As a follow-up to yesterday's "series premier," I wanted to use today's post to discuss another topic that rarely gets sufficient attention in the typical exercise science textbook: synergists and antagonists.
The typical explanation of the relationship of the two is that they're on opposite sides of the joint and perform opposite actions. As an example, the hamstrings flex the knee, and quadriceps extend the knee. Simple enough, right? Not so much.
Muscles can be synergists and antagonists at the same time.
Let's just look at the hip extensors to explain this point. Your primary hip extensors are the hamstrings, gluteus maximus, and adductor magnus (there are more, but we're keeping this discussion simple). They all work together to extend the hip each time you squat, lunge, deadlift, sprint, push the sled, or bust a move on the dance floor. That said, the hip can do a lot of things as it extends.
If we use more gluteus maximus and biceps femoris, it externally rotates and abducts a bit as we extend. If we use more adductor magnus, semitendinosis, and semimembranosus, it internally rotates and adducts.
Taking it a step further, as the hamstrings extend the hip, they have little control over the femoral head, so it tends to glide anteriorly in the acetabulum (hip socket) in a hamstrings-dominant hip extension pattern. The glutes have more direct control over the femoral head and can posteriorly pull the head of the femur to avoid anterior hip irritation (usually the capsule). Shirley Sahrmann did a great job of outlining femoral anterior glide syndrome in her landmark book, Diagnosis and Treatment of Movement Impairment Syndromes.
Herein exists the issue: typical discussions of synergists and antagonists focus on things things:
1. Single planes of motion (sagittal, frontal, transverse), but not the interaction of multiple planes
2. Osteokinematics (gross movement of bones at joints: flexion/extension, abduction/adduction, internal/external rotation), rather than arthrokinematics (smaller movements at joint surfaces: rolling, gliding, spinning)
3. Active restraints (muscles, tendons), but not passive restraints (ligaments, bones, labra, intervertebral discs) that may be synergists to them in creating stability
As another example, think about stabilization at the glenohumeral (shoulder's ball and socket) joint. There are a wide range of movements taking place, yet these movements must be controlled arthrokinematically in a very precise range via a complex system of checks and balances at the joint. If the active restraints (primarily the rotator cuff) don't do their job, one could wind up with stretched/torn ligaments, a torn labrum, or bony defects. In other words, it isn't a stretch (no pun intended) to say that muscles can be synergists to ligaments. Put that in your osteokinematic pipe and smoke it!
This is really a topic that deserves far more than a 500-word post; it could be an entire college curriculum in itself! And, the more you can understand it, the better you'll be able to help your clients and athletes. A great resource to get the ball rolling in this regard is Building the Efficient Athlete, a two-day seminar Mike Robertson and I filmed with functional anatomy heavily in mind.
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I'm always surprised when I see "arm care" portions of baseball strength and conditioning programs that attempt to break rotator cuff exercises and scapular stability exercises into different categories. In my eyes, while you can certainly prioritize one over the other, treating them as mutually exclusive means that you're missing out on a great opportunity to educate an athlete on "positional stability." Here are a few examples to demonstrate my point:
In Band Distractions w/Rhythmic Stabilizations, you'll see that Orioles prospect (and Twitter phenom) Oliver Drake, actively counteracts the distraction force created by the band by pulling the scapula back onto the rib cage. Then, we challenge the rotator cuff with rhythmic stabilizations.
Likewise, in this Half-Kneeling 1-arm Manual Resistance External Rotation, Sam needs to make sure to position the scapula appropriately on the rib cage to make sure that he's in the best position to create eccentric strength for the cuff. This is of particular importance in guys with low shoulders who may be very lat-dominant; gravity will have an additional downward pull on the scapula, so many guys need to intentionally activate upper trapezius prior to starting the set.
Or, consider a Prone External Rotation (one of our old Strength Exercises of the Week). This is definitely viewed as a rotator cuff exercise, as the goal is to learn to externally the humeral head in the socket without the "ball" migrating forward (preventing anterior instability). However, you also have to appreciate that gravity is forcing the scapula forward into anterior tilt, so the lower trapezius must be turned on to counteract it.
Likewise, just about every time you do any exercise that involves holding weights in your hands, your rotator cuff is firing reflexively.
With all these examples - and surely many more - in mind, we realize that "categorizing" arm care exercises can be pretty difficult, as we're always looking to find a balance between doing enough and doing too much.
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Q: What are your thoughts on the right amount of volume, intensity and frequency on core exercises ranging from bridging variations to ab wheel rollouts from the feet for the intermediate to advanced lifter looking to decrease back pain and get out of anterior pelvic tilt? Is it possible to make progress for a while, but overdue it on volume, intensity or frequency and actually have your core get weaker or stop progressing/responding, and start to experience back pain and anterior pelvic tilt again?
A: This is an outstanding question, and I can really go in a number of different directions with it.
First, let me say that the single best way to get out of excessive anterior tilt is training oneself to not live in anterior tilt! No amount of exercise will undo the damage you can do with your daily posture. That’s the easy part of this response, though.
Next, I’ll say that I absolutely believe that we can overdo it with “core-specific” exercises.
As a parallel, just consider the shoulder. The glenohumeral (ball and socket) joint is heavily reliant on both active (muscles/tendons) and passive (capsule/ligaments and labrum) restraints for stability. If you overdo it with rotator cuff exercises and train the cuff to excessive fatigue, individuals lose dynamic stability and can’t maintain the position of the humeral head in the glenoid fossa. Overuse conditions and injuries can occur. I wrote about this in an old series, How Much Rotator Cuff Work is Too Much? - Part 1 and Part 2.
Similarly, the lumbar spine relies heavily on both active and passive restraints. People can overcome lumbar ligament and disc injuries to live pain-free if they maintain adequate soft tissue control. Likewise, many sedentary folks can live pain-free in spite of poor soft tissue function simply because the challenges of their daily activities don’t exceed the tolerance of the passive restraints (these are the folks who often blow out their backs trying move couches).
That said, we have to be careful about overreacting to this realization. Just as the trend of doing thousands of sit-ups in the past few decades created a ton of back pain, you see a lot of completely deconditioned individuals who are hurting, too. There has to be a middle ground between the two. So, you could say:
Optimizing core function is really a delicate balance of exercise selection, volume, frequency, and intensity.
Unfortunately, I don’t know that we have a perfect (or even close to perfect) answer with respect to all of these factors, as everyone is different. Consider the following:
1. Flexion-intolerant backs must be treated differently than extension-intolerant backs.
2. Trained athletes probably need a lower frequency because of their sport participation and neural efficiency, but can handle a greater intensity and more complex exercises – and need to prepare the core for fatigue over an extended period (e.g., soccer game, tennis match, 100-pitch outing).
3. A sedentary individual probably needs a greater frequency of low-intensity exercises.
4. In-season athletes must be careful not to do too much work and pre-fatigue the core before competition.
5. Those with congenital laxity (loose joints) likely need a greater frequency of core work for “neuromuscular reminding.”
6. The general exercises we can do in a weight room or rehab setting must be complemented by sport-specific activities in the appropriate volume. When general volume goes down, specific can go up – and vice versa.
7. Athletes with a previous history of injury – or known diagnostic imaging red flags – may need to do more just to maintain.
8. Everyone’s definitions of “core” is different. I view the core as pretty much everything between the knees and the shoulders – but the truth is that poor core control can also lead to elbow and foot/ankle issues; should we include those joints as part of the equation?
9. Everyone’s definition of and “core stability exercises” is also different. Rollouts – an anterior core stability exercise – were mentioned in the question above, but I’ve never had more soreness in my anterior core than after doing heavy push presses. Simply holding a weight overhead forces our anterior core to work to prevent lumbar hyperextension (the photo below shows what happens when the anterior core isn't properly engaged).
As you can see, the “how much is too much” question is a big, fat, hairy one. Ask 100 fitness professionals and rehabilitation specialists, and they’ll all have different answers – and even then, it will still be dependent on the athlete/client/patient. We can’t even effectively define “core,” let alone “core stability exercises” to answer today’s question.
Taking it a step further, only 15% of low back pain has a definitive diagnosis. One could make the argument, therefore, that only 15% of core function can be adequately assessed/interpreted. We’d like to think that we know exactly what is going on with a spine, but it’s just not reflected in the research.
The good news, though, is that while most people encounter low back pain at some point in their lives, the overwhelming majority of them do get better with rehabilitation. We just don’t know what’s optimal - and I’m not sure we ever will, but we are getting a lot better, thanks to the availability of both research and anecdotal experience of rehabilitation specialists, fitness professionals, and folks who have stayed healthy.
This is one reason why I’m so proud of the Functional Stability Trainingseries from Mike Reinold and me. The two of us collaborated in the past to bridge the gap between rehabilitation and performance training, and we have done it again with project.
Whether you’re a fitness or rehabilitation professional, or exercise enthusiast or athlete looking to learn more about how to effectively prepare the core, train around various lumbo-pelvic injuries/conditions, or learn about developing power in the frontal and transverse planes with medicine ball drills, there is much to be gained from watching Functional Stability Training.
To sweeten the deal, the entire series is on sale for 20% off through the end of the weekend. You can check it out HERE.
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In part 1 of this feature, I talked about how many throwers actually overuse the rotator cuff because they don't appreciate that throwing in itself is a tremendously stressful challenge to the shoulder. I also made the point that cuff timing is more often the problem than cuff strength, so many folks are really training the rotator cuff incorrectly with thousands of reps of band exercises. Let's examine that in a bit more depth.
First, I should preface this piece by saying that I think there are definitely places for utilizing bands to strengthen the rotator cuff in a baseball training context. They obviously provide outstanding convenience for on-field work and travel circumstances, as well as scenarios where players may not have qualified professionals at hand to help with manual resistance work and rhythmic stabilizations. Some cuff work is better than no cuff work! Additionally, many players swear by bands during the warm-up phase to help with getting blood flow to the shoulder complex with a bit of activation at the same time.
However, there are two primary issues with relying exclusively on bands:
1. In an external rotation variation, the resistance is actually greatest at the point (near maximal external rotation) where the athlete is weakest. In other words, the band doesn't ideally accommodate the strength curve. This is a huge concern for me, as one of the biggest things I notice in athletes is that when training in a position of somewhat significant external rotation, they can't "pick up" the resistance quickly enough. More on this later.
2. Most people simply overlook eccentric control. This is something that is coachable, no doubt, but most people do band exercises for so many reps per set that the athlete can quickly lose focus and resort back to bad habits.
As you can imagine, these are shortcomings that also exist - albeit to a slightly lesser extent - with cable and dumbbell/plate external rotation rotator cuff strength exercises:
So, how do we overcome these shortcomings while helping to address rotator cuff timing? You have two great options.
1. Rhythmic Stabilizations
The true role of the rotator cuff is to stabilize the humeral head (ball) in the glenoid fossa (socket). And, during throwing, it does a ton of work, as the humerus goes through extreme ranges of motion in all three planes. Rhythmic stabilization drills are a great way to train the cuff to fire quicker, and they're particularly valuable because you can train them at various points in the range of motion, modifying the challenge depending on how stable an individual is in a given position. Plus, this is an outstanding way of monitoring cuff function over the course of weeks and months with athletes you see regularly; regular improvements are easily perceived.
You'll notice that I don't crank him back to extreme external rotation in this video; rather, we stop short of it and just assume that we'll get some carryover in stability a bit further (as per previous research on carryover of isometric exercise).
The sky is really the limit in terms of how you train this one; we have about a dozen variations that we use on a daily basis. A few quick guidelines:
a. The more congenital or acquired laxity an athlete has, the less aggressive you'll want to be with your perturbations. When someone is less proficient, gently destabilizer, and apply the prturbations closer to the shoulder. When someone is more stable, perturbate a bit more firmly, and apply it further down the arm.
b. I sometimes start those with significant laxity with closed chain exercises so that they can draw some stability from the floor or wall.
c. Make sure that the scapula is positioned appropriately; it certainly shouldn't be protracted, but don't crank it into excessive retraction, either. Just keep it from winging off the rib cage.
d. I like 2x/week rhythmic stabilizations during off-season training. We typically integrate it between sets on lower-body strength training days.
2. Manual Resistance External Rotations
These drills are "where it's at." On one hand, they are the best strength-building exercise for the cuff because they train it in its most function context: eccentric control. However, more specific to today's point, they are great for improving cuff recruitment at the most vulnerable point in the throwing motion: lay-back.
When we do a drill like this, I encourage the athlete to "pick it up early." In other words, I won't apply downward pressure (eccentric overload) until they apply some external rotation force into my hand).
Some quick guidelines for manual resistance external rotations:
a. Emphasize eccentric overload, but make sure you aren't pushing all the way down, as most people will go into scapular anterior tilt as they are more internally rotated. Pushing someone all the way down puts the shoulder in a pretty vulnerable position, as scapular stability is lost and the subacromial space is closed down.
b. Given that you have to apply the force further down the arm, make sure that the athlete isn't cheating by just utilizing the wrist extensors.
c. In the manual resistance external rotations at 90 degrees in the scapular plane, your other hand should "cup" the elbow to make sure that the rotation is taking place at the shoulder (as opposed to horizontal adduction/abduction).
d. I like to utilize manual resistance external rotations twice a week during the off-season, usually toward the end of upper body strength training sessions. We'll use less manual resistance work in this regard, though, when guys start to ramp up their throwing, as it tends to create a bit more soreness.
In a recent presentation in front of a bunch of baseball coaches, I made the following statement - and it turned a lot of heads:
I think most people overtrain the rotator cuff nowadays, and they do so with the wrong exercises, anyway.
To illustrate my point, I'm going to ask a question:
Q: What is the most common complication you see in guys as they rehabilitate following a Tommy John Surgery?
A: Shoulder problems - generally right around the time they get up to 120 feet.
Huh? Shoulder pain is a post-operative complication of an elbow surgery? What gives?
First, I should make a very obvious point: many of these guys deal with shoulder stiffness as they get back to throwing simply because they've been shut down for months. That I completely expect - but remember that it's stiffness, and not pain. They always throw their way out of it.
The more pressing issue is what is taking place in their rehabilitation - and more specifically, what's taking place with the synergy between their rehabilitation and throwing program. Let me explain.
Rehabilitation following a UCL reconstruction is extensive. While different physical therapists certainly have different approaches, it will always be incredibly heavy on rotator cuff strength and timing, as well as adequate function of the scapular stabilizers. Guys always make huge strides on this front during rehab, but why do so many have shoulder pain when they get further out with their long tossing? The answer is very simple:
Most people don't appreciate that throwing a baseball IS rotator cuff training.
Your cuff is working tremendously hard to center the humeral head in the glenoid fossa. It controls excessive external rotation and anterior instability during lay-back.
It's fighting against distraction forces at ball release.
And, it's controlling internal rotation and horizontal adduction during follow-through.
Simultaneously, the scapular stabilizers are working incredibly hard to appropriately position and stabilize the scapula on the rib cage in various positions so that it can provide an ideal anchor point for those rotator cuff muscles to do their job.
A post-op Tommy John thrower - and really every player going through a throwing program - has all the same demands on his arm (even if he isn't on the mound, where stress is highest). And, as I wrote previously in a blog about why pitchers shouldn't throw year-round, every pitcher is always throwing with some degree of muscle damage at all times during the season (or a throwing program).
Keeping this in mind, think about the traditional Tommy John rehabilitation approach. It is intensive work for the cuff and scapular stabilizers three times a week with the physical therapists - plus many of the same exercises in a home program for off-days. They're already training these areas almost every day - and then they add in 3-6 throwing sessions a week. Wouldn't you almost expect shoulder problems? They are overusing it to the max! This is a conversation I recently had with physical therapist Eric Schoenberg, and he made another great point:
Most guys - especially at higher levels - don't have rotator cuff strength issues; they have rotator cuff timing issues.
In throwing - the single-fastest motion in all of sports - you're better off having a cuff that fires at the right time than a cuff that fires strong, but late. Very few rotator cuff exercise programs for healthy pitchers take that into account; rather, it's left to those doing rehabilitation. Likewise, most of the programs I see altogether ignore scapular stability and leave out other ways to train the cuff that are far more functional than just using bands.
Now, apply this example back to the everyday management of pitchers during the season. Pitchers are throwing much more aggressively: game appearances, bullpens, and long toss. They need to do some rotator cuff work, but it certainly doesn't need to be every day like so many people think.
I'll cover how much and what kind in Part 2. In the meantime, if you'd like to learn more about the evaluation and management of pitchers, check out Optimal Shoulder Performance.
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The prone external rotation is a strength exercise for the posterior rotator cuff that we've added to our strength and conditioning programs over the past few months with good success. And, while the primary goal is to increase shoulder stability via improved rotator cuff function, the truth is that this drill also served as a motor control exercise to reeducate folks on what should be moving and when.
We use this drill a lot with guys who are in a dramatic anterior pelvic tilt, and start everything with the "gluteus tight, core braced" cues. Effectively, this means that you force the athlete to actually externally rotate the shoulder instead of simply arching through the lower back to get to the desired "finish" point. You'll be amazed to see how many athletes have significantly less "observable external rotation" when they are locked into neutral spine.
You also want to cue the athlete to keep the scapula (shoulder blade) on the rib cage, but he/she doesn't need to be aggressively pulled into scapular retraction in order to get there.
Once the scapula is set, I tell athletes to think about getting the ball to rotate in the socket without allowing the head of the humerus to slide down toward the table. This is a very important cue, as many athletes will allow excessive anterior migration of the humeral head during external rotation exercises; we want them to learn to keep the ball centered in the socket. If an athlete is really struggling with this, we may place a rolled up towel or half-roller underneath the anterior shoulder as feedback on where things should be.
Very rarely will we load this up, and in the rare instances we do, it wouldn't be for more than 2.5 -5 pounds. The shoulder is a joint with a broad range of movements that mandate a lot of dynamic stability, so we want to make sure things are working perfectly.
I'll generally include this movement in the warm-ups for sets of eight reps - or we may use it as a filler on a lower-body day between sets of more compound strength exercises. It can also serve as a great follow-up to shoulder mobility drill geared toward improving external rotation, as this is an avenue through which you can add stability to the range-of-motion you're creating.
Give it a shot in your strength and conditioning programs and then let me know how it goes in the comments section below!
In Part 1 of this series, I outlined the first three reasons that I'm opposed to baseball pitchers using year-round throwing programs. Here are the next four:
4. They need to get their shoulder and elbow range of motion back.
As I noted in Part 1, throwing a baseball is the single-fastest motion in sports. With the crazy arm speeds one encounters, you have to keep in mind not only the muscles trying to accelerate the arm, but also the ones trying to slow it down. This "braking" challenge is called eccentric stress - and I'll talk more about it in a second.
What you need to know now, though, is that when left unchecked, significant eccentric stress can lead to tissue shortening. If you need further proof, Reinold et al. reported that immediately after a pitching outing, pitchers lose an average of 9.5° of shoulder internal rotation and 3.2° of elbow extension - and that these losses persisted at 24 hours post-throwing.
Now, imagine these acute range of motion losses being left unchecked for an entire season - or a season that simply never ends because pitchers are always throwing. That's how elbows wind up looking like this:
Fortunately, we can prevent losses in range of motion during the season with appropriate mobility exercises, manual therapy, and breathing exercises - but the truth is that not everyone has access to these initiatives in terms of expertise, finances, or convenience. So, while we work to educate the masses on arm care, emphasizing time off from throwing programs is also a key component of an overall strategy to reduce injury risk.
One last thing on this topic: it is a nightmare to try to improve shoulder or elbow range of motion in a pitcher during a season, as the very nature of throwing works against everything you're trying to achieve. The off-season is "where it's at" in terms of optimizing range of motion in throwers.
5. They need to “dissipate” eccentric stress.
Okay, here's where I take #4 and geek out a bit. I apologize in advance.
Sometimes, you have to get away from the baseball world in order to learn about the baseball world. To that end, I need to think Mike Reinold for bringing this great 2004 study from Tomiya et al to my attention.
These researchers created eccentric stress in muscle tissue of mice using an electrical stimulation model, and monitored blood markers of muscle damage for a period of time thereafter. What you'll see in the graph below is that myofiber disruption really peaks at three-days post-exercise, then start to return down to baseline, yet they still aren't even there at seven days post-intervention.
Source: Tomiya A, et al. Myofibers express IL-6 after eccentric exercise. Am J Sports Med. 2004 Mar;32(2):503-8.
Now, let's apply this to the world of pitching. Every single pitcher who throws more than once every 7-10 days is surely pitching with some degree of muscle damage. And, I can tell you that the two toughest challenges pitchers have reported to me are:
a) moving from starting to relieving
b) going from a 7-day high school or college rotation to a 5-day professional rotation
I'm firmly believe that pitchers need to throw in-season to stay strong, but I also know that we can't trump physiology. Sure, we need to have optimal nutrition and regeneration strategies in place, as we can't just baby guys and expect them to get better. However, make no mistake about it: high-level pitchers simply have to get good at pitching at 90% capacity (at best) if they are going to succeed.
If I already have a guy whose arm is working at a deficit for 8-9 months of throwing, the last thing I want to do is beat him up for the other three months with the same kind of volume and stress.
6. They need to allow any undetected low-grade injuries to heal.
As I discussed in an old blog, Pitching Injuries: It's Not Just What You're Doing; It's What You've Already Done, most injuries (especially ulnar collateral ligament tears) come from the accumulation of chronic, low-level stress. Maybe you get some calcification on your ulnar collateral ligament or a low-level rotator cuff tendinosis, and it takes a few years and hundreds of innings before something finally "goes."
Old, low-level injuries are less likely to reach threshold if you give them some downtime and work on redistributing training stress. By strengthening the rest of your body in the off-season, you're dramatically reducing the demands on your rotator cuff with throwing.
You can't teach other joints to share the burden if the burden is never removed temporarily.
7. They need a chance to prioritize other competing demands.
Throwing is a good 20-30 minute endeavor each time you do it - and possibly even more. When I think about all the things that pitchers can be doing to get better in the off-season from a strength and conditioning standpoint, I have a really hard time justifying giving away that much time and recovery capability. There are other things that need to be prioritized at this time - and year-round throwing is an especially tough pill to swallow when you know that throwing is working against many of the very qualities - rotator cuff strength, scapular stability, mobility, and tissue quality - that you're trying to establish.
Closing Thoughts
The lack of downtime from throwing is especially problematic in younger populations, as they are skeletally immature and weaker. I’d argue that a really weak 15-year-old kid throwing 74-76 mph does far more damage to his body on each throw than a moderately strong professional player throwing 90-92 mph, especially given that the pro pitcher’s mechanics are more optimized to protect the arm. This underscores the importance of "syncing up" mechanics, throwing programs, and the overall baseball strength and conditioning program.
Last, but certainly not least, remember that two weeks doesn't constitute "time off." Rather, I firmly believe that pitchers need the ball completely out of their hands for at least two month per year, preferably continuously. In other words, eight one-week breaks throughout the year is far from ideal, as it doesn't really allow for positive adaptations to occur.
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When Thanksgiving rolls around, many of our professional baseball players at Cressey Sports Performance will start up their winter throwing programs after a full 10-12 week break from throwing. They're always a bit rusty in the first week of tossing after the layoff, but every single one of them always "figures it out" in a matter of a few weeks - and still has plenty of time to get in a solid throwing program prior to heading off to spring training. And, because they've been working hard in the gym on their strength, mobility, and soft tissue quality, they're always better off in the end.
Still, there are those who insist that baseball pitchers don't need time off from throwing.
I couldn't disagree more.
I'm sure this will rub some folks the wrong way, but I can't say that I really care, as most of those individuals can't rationalize their perspectives outside of "guys need to work on stuff." I, on the other hand, have seven reasons why baseball pitchers need time off from throwing:
1. They need to lose external rotation to gain anterior stability.
Having external rotation - or "lay back" - when is important for throwing hard, and research has demonstrated that simply throwing will increase shoulder external rotation range-of-motion over the course of a season. This does not mean, however, that it's a good idea to just have someone stretch your shoulder into external rotation, as I wrote previously: Shoulder Mobility Drills: How to Improve External Rotation (if you even need it).
You see, when you externally rotate the humerus (ball) on the glenoid (socket), the humeral head has a tendency to also translate anteriorly (forward). In a well-functioning shoulder girdle, the rotator cuff musculature should prevent anterior instability, and it's assisted by adequate function of the scapular stabilizers, which offer the dynamic stability to reposition the scapula in the right place to "accommodate" the humeral head's positioning. For the athletic trainers and physical therapists out there, this is really what you're testing with an apprehension/relocation test.
The apprehension comes about because of either anterior instability or actual structural pathology (SLAP tear, rotator cuff impingement, or biceps tendinosis). The relocation component is just the clinician posteriorly directing the humeral head to create the stability that should otherwise be created by the rotator cuff and scapular stabilizers.
The take-home message is that while just going on year-round throwing programs in hopes of increasing external rotation seems like a good idea on paper, it's actually a terrible idea in the context of injury prevention. Pitchers should actually lose a few degrees of external rotation each off-season intentionally, as it affords them an opportunity to improve their stability. This leads us to...
2. They need a chance to get their cuff strength and scapular stability up.
Baseball pitching is the single-fastest motion in all of sports, as the humerus internally rotates at velocities in excess of 7,000°/second. So, it should come as no surprise that at the end of a season, the strength of the rotator cuff and scapular stabilizers is significantly reduced. Having dealt with many of our players for up to five off-seasons now, I have a unique appreciation for how they each respond differently to not only the stress of the season, but also to arm care programs that we initiate at season's end.
It's important to remember that improving rotator cuff strength is no different in terms of adaptation than improving a bench press or squat. Adding 10% to a guy's bench press might take three months in an intermediate population, or 12 months in a high-level lifter! Adaptation of the rotator cuff and scapular stabilizers is comparable. I need every minutes of those three months without throwing to get guys back to at least baseline, and hopefully a bit above it.
Can you imagine if some clown trying to improve his bench press went out and benched an additional 4-5 times a week on top of his regular strength and conditioning program?
His progress would be minimal, at best, and he'd be at a dramatically increased risk of injury. Throwing during a dedicated, appropriate structured early off-season arm care program is no different.
3. They need an opportunity to do dedicated manual resistance rotator cuff exercises.
Ask anyone who has worked with throwers for any length of time, and they'll always tell you that manual resistance exercises are the single-best option for improving rotator cuff strength. This rotator cuff exercise approach allows you to emphasis eccentric strength better than bands, cables, and dumbbells allow. It also keeps athletes more strict, as the one providing the resistance can ensure that the athlete isn't just powering through the exercise with scapular stabilizers or lower back.
The only downside to manual resistance rotator cuff exercises, though, is that because they generally prioritize eccentric strength, they will create more soreness. With that in mind, we use them much more in the off-season than in the in-season, as we don't want a pitcher throwing with added soreness. They're a great initiative in a comprehensive off-season baseball strength and conditioning program, but guys just don't seem to like them as much in-season, presumably because both throwing and manual resistance rotator cuff exercises can be too much eccentric stress when combined. As such, we used them a lot during the September-November periods, and then hold back in this area the rest of the year.
Of course, if you throw year-round, then you can forget about getting these benefits, as the last thing you want is to be sore while you're "working on stuff" in the off-season. That was sarcasm, in case you weren't picking up on it.
In Part 2, I'll be back with four more reasons baseball pitchers shouldn't throw year-round.
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In Part 1 of this off-season baseball strength and conditioning series, I outlined the first five of my top 10 priorities when dealing with baseball players at the start of their off-season. Today, I round out the top 10 “general” things always seem to be addressing with players coming in after a season.
1. Regaining lost mobility - This is an incredibly loaded topic that goes far beyond the scope of any blog or article, as it's an entire two-day seminar or book! You see, losses in mobility - the ability to reach a desired position or posture - can be caused by a number of issues - and usually a combination of several of them. Tissues can actually lose sarcomeres and become short after immobilization or significant eccentric stress (as with the deceleration component of throwing). They can become stiff because of inadequate stability at adjacent joints (learn more HERE), protective tension (e.g., "tight" hamstrings in someone with crazy anterior pelvic tilt), or neural tension from an injury (e.g., disc herniation causing "tight" hamstrings).
The "Short vs. Stiff" issue is why you need to have a variety of tools in your "mobility toolbox." You need focal modalities like Active Release, Graston, and ASTYM techniques to assist with dealing with short tissues, whereas you need more diffuse modalities like traditional massage and foam rolling for dealing with stiffness (although both modalities can certainly help in the other regards, this is how I prefer to use them).
You need to understand retraining breathing appropriately and how posture affects respiratory function. If you live in extension, you'll have a poor zone of apposition in which the diaphragm can function. The average human takes over 20,000 breaths per day. If you don't use your diaphragm properly, more of the stress is placed on the supplemental respiratory muscles: sternocleidomastoid, scalenes, pec major and minor, upper trapezius, and latissimus dorsi (to only name a few). What are some insanely common sites of trigger points in just about everyone - especially thrower? Sternocleidomastoid, scalenes, pec major and minor, upper trapezius, and latissimus dorsi. Improving respiratory function can be a complete game changer when it comes to enhancing mobility. If you see a baseball player with a low right shoulder, prominent anterior left ribs, adducted right hip, huge anterior pelvic tilt, and limited right shoulder internal rotation, it's almost always a slam dunk.
You may need low-load, long-duration static stretches to improve length in tissues that have lost sarcomeres. This research has been around in the post-surgery community for decades (1984 research example here), but it's actually not used all that much in strength and conditioning programs - presumably because of time constraints or the fact that most coaches simply don't know how well it can work in the right people.
Finally, as we noted in our Assess and Correct DVD set, you also need dynamic flexibility drills in your warm-ups to reduce tissue and joint stiffness, and subsequent strength exercises in your strength and conditioning program to create adequate stability at adjacent joints to "hold" that new range of motion in place.
Many physical therapist employ heat early in a session to decrease stiffness prior to strengthening exercises, too. The point is that there may be many different ways to skin a cat - but there are also a lot different types and sizes of cat. And, for the record, I don't condone skinning cats; it's just a really gruesome analogy that has somehow "stuck" in our normally very politically correct society. Weird...but let's move on.
2.Improving dynamic stabilization of the scapula - I say "dynamic stabilization" because you don't just want scapular stability; you want a scapula with appropriate tissue length, stiffness, and density to allow for the desired movement. A scapula that doesn't move might be "stable," but that's not actually a good thing!
Truth be told, the scapular stabilizers generally fatigue before the rotator cuff does. And, when the scapula isn't positioned appropriately, the rotator cuff is at a mechanical disadvantage, anyway. Additionally, poor scapular control can present as an internal rotation deficit at the shoulder, as you'll just protract the shoulder excessively in place of internally rotating. In other words, you can do all the rotator cuff exercises you want, but you don't increase strength of the periscapular muscles, you'll be spinning your wheels. There are loads of drills that we use, but forearm wall slide variations are among our favorites:
3. Enhancing global strength while minimizing reactive training - As I've already noted in this series, we're certainly spending a lot of time addressing specific areas of weakness like the rotator cuff, scapular stabilizers, and anterior core. However, I should be very clear that we're still using "money" strength exercises like variations of the deadlift, single-leg exercises, squatting (in some of our guys), pull-ups, rows, push-ups, and dumbbell bench presses to get strong. That said, the volume and intensity come down a ton on the reactive training side of things. We'll give our guys a few weeks off altogether from sprinting, as they've usually done a lot of that all season. Plus, nixing all the sprinting and jumping for a few weeks ensures that they won't tweak anything, given the soreness they'll be working with from the strength training program - and it allows us to increase strength faster.
4. Putting guys in the right footwear - One thing that many folks don't appreciate about playing baseball every day from February to October is the sheer amount of time one spends standing around in cleats, which will never be as comfortable as sneakers or going barefoot. As such, one of the first things we do with most of our guys is get them into a good pair of minimalist shoes for training, as it gets them away from the rigidity, separation from the ground, and ankle mobility deficits that come with wearing cleats. As I wrote previously, I'm a big fan of the New Balance Minimus.
Keep in mind that we ease guys into these minimalist shoe options, rather than throwing them in the footwear 24/7 right away. They'll start out just wearing them during training, and increase from there, assuming all goes well.
5. Normalizing sleep schedules - Professional baseball players (and really all professional athletes) have terrible sleep schedules. Because most games are night games, they generally go to bed around 1-2AM and wake up anywhere from 7AM to 11AM. The early risers I know will usually take a nap before going to the park, whereas the guys who sleep in roll out of bed and go straight to the park. Additionally, much of this sleeping comes on planes and buses, which aren't exactly comfortable places to get quality sleep. I'm a firm believer that one hour of sleep before midnight is worth two hours after midnight - but this simply isn't an option for professional baseball players.
That said, we try to normalize things as much as possible in the off-season. All our athletes are encouraged to try to go to bed and wake up at the same time - and to hit the hay before 11pm every night. Any naps they can get during the day are a bonus, too!
Wrap-up
While I've outlined ten things we address in the early off-season, these are really just the tip of the iceberg, as every player is unique and needs an individual approach. That said, the one general theme that applies to all of them is that we're shifting paradigms - meaning that some things about our philosophy may differ from what they've experienced. Some guys may be accustomed to just "football workouts." Others may have been coddled with foo-foo training programs where they didn't work hard. Some guys ran distances. Some guys crushed the rotator cuffs every day while ignoring the rest of the body.
The point is that it's not just our job to find what we feel is the best fit for these athletes, but also to educate them on why the unique program we've designed for them is a better approach than they can get anywhere else.
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Over the weekend, I attended my third Postural Restoration Institute seminar, Impingement and Instability. I’ve written previously about how this school of thought has profoundly impacted the way that we handle many of our athletes – and this past weekend was certainly no exception. This weekend was also my first chance to meet and learn directly from Ron Hruska, the man initially responsible for bringing many of these great ideas to light.
While I am admittedly still processing all the awesome information from the weekend, I wanted to write today about one big “Ah-Ha” moment for me over the weekend. At some point on Day 2, Ron said something to the effect of (paraphrased):
“A superior acetabulum isn’t much different than an acromion on a scapula.”
My jaw practically hit the floor. I joked with the seminar organizer that I needed to go into the restroom to yell at myself for a few minutes for not thinking of this sooner. Let me explain…
Over the past few years, there has been a huge rise in hip injuries in athletes (I'd even written about it HERE in response to a New York Times article about number of hip injuries in baseball). Sports hernias, labral tears, and femoroacetabular impingement (FAI) are commonplace findings on the health histories that I see every day on first-time evaluations. In terms of FAI, you can have bony overgrowth of the femoral head (cam), acetabulum (pincer), or both (mixed), as the graphic from Lavigne et al. below demonstrates:
Many folks say that we’re getting better diagnostically and that’s why the prevalence has increased in recent years. Let’s be real, though, folks: if we’d had hip pain and dysfunction on this level for decades, don’t you think anecdotal evidence would have at least tipped us off? I find it hard that generations of athletes would have just rubbed some dirt on a painful hip, cowboyed up, and put up with it.
Consider those over the age of 60, though. Sher et al. reported that a whopping 54% of asymptomatic shoulders in this population have rotator cuff tears; that doesn’t even include those who actually have pain! Why does this happen? They impinge over and over again on the undersurfaced of the acromion process secondary to poor thoracic positioning, scapular stabilization, breathing patterns, and rotator cuff function. The end result is reactive changes on the acromion process that lay down more and more bone as the years go on. And, an anteriorly tilted scapula kicks that impingement up a notch. The “early” cuff irritation likely comes in those with Type 3 (beak-shaped) acromions, whereas the Type 1 (flat) and Type 2 (hook) acromions need time to lay down more and more bone for their anterior tilt to bring them to threshold.
Conversely, consider femoroacetabular impingement of the hip. You can get bony overgrowth of the acetabulum, femoral head, or both. It’s widely debated whether those with FAI are born with it, or whether it becomes part of normal development in some kids. Well, I guess it would depend on whether you consider playing one sport to excess year-round “normal.”
You know what? I’d estimate that over 90% of the femoroacetabular impingement cases I’ve seen have come in hockey, soccer, and baseball players. What do these sports have in common? They all live in anterior pelvic tilt – with hockey being the absolute worst. Is it any surprise that the incidence of FAI and associated hip issues has increased dramatically since the AAU generation rolled in and kids played the same sport all 12 months of the year?
Conversely, I’ve never seen a case of FAI in a field hockey player. Additionally, when I just asked my wife (who rowed competitively in college) if she ever saw any hip issues in her teammates in years of rowing, she joked that there weren’t any until they added distance running to their training. Field hockey players and rowers live in flexion (probably one reason why they have far more disc issues). And, taking it a step further, I’ve never seen an athlete with FAI whose symptoms didn’t improve by getting into a bit more posterior pelvic tilt.
Finally, a 2009 study by Allen et al. demonstrated that in 78% of cases of cam impingement symptoms in one hip, the cam-type femoroacetabular impingement was bilateral (they also found pincer-type FAI on the opposite side in 42% of cases). If this was just some “chance” occurrence, I find it hard to believe that it would occur bilaterally in such a high percentage of cases. Excessive anterior pelvic tilt (sagittal plane) would be, in my eyes, what seems to bring it about the most quickly, and problems in the frontal and transverse planes are likely to blame for why one side presents with symptoms before the other.
People have tried to blame the increased incidence of hip injuries on resistance training. My personal opinion is that you can’t blame resistance training for the incidence, but rather the rate at which these issues reach threshold. Quality resistance training could certainly provide the variety necessary to prevent these reactive changes from occurring at a young age, or by creating a more ideal pelvic alignment to avoid a FAI hip from reaching threshold.
Conversely, a “clean-squat-bench” program is a recipe for living in anterior tilt – and squatting someone with a FAI is like overhead pressing someone with a full-thickness cuff tear; things get ugly quickly.
Honestly, this probably isn’t revolutionary for folks out there – particularly in the medical field – who have watched the prevalence of femoroacetabular impingement rise exponentially in recent years, but Ron made a great point to reaffirm a thought I’d been having for years and strengthened the argument. And, more important than the simple “Ah-Ha” that comes with this perspective is the realization that an entire generation of young athletes have been so mismanaged that we’ve actually created a new classification of developmental problems and pathologies: femoroacetabular impingement, labral tears, and sports hernias.
Thanks, Ron, for getting me thinking!
For more information on appropriately managing kids during these critical development time periods, check out the International Youth Conditioning Association’s High School Strength and Conditioning Certification, which I helped to write.
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