Getting Geeky with AC Joint Injuries
Lately, I've gotten quite a few in-person evaluations and emails relating to acromioclavicular (AC) joint issues. As such, I figured I'd devote a newsletter to talking about why these injuries are such a pain in the butt, what to do to train around them, and how to prevent them in the first place (or address the issue once it's in place).
First off, there is a little bit about the joint that you ought to know. While the glenohumeral joint (ball-and-socket) is stabilized by a combination of ligamentous and muscular (rotator cuff) restraints, the AC joint doesn't really have the benefit of muscles directly crossing the joint to stabilize it. As such, it has to rely on ligaments almost exclusively to prevent against "shifting."
As you can imagine, then, a traumatic injury or a significant dysfunction that affects clavicle positioning can easily make that joint chronically hypermobile. This is why many significant traumatic injuries may require surgery. While almost all Grade 4-6 separations are treated surgically, Grades 1-2 separations are generally left alone to heal - with Grade 3 surgeries going in either direction.
In many cases, you'll actually see a "piano key sign," which occurs when the separation allows the clavicle to ride up higher relative to the acromion. Here's one I saw last year that was completely asymptomatic after conservative treatment. It won't win him any beauty contests, and it may become arthritic way down the road, but for now, it's no problem.
Now that I've grossed you out, let's talk about how an AC joint gets injured. First, we've got traumatic (contact) injuries, and we can also see it in people who bench like this:
Actually, that's probably a fractured sternum, but you can probably get the takeaway point: don't bounce the bar off your chest, you weenie. But I digress...
Insidious (gradual) onset injuries occur just as frequently, and even moreso in a lifting population. Most of the insidious onset AC joint problems I've encountered have been individuals with glaring scapular instability. With lower trapezius and serratus anterior weakness in combination with shortness of pec minor, the scapula anteriorly tilts and abducts (wings out) - and you'll see that this leads to a more inferior (lower) resting posture.
In the process, the interaction between the acromion (part of the scapula) and clavicle can go a little haywire. The acromion and clavicle can get pulled apart slightly, or the entire complex can get pulled downward a bit. In this latter situation, you can also see thoracic outlet syndrome (several important nerves track under the clavicle) and sternoclavicular joint issues in addition to the AC joint problems we're discussing.
As such, regardless of whether we're dealing with a chronic or insidious onset AC joint issue, it's imperative to implement a good scapular stabilization program focusing on lower trapezius and serratus anterior to get the acromion "back in line" with the clavicle. Likewise, soft tissue and flexibility work for the pec minor can also help the cause tremendously.
Anecdotally, a good chunk of the insidious onset AC joint problems I've seen have been individuals with significant glenohumeral internal rotation deficits (GIRD). The images below demonstrate a 34-degree GIRD on the right side.
It isn't hard to understand why, either; if you lack internal rotation, you'll substitute scapular anterior tilt and abduction as a compensation pattern - whether you're lifting heavy stuff or just reaching for something. And, as I discussed in the paragraph above, a scapular dyskinesis can definitely have a negative effect on the AC joint.
Lastly, you can't ever overlook the role of thoracic spine mobility. If your thoracic spine doesn't move, you'll get hypermobile at the scapulae as a compensation - and we already know that's not good. And, as Bill Hartman discussed previously, simply mobilizing the thoracic spine can actually improve glenohumeral rotation range-of-motion, particularly in internal rotation. Inside-Out is a fantastic resource in this regard - and is on sale this week, conveniently!
So, as you can see, everything is interconnected! In part 2 of this series, I'll discuss training modifications to work around acromioclavicular joint problems and progress back to more "normal" training programs.
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All the Best,
EC
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Avoiding Tendinopathies by Reallocating Stress
In a previous newsletter, I wrote about how people become symptomatic for some musculoskeletal problem because numerous issues have collectively brought them to the threshold where pain kicks in. If you haven't read it, definitely check it out now HERE.
Basically, the gist is that injury prevention and rehabilitation programs that only address single factors aren't sufficient. You shouldn't fix a shoulder problem with just rotator cuff strengthening exercises and rest. You can't just get a massage and take some rest to get your lower back pain to go away.
In this newsletter, I highlighted how poor exercise technique - or even just faulty movement patterns in daily life - is something that can push someone to threshold. It's one of the reasons why we go to such great lengths on our Building the Efficient Athlete DVD set to outline common technique mistakes and how to correct them with over 30 common resistance-training exercises.
One quick example of how this can push an athlete over the symptom threshold (or pull that athlete back under it) is kinesiotaping. In the past two years - and particularly at the Beijing Olympics - this modality spread rapidly in the world of athletics, treating everything from the ankles up to the shoulders.
While the creators of this tape assert that it has effects on the lymphatic and circulatory systems, it's my impression that the most marked changes occur with respect to the reallocation of stress on particular tissues. I've perused all their reading materials, and nowhere do I see any claims that it reduces inflammation.
Here, then, we get support for the new (and correct) era of thinking that tendinitis is very uncommon. The -itis ending indicates an inflammatory condition, and if that was the case, some anti-inflammatories would quickly and easily take care of the overuse pain folks so commonly feel in the athletic world. Anyone who has struggled with an achilles, patellar, or supraspinatus tendinopathy will tell you that it really isn't that simple, so what gives?
The truth is that most folks are dealing with a tendinosis. The -osis ending tells us that we're dealing with a degenerative - not inflammatory - problem. Essentially, tissue loading exceeds tissue tolerance - and that means that we need to find a way to reallocate stress to ease the burden on that tissue both acutely (kinesiotaping) and chronically (appropriate movement patterns).
The difference between tendinitis and tendinosis has been highlighted at-length in the research world. Unfortunately, the correct terminology has been slow to catch on both in the medical community and lay population. As a result, many individuals underestimate the chronic nature of these problems.
In the photo above, a tape-job might help at the shoulder acutely by posteriorly tilting the scapula or altering the degree of humeral rotation to allow for safe overhead movements (less mechanical impingement of the rotator cuff on the undersurface of the acromion process of the scapula). Long-term, though, an athlete with this type of shoulder problem would need to work on scapular stability, glenohumeral range-of-motion, rotator cuff strength, and thoracic spine range-of-motion. And, of course, he'd need to ingrain these appropriate movement patterns with a resistance training program with perfect form.
Oh, and speaking of tendinopathies, it is only somewhat coincidental that I'm publishing this newsletter today: the day of the Boston Marathon. Thousands and thousands of runners who are at the brink of threshold are going to be piling 26.2 miles of volume on top of their glaring dysfunctions. I'm headed out to watch the best reality TV show in the world: the hip replacement docs in Boston are going to be busy for the rest of the week!
Q: I know that you're tops when it comes to keeping baseball guys (especially pitchers) healthy and performing at the top level. How would your approach to training baseball players in general, and pitchers more specifically, differ when working with somewhat similar athletes such as:(a) football quarterbacks(b) swimmers other than backstrokers(c) swimmers specializing in the back strokeI realize there would be obvious differences, especially for C, since that is actually the opposite of pitching, so I'd love to hear some of your general thoughts on this.
A: This is actually a great question. I guess it's one of those things you do subconsciously and then think about after the fact. I'm assuming you are referring to the shoulder and elbow demands in particular, so I'll start with that.
Training football quarterbacks and pitchers would be virtually identical in terms of demands on the hips, ankles, and shoulders. Anecdotal experience tells me that there would be a higher correlation between hip dysfunction and shoulder/elbow problems in pitchers than in quarterbacks, though.
Swimmers would be similar at the shoulder, but I don't see the same kind of correlation b/t hip and shoulder dysfunction. Obviously, though, issues like scapular stability, thoracic spine range-of-motion, and tissue quality would all be present in all three populations.
Backstrokers would have comparable scapular stabilization demands, but different glenohumeral rotation patterns. With them, you assess total shoulder rotation and go from there (this is my strategy with everyone, but it just warrants extra mention in this discussion).
Above all, you've got to realize that while you might see trends in different athletic populations, each one is still unique, so assessment tells you what you need to know. For instance, I have a few pro pitchers throwing well over 90mph, and from looking at their shoulders, you'd never know they had ever thrown a baseball in their lives. At initial testing (i.e., right after the long season ended), the total motion among my eleven pro pitchers from this past off-season ranged from 133 degrees to 186 degrees. The guy with 186 degrees actually had more external rotation (135 degrees) than the least "lax" guy had in total motion!
So, a guy with a 3/4 arm slot is going to have different adaptive changes than a guy who is more over-the-top or sidearm - and you can certainly carry those variations across the board to different throwing styles in football, and the wide variety of shoulders you'll see in a swimming population that might be proficient in more than one stroke.
Related Posts:Flexibility Deficits in PitchersThe Truth About Impingement: Part 2
Q: Recently, I've noticed that I've lost a lot of mobility/flexibility that means I can't squat with my hands close in and with a high bar like I used to, I now have to go low bar and hands almost at the collars. What stretches/mobility work would you recommend to remedy this problem? I don't think this situation's very good for my shoulder health.
A: It's a common problem, and while the solution is pretty simple, it takes a dedicated effort to regular flexibility and soft tissue work. And, you're right that it isn't very good for shoulder health; that low-bar position can really wreak havoc on the long head of the biceps.
For starters, it's important to address thoracic spine mobility. If you're rounded over at the upper back, it'll be impossible to get the bar in the right "rack" position - regardless of what's going on with the shoulder itself. The first thing I do with folks in these situations is check to make sure that they aren't doing any sit-ups or crunches, which shorten the rectus abdominus and depress the rib cage, causing a more "hunchback" posture.
After you've eliminated these exercises from their programming, you can get to work on their thoracic spine mobility with drills from Optimal Shoulder Performance; one example would be thoracic extensions on the foam roller.
As you work to regain that mobility, it's valuable to build stability within that newly acquired range-of-motion (ROM) with loads of horizontal pulling (rows) and deadlift variations.
With respect to the shoulder itself, it's important to regain lost external rotation ROM and scapular posterior tilt. As I recently wrote in "The Right Way to Stretch the Pecs," I prefer the 1-arm doorway pec stretch and supine pec minor stretches. You can find videos of both HERE - and you can expedite the process with regular foam rolling on the pecs.
In the interim, substitute front squats, overhead squats, single-leg exercises, and deadlift variations to maintain a training effect.
As you progress back to squatting, you can ease the stress on your shoulders by going with a pinky-less grip in the short-term.
That said, for many individuals, the back squat set-up may not be appropriate. These include overhead throwing athletes, those with flexion-based back pain (e.g., disc herniations), and individuals with posterior labral tears.
I'd estimate that only about 25% of Cressey Performance clients do a true back squat, but that's influenced considerably by the fact that we deal with a ton of baseball players, and I get a lot of shoulder corrective exercise cases. Instead, we do a lot of work with the giant cambered bar and safety squat bar, in addition to front squatting.
Hopefully, these recommendations get you headed in the right direction and back to squatting as soon as possible!
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In this week's "The Biggest Loser made me want to stab my eye out with a hot poker" moment, I watched what appeared to be a 1,742-pound woman attempt to do an inverted row. It was an admirable attempt, for sure, but I'm sorry to say that in all my years of coaching and writing strength and conditioning programs, I've can think of fewer than 20 females who have ever been able to perform a single good inverted row.
This isn't a knock on women; it's just that they, on average, have markedly less strength than men in the upper body. And, more importantly, the inverted row is a more advanced strength exercise than people realize - so that strength discrepancy will be more readily apparent.
As a frame of reference, here is what a good inverted row looks like:
As you can see, the chin stays tucked to keep the cervical spine (neck) in line with the rest of the body. Without that forward head posture, you're getting just the kind of scapular retraction you want. Speaking of scapular retraction, you'll also notice that the chest is going ALL THE WAY up to the bar.
There are three compensation patterns that you'll come across. To protect the innocent, I won't post videos, but rest assured that if you did a quick YouTube search for "inverted row," you'd quickly come across example of the following:
1. The Ceiling Humper: This individual will give a little tug of elbow flexion and scapular retraction to get about halfway up, and then he/she will violently thrust the crotch to the heavens. In some circles, this individual is known as "The Fish." Regardless, it isn't pretty.
2. The Scared Cat: This individual basically does a curl - including curling the wrists in - so that there is essentially everything occurring except scapular retraction. In the process, they get to the top - but in that top position, they are rounded up in a ball like - you guessed it - a scared cat. There is, however, a delightful chin protrusion/forward head posture that makes that individual believe that the movement actually took place. Unfortunately, it didn't - and this effort, too, isn't pretty.
3. The Half-Asser: This individual is the lazy cousin of the Ceiling Humper and Scared Cat. He can be found around dudes who do half pull-ups, pop their collars, and live in their parents' basements. Very simply, he (or she, for that mattter) only goes halfway up - but usually still insists on using the feet-on-the-box set-up (the most advanced progression).
Sadly, the acronym IRA was already taken, so Inverted Rows Anonymous could never get off the ground - and these issues persist. I suspect that we're looking at a $47 million government stimulus package to remedy the issue. And, as our new commander-in-chief has stated, "things are going to get worse before they get better," be prepared to observe this inverted row ignorance for quite some time before it's addressed.
For a host of better scapular stabilization exercises, check out Optimal Shoulder Performance.
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Q: I attended the baseball strength training clinic you gave in Long Island. I have a question for you about push-ups for pitchers. I am using push-ups with all player, and one of the parents has been concerned that push-ups are not good for pitchers. I was wondering if you could help me explain why push-ups are good for pitchers.
A: No problem. The two big "players" in scapular dysfunction are lower trapezius and serratus anterior. These muscles work in conjunction with the upper trapezius to upwardly rotate the scapula, which allows for safe overhead movements. Research has shown that baseball pitchers have less scapular upward rotation compared with position players and non-athletes - so it's definitely an adaptive change that we need to work to address.
Push-ups (when done correctly) can be useful for activating the serratus anterior, and as a closed-chain exercise, it has proprioceptive benefits at the shoulder girdle. Plus, you get a considerable effect in terms of core stability training, as you're resisting the effects of gravity in the "plank" position where the lumbar spine wants to slip into extension.
That said, if you're dealing with high school athletes, I'll warn you that over 90% of them (in my experience) need to be coached on how to do a push-up correctly. It isn't as simple as "just do this," as most of them will resort to incorrect technique. With a good pushup, the upper arms should be tucked to a 45-degree angle to the torso, and the athlete should actively "pull" himself down to the bottom position with the scapular retractors. The hips shouldn't sag, and there shouldn't be a forward head posture. Essentially, the chest - not the chin or hips - should get to the ground first.
We see a lot of baseball players, so a lot of these guys come to use with elbow problems. In most cases, the doctors they’ve seen have said, flat-out, “NO LIFTING WEIGHTS.” This drives me nuts for a variety of reasons:
1. They’ve still got two good legs, one good arm, and a bunch of core musculature that needs to be strong and functional.
2. This recommendation implicitly means “Stay away from personal trainers and strength coaches.” It’s probably due to the fact that there are a lot of bonehead personal trainers out there who could do more harm than good, but the truth is that these services comprise more than just lifting weights. We do a lot of mobility and activation work and self-myofascial release on the foam roller.
Collectively, #1 and #2 demonstrate that this blanket recommendation includes an insanely ignorant omission, as the majority of elbow problems can be attributed to mobility and strength deficits at the shoulder. You can train a shoulder a thousand different ways without even involving elbow motion – let alone challenging it sufficiently to cause a problem. In fact, I'd estimate that you could prevent 90% of elbow problems in baseball guys if we simply taught all of them how to sleeper stretch in their early teenage years:
I'd strongly encourage you to check out this article I wrote, where I go over the common mistakes folks make when performing the sleeper stretch.
3. This recommendation flat-out ignores the specific nature of the overwhelming majority of elbow problems in throwing athletes. Let me elaborate..
In my estimation, 95% of baseball players with elbow pain couldn’t elicit their pain in a weight room if they wanted to; seriously! The reason is that this elbow pain is typically mechanical in nature; that is, it’s only aggravated by specific activities (in their case, throwing).
Believe it or not, I have had guys do everything from pull-ups, to dumbbell bench presses, to rows, to push-ups, to grip work just days out from elbow surgery. It isn’t true in every case, but it’s definitely the majority. And, they can all get diesel in the lower body during this time period.
Some great related reading for you:
Inefficiency vs. PathologyLay Back to Throw GasSign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches
used by Cressey Performance Pitchers after they Throw!
In a 2007 study, Ellenbecker et al. compared hip internal and external rotation range-of-motion in elite baseball pitchers and elite tennis players. They noted the following:
An analysis of the number of subjects in each group with a bilateral difference in hip rotation greater than 10 degrees identified 17% of the professional baseball pitchers with internal rotation differences and 42% with external rotation differences. Differences in the elite male tennis players occurred in only 15% of the players for internal rotation and 9% in external rotation. Female subjects had differences in 8% and 12% of the players for internal and external rotation, respectively.
So, in other words, baseball pitchers were more likely to be asymmetrical than tennis players. While they both serve/pitch with one arm and push off the same-side leg. Tennis players, move a lot more in various directions. And, just as importantly, they hit backhands - so the asymmetries you see at the shoulder are less pronounced as well.
Who would have thought: moving more and doing the opposite of what you normally do is a good way to stay healthy? Yes, I'm being sarcastic. Regardless of your sport, you need to get out of your comfort zone more often if you want to stay healthy.
To learn more about the common asymmetries affecting overhead athletes and how to manage them, definitely check out the Optimal Shoulder Performance DVD set.
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Q: I have pain in the front of my shoulder just at the end of my range of motion on rows. I thought rows were the universally safe exercise when it comes to shoulder health?
A: Normally, they’re a very safe bet – but as with any exercise, if performed incorrectly (or not matched to individual tolerances), they can cause problems.
This scenario most commonly occurs when the humerus goes into end-ROM extension, but the scapula stops retracting. Generally, this early end to retraction occurs secondary to a tight pec minor, which gets people stuck in protraction and anterior tilt. When you keep forcing extension on a fixed scapula, the humeral head translates forward in the joint capsule – and you can develop anterior shoulder laxity over time. A strong subscapularis can help to resist this anterior pull.
However, if your pec minor and infraspinatus/teres minor are tight, subscapularis is weak, and you’re forcing end-range a bit too hard, it’ll irritate you sooner than later. This is why it’s so important to ensure that the shoulder blade move back AND down as you row. You’ll be in trouble if the scapula tilts anteriorly as you approach end-range.
Obviously, there are a ton of other factors at work with shoulder function, but this is a good Cliff’s Notes version to what’s going on with you.
Eric Cressey
EL: First off, thanks for agreeing to the interview. We've known each other for a number of years now. I used to always refer to you as the "Anatomy Guy." You then became know for being "The Shoulder Guy" and have since garnered another title, "The Mobility Guy." Who is Eric Cressey?
EC: Good question. As you implied, it's the nature of this industry to try to pigeonhole guys into certain professional "diagnoses." Personally, even though I specialize in athletic performance enhancement and corrective exercise, I pride myself on being pretty well-versed in a variety of areas - endocrinology, endurance training, body recomposition, nutrition, supplementation, recovery/regeneration, and a host of other facets of our industry. To some degree, I think it's a good thing to be a bit all over the place in this "biz," as it helps you to see the relationships among a host of different factors. Ultimately, I'd like to be considered a guy who is equal parts athlete, coach, and scholar/researcher.
All that said, for the more "traditional answer," readers can check out my bio.
EL: What are the three most underrated and underused exercises? Does it differ across gender?
EC: Well, I'm not sure that the basics - squats, deadlifts, various presses, pull-ups, and rows - can ever be considered overrated or overappreciated in both a male and female population.
Still, I think that single-leg exercises are tremendously beneficial, but are ignored by far too many trainers and lifters. Variations of lunges, step-ups, split squats, and single-leg RDLs play key roles in injury prevention and development of a great lower body.
Specific to females, we know that we need a ton of posterior chain work and correctly performed single-leg work to counteract several biomechanical and physiological differences. Namely, we're talking about quad dominance/posterior chain weakness and an increased Q-angle. Increasing glute and hamstrings strength and optimizing frontal plane stability is crucial for resisting knock-knee tendencies and preventing ACL tears. If more women could do glute-ham raises, the world would be a much better place!
EL: What common issues do you see with female trainees in terms of muscular or postural imbalances that may predispose them to some kind of injury if not corrected? How would you suggest they be corrected or prevented?
EC: 1. A lack of overall lower body strength, specifically in the glutes and hamstrings; these shortcomings resolve when you get in more deadlifts, glute-ham raises, box squats, single-leg movements, etc.
2. Poor soft-tissue quality all over; this can be corrected with plenty of foam rolling and lacrosse/tennis ball work.
3. Poor core stability (as much as I hate that word); the best solution is to can all the "turn your lumbar spine into a pretzel" movements and focus on pure stability at the lower back while mobilizing the hips and thoracic spine.
4. General weakness in the upper body, specifically with respect to the postural muscles of the upper back; we'd see much fewer shoulder problems in females if they would just do a LOT more rowing.
EL: You've mentioned to me in the past the issues with the ever popular Nike Shox training shoe as well as high heels in women. What's are the potential problems?
EC: When you elevate the heels chronically - via certain sneakers, high-heels, or any other footwear - you lose range of motion in dorsiflexion (think toe-to-shin range of motion). When you lack mobility at a joint, your body tries to compensate by looking anywhere it can to find range of motion. In the case of restricted ankle mobility, you turn the foot outward and internally rotate your lower and upper legs to make up for the deficit. This occurs as torque is "converted" through subtalar joint pronation.
As the leg rotates inward (think of the upper leg swiveling in your hip joint socket), you lose range of motion in external rotation at your hip. This is one of several reasons why females have a tendency to let their knees fall inward when they squat, lunge, deadlift, etc. And, it can relate to anterior/lateral knee pain (think of the term patellofemoral pain ... you've got restriction on things pulling on the patella, and on the things controlling the femur ... it's no wonder that they're out of whack relative to one another). And, by tightening up at the ankle and the hip, you've taken a joint (knee) that should be stable (it's just a hinge) and made it mobile/unstable. You can also get problems at the hip and lower back because ...
Just as losing range of motion at the ankle messes with how your leg is aligned, losing range of motion at your hip - both in external rotation and hip extension - leads to extra range of motion at your lumbar spine (lower back). We want our lower back to be completely stable so that it can transfer force from our lower body to our upper body and vice versa; if you have a lot of range of motion at your lower back, you don't transfer force effectively, and the vertebrae themselves can get irritated. This can lead to bone problems (think stress fractures in gymnasts), nerve issues (vertebrae impinge on discs/nerve roots), or muscular troubles (basic strains).
So, the take-home message is that crappy ankle mobility - as caused by high-top shoes, excessive ankle taping, poor footwear (heel lifts) - can cause any of a number of problems further up the kinetic chain. Sure, we see plantar fasciitis, Achilles tendinosis, and shin splints, but that's just the tip of the iceberg in terms of what can happen.
How do we fix the problems? First, get out of the bad footwear and pick up a shoe that puts you closer in contact with the ground. Second, go barefoot more often (we do it for all our dynamic flexibility warm-ups and about 50% of the volume of our lifting sessions). Third, incorporate specific ankle (and hip) mobility drills - as featured in our Magnificent Mobility DVD.
Oh, I should mention that elevating the heels in women is also problematic simply because it shifts the weight so far forward. If we're dealing with a population that needs to increase recruitment of the glutes and hamstrings, why are we throwing more stress on the quads?
