Unilateral lower body training is well accepted, but unilateral upper body training is no less valuable and gets ignored by most trainers and coaches. It’s not uncommon for strength and conditioning coaches to recommend unilateral lower body exercises in an effort to maintain functional relationships in the trunk and hips. There are equally if not more important relationships between the upper extremity, the trunk, and the hips. Consider working toward developing the ability to perform a single-arm push-up as much as you develop your single-leg strength. It will go a long way toward maintaining your shoulder health and improve your performance.

9. It is a rare occasion that athletes needs complex training programs. Most athletes, regardless of level, are not well-trained strength athletes. Just as many HATE supplementary strength/performance training and don’t understand the value that it provides by allowing them to perform at their highest levels of performance. They would rather just play their sport. The exceptions are those athletes who have spent 3 to 4 years in a progressive, controlled, and properly designed strength program. Being advanced in a particular sport does not mean they are advanced in regard to supplementary training. When in doubt simplify.

10. If you choose to emphasize bench pressing in your training program, you need to spend more time strengthening your lower trapezius and rotator cuff.

The lower trapezius tends to be the weak point in your ability to stabilize the scapula and the rotator cuff is the big stabilizer for the glenohumeral joint. It is the ability to stabilize these areas that allows the larger prime movers to lift big weights. If these muscles don’t keep pace, your bench press will stall and you will most likely get injured.

11. Stand more and sit less. If you’re sitting on your ass, you’re not using it. If you’re not using it, you’ll forget how to use it when you train or play a sport. This can result in lower back pain, hip pain, or pain anywhere down the kinetic chain. You’ll also go a long way to prevent the loss of hip motion that will increase joint wear and tear and rob you of your athleticism at a premature age.

12. I recommend four recovery/restoration tools for everyone: sleep, food, soft-tissue work, and ice because they work for everyone.

I know a lot of things that have been used as recovery tools with world-class athletes. Most people are not world-class athletes and I question the value of many restorative tools. I’ve never been able to identify a measurable effect from something like a contrast shower other than shrinkage (you know what I mean). However, the four tools I recommend will apply to everyone.

Sleep is essential. The nervous system needs sleep to function at top efficiency. Food provides energy, reparative materials, and nutrient-based recovery. Soft-tissue work, whether it be massage, foam rolling, ART, or whatever, will maintain a more optimal condition of the soft-tissues. Trigger point, adhesions, and scar tissue affects mobility, tissue extensibility, and the ability to produce strength. An ounce of prevention goes a long way to assure optimal functional relationship between and within muscles and groups of muscles. Ice is under utilized by just about everyone. It is inexpensive and will go a long way to preserve your joint surface. Fifteen minutes of ice to heavily trained joints has been shown to have a preservation effect on joint cartilage.

13. Make your icing more effective by periodically moving the joint or muscle to which you’re applying ice. It promotes a more uniform application of the cold to the affected area. After you remove the ice, limit the motion of the affected area to preserve the cooling effect, as movement will increase rewarming.

14. Hip mobility affects more than you think. A lack of hip mobility will promote overuse of the lumbar spine to compensate for the lack of mobility. In patients with unilateral shoulder instability, almost half of those patients also showed poor hip mobility on the opposite side.

15. There are “money muscles” in almost every type of injury that when treated or activated immediately improve function. For shoulders, it’s the subscapularis. The subscapularis prevents the humeral head from moving forward and upward into the acromion in cases of impingement. Many times it’s overused due to repetitive movement, heavy loading, or both. Get it functioning again (ART does wonders) immediately restores shoulder function in a majority of cases.

For lower back pain, it’s the psoas. If someone has trouble forward flexing AND extending the spine (you can also see that they limit hip extension when they walk) check the psoas for spasm or adhesions. Restoring normal psoas function immediately restores spinal range of motion.

For lower back pain, it’s the psoas. If someone has trouble forward flexing AND extending the spine (you can also see that they limit hip extension when they walk) check the psoas for spasm or adhesions. Restoring normal psoas function immediately restores spinal range of motion.

For the knee, it’s the popliteus. Many times when rehabbing an athlete or patient with a knee injury, there’s sense of residual instability. Rather than going for the wobble board, consider checking the function of the popliteus. The popliteus assists in rotatory control of the knee. Restoring the popliteus function with soft-tissue work and a little strengthening often restores stability in no time.

I’m off to Maine to lift some heavy stuff and see the family. Have a great weekend, everyone!

EC

Yesterday morning, Tony Gentilcore and I got out to the local track to do some sprinting work.  After we had wrapped up our 45-minute session, as we walked off the track, we noticed a 20-something year-old female runner on the ground banging out crunches in what we estimated were sets of 800.

What caught my eye even more than her elite training protocol  (insert sarcastic smirk here), though, was a knee brace so large that it looked like a giant octopus had devoured her leg.  Geek that I am, I started pondering things over.

Most people would say that she’s probably got an overuse injury from all the running.  I wouldn’t disagree.

To take it a step further, though I immediately started thinking about why she had a dysfunction/ imbalance that could be predisposing her to pain with all that running.

Think about what happens with a crunch: trunk flexion.

In most cases, when we round over at the upper back, as a compensation to keep us upright, the lumbar spine tends to become more lordotic – meaning that the natural lumbar arch is exaggerated.  Go to a more lordotic position, and you’ll “trigger” an increased amount of anterior pelvic tilt (associated with shortening/tightness of the hip flexors, including the rectus femoris, psoas, iliacus, tensor fascia latae, among others).

We know that the hip flexors play a very important role in knee health; the rectus femoris actually attaches to the patella, too.   In addition to the pull these muscles have on the leg, they also tend to force one into anterior weight-bearing (already a problem in most females, thanks to evolution and high-heeled shoes).

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And, to add on the above points, you can ignore the value of that mobility and activation work when it comes to preventing injury.  Many times, form will start to break down with some of the longer time-under-tension prescriptions in more metabolically demanding resistance training protocols.  When you get things firing the way they should, you immediately make these complexes and circuits safer.