Home Posts tagged "Rotator Cuff Rehab"

Random Thoughts on Sports Performance Training – Installment 33

It's time for this month's installment of my random thoughts on sports performance training. In light of my ongoing 30% off sale (ending Sunday at midnight) on my Sturdy Shoulder Solutions resource (enter coupon code BASEBALL at checkout for the discount), I thought I'd focus this edition on the shoulder.

1. If you want a healthy shoulder, getting tobacco products out of your life is a good place to start.

The research is pretty clear: smoking is a bad idea (and an independent risk factor) if you're looking to stay healthy from a musculoskeletal standpoint, or have a good outcome in rehabilitation (whether conservative or post-surgical) . Here's an excerpt from a recent study with an excellent review of the literature:

"Cigarette smoking adversely affects a variety of musculoskeletal conditions and procedures, including spinal fusion, fracture healing, surgical wound healing, tendon injury and knee ligament reconstruction. More recently, smoking has been suggested to negatively impact rotator cuff tear pathogenesis and healing. Tobacco smoke contains nicotine, a potent vasoconstrictor that can reduce the blood supply to the already relatively avascular rotator cuff insertion. Furthermore, carbon monoxide in smoke reduces the oxygen tension levels available for cellular metabolism. The combination of these toxins may lead to the development of attritional rotator cuff tears with a decreased capacity for healing."

Many times, we're looking for the best exercise, rehabilitation protocol, soft tissue treatment, or volume amounts - but we really ought to be looking at lifestyle factors.

With a large baseball readership on this site, the logical next question: are these harmful effects also noted with smokeless tobacco (i.e., dip/chew)? The research is somewhat sparse, as it's harder to study a younger, active population than a bunch of middle-aged post-operative rotator cuff patients. However, it's hard to believe that the aforementioned carbon monoxide implications would cause 100% of the issues and that the nicotine would serve as just an innocent bystander. So if you're looking to check every box in your quest to stay healthy, it's not a bad idea to lay off the dip.

And, if healthy tendons aren't enough to convince you, do yourself a favor and read this article by Curt Schilling.

2. The 1-arm, 1-leg landmine press isn't a mainstay in your training programs, but can be a perfect fit in a few circumstances.

This looks like kind of a wussy exercise, but I actually really like it in two circumstances.

a. It's awesome in a post-surgery period when you can't load like crazy, but still want folks to be challenged in their upper extremity progressions. The single-leg support creates a more unstable environment, which means that antagonist activity is higher and there is more work going to joint stability than actual movement. In other words, it makes pressing safer.

b. Once we get to the inseason period, it allows us to check two boxes with a single exercise: single-leg balance and upper body strength (plus serratus activation/scapular upward rotation).

3. Posterior pelvic tilt increases lower trap activation.

I've written about it a lot in the past: core positioning has an incredibly important impact on shoulder function. Check out this study on how reducing anterior pelvic tilt increases lower trapezius activation during arm elevation and the return from the overhead position.

In my experience working with extension-rotation athletes (particularly baseball players), one of the biggest risk factors for shoulder injury is when the lower trapezius can't keep up with the latissimus dorsi. Just consider the attachment points of the lat in the picture below; as you can imagine, if you posteriorly tilt the pelvis, the lat is inhibited, making it easier for lower trap to get to work.

The lower trapezius is very important for providing posterior tilt (slight tipping back) of the scapula and assisting in upward rotation. These two functions are key for a pitcher to get the scapula in the correct position during the lay-back phase of throwing.

By contrast, the lat has more of a "gross" depression effect on the scapula; it pulls it down, but doesn't contribute to posterior tilting or upward rotation. This might help with an adult rotator cuff pain patient who has an aggressive scapular elevation (shrug) substitution pattern, but it's actually problematic for a thrower who is trying to get his scapula up and around the rib cage to make sure that the ball-on-socket congruency is "flush" when it really matters: the maximal external rotation position.

As such, you can say that the lat and lower trap "compete" for control of the scapula - and the lat has a big advantage because of its cross-sectional area and multiple attachment points. It's also much easier to train and strengthen - even if it's by accident. Upper body work in faulty core positioning (in this case, too much anterior pelvic tilt and the accompanying lumbar extension) shifts the balance to the lats.

We'll often hear throwers cued "down and back" during arm care drills. The intention - improving posterior tilt via lower trap activation - is admirable, but the outcome usually isn't what's desired. Unless athletes are actually put in a position of posterior tilt where they can actually feel the lower traps working, they don't get it. Instead, they pull further down into scapular depression, which feeds the lat-dominant strategy. This is why we teach almost all our throwers to differentiate between depression and posterior tilt early on in their training at Cressey Sports Performance.

If you're looking to learn more about how I assess, program, and coach at the shoulder, be sure to check out my popular resource, Sturdy Shoulder Solutions. It's on sale for 30% off through Sunday at midnight; just enter the coupon code BASEBALL at checkout to get the discount. Learn more at www.SturdyShoulders.com.

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Troubleshooting the Side-Lying External Rotation

The side-lying external rotation is one of the most popular rotator cuff exercises in rehabilitation and "pre-habilitation" history, but in spite of its apparent simplicity, there are a few common mistakes I see folks make with it. Check out today's video to learn more:

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Baseball Strength and Conditioning Programs: How Much Rotator Cuff Work is Too Much? – Part 1

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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Strength Exercise of the Week: Prone External Rotation

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!

For more exercises along these lines, I'd encourage you to check out our Optimal Shoulder Performance DVD set.

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High Performance Training without the Equipment: Installment 2

It goes without saying that some of the absolute posterior rotator cuff exercises are cable external rotation variations.

Unfortunately - as you may have inferred from the title of this post - not everyone has access to a cable column or functional trainer where exercises like this can be performed.  To that end, I thought I'd devote today's post to a few exercises one can substitute to get a very similar training effect without cable access.

Option 1: Elbow-Supported DB External Rotation

This movement parallels that of the cable option, but all you need is a dumbbell and something to prop your upper arm.  The only downside is that the resistance just isn't as "continuous" throughout the range of motion - but it's still a good option.

Options 2 and 3: Horizontal Abduction Variations

While the recruitment patterns aren't going to be exactly the same, it's safe to say that you're getting almost all the same benefits when you do horizontal abduction work as with true external rotation work (and likely a bit extra scapular stabilization benefits).  Two variations I like:

Prone Horizontal Abduction off Table

Side-Lying Horizontal Abduction (I like to load this one up more eccentrically and focus on really controlling the load on the way down)

Option 4: Side-Lying External Rotations - arm abducted 30 degrees

This movement might not be the most "specific" of all rotator cuff exercises because of the position in which it occurs, but it does give you the best posterior cuff EMG of just about any drill.  We use it a ton, especially in those who may have pain with positions requiring more shoulder elevation.

These drills are just the tip of the iceberg in terms of the modifications you can use - and, indeed, what should comprise a comprehensive shoulder health program.  However, they should be enough to help you work around the lack of a cable in your resistance training arsenal.

For more information, check out our Optimal Shoulder Performance DVD set.

Related Posts

High Performance Training without the Equipment: Installment 1 Clearing up the Rotator Cuff Controversy

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Sports Rehab to Sports Performance Interview

Just a quick heads-up that Joe Heiler is running my interview from the Sports Rehab to Sports Performance Teleseminar Series tonight.  For some information on the interview, head HERE. Or, just head straight to the sign-up page.  There are a few more interviews in store, so you'd still be able to catch them (and access the previous ones from this year's series).

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The Single Dumbest Thing Trainers Do

This might come across as a completely random blog post, but in light of the time of year and the fact that I have five accountants in my family, I'm going to write it anyway.

If you are a trainer who does your own taxes, you are an idiot.

Yes, you're dumber than the guy doing handstand push-ups on the stability ball.  And, you're giving your money away and likely increasing your risk of being audited down the road.

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People come to you to learn how to get fit, more athletic, and healthy.  In your eyes, they'd be crazy to try to program or coach themselves.  And, just walk into any commercial gym and from the exercises and techniques you'll see executed, and you'll want to pull out your hair.  While accountants on the whole are generally very patient people, I'm sure they want to do the same when they hear about Average Joe sitting down for some quality team (read: three days) with Turbo Tax.

Imagine you're going to pay an accountant a few hundred dollars to do your taxes.  That's a few extra training sessions added to your week - and you aren't giving up any time to figure out the tax code (which is constantly changing).  You can read a book, have fun with your family, or do whatever else it is you enjoy.

Tony Gentilcore is one of my best friends and a business partner, so he won't mind me using him as an example.  In the summer of 2007, I watched Tony slave over Turbo Tax for an entire weekend.He had a puzzled look on his face the entire time.  When he was done (late Sunday night), I went over and asked him if he's deducted 7-8 different things that my accountant (my brother) taught me about that year.  He had no idea what I was talking about.

Tony is a guy that buys books, attends seminars, has professional memberships (NSCA, PETA, and the Chuck 'E Cheese Pizza of the Month Club).  None of these were deducted.  So, by attempting to "save" some money and do it himself, Tony missed out on a bunch of key deductions and overreported net income.  Say, for ease of calculation, that was $1,000 of expenses he didn't write off.  That means he reported $1,000 more net income - and in a (arbitrarily assigned) tax bracket of 30%, he gave Uncle Sam a $300 bonus - which would have more than paid for the cost of an accountant and freed up Tony's weekend to listen to do the robot, drool all over his Nora Jones CD, and attack stability balls with scissors.

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Now, here's an example of our business finances from our 2008 tax return that will really drive home the point.  When we opened Cressey Sports Performance in the summer of 2007, we had to put up $30,000 worth of renovations: walls, doors, carpeting, a ceiling for the offices, and painting, as we were subletting from another tenant and wanted to "separate" our space.  It went from this...

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To this...

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These renovations were placed on a 15-year depreciation schedule - so we got a $2,000 deduction from net income in year 1 (very few people would know to do this on their tax returns without an accountant).

Business grew quickly, and we decided to move (also a deduction) three miles east in May of 2008, which was the end of the lease we were under.  When we went, we had to demolish renovations to the old place (which was one of the funnest hours of my life, for the record) - but we also got to write off the remaining $28,000 from that depreciation schedule against our net income for 2008.  None of us would have even remembered to do that - but our accountant absolutely, positively did.  In the process, he saved us a ton of money that was rightfully ours and kept out balance sheet accurate - and it was no extra effort on our part.  That move alone probably saved us enough taxes to cover his accounting fees for 6-7 years - or the cost of our turf and crash wall combined.

Another example on my personal finances was the recommendation I received to maximize my contributions to a SEP IRA to lessen my net taxable income at this point in my life when I don't have any quality deductions - kids, a spouse (yet), or a mortgage (yet).  I'll be taxed on it down the road, but at least it's mine in the interim to grow it as I please (and I know there are different schools of thought on this, but you get the point).

Getting an accountant is an investment, not an expense.  And, the more diversified I have become in my revenue streams - from CSP, to products, to seminars - the more essential and valuable that investment has become.

You are an idiot if you are going it alone.  And, we just found out that our taxes will be going up yet again, so your mistakes are going to be further magnified.  I don't know why this happens so much in the fitness industry, but it absolutely does.  Find a good accountant.

Have a comment or question?  Post 'em below.

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Stuff You Should Read: 3/22/10

I had a great weekend at a Postural Restoration Institute Myokinematic Dysfunction course, so it seems fitting that my first reading recommendation of the week would direct you to their website: Postural Restoration Institute.  There are a lot of free articles that give you a good introduction to the PRI philosophy.  I'd highly recommend checking out their courses, as I'm going to be going more.  It was worth every penny. Does a SLAP lesion affect shoulder muscle activity as measured by EMG activity during a rugby tackle? - This is a really interesting study that shows that in athletes with labral tears (SLAP lesions), the serratus anterior fires sooner - presumably as a compensation strategy to make up for the slower reaction time of the biceps.

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It is just another example of how our body has a great system of checks and balances.  When a passive structure is injured, the active restraints can pick up the slack. For related reading, check out Active vs. Passive Restraints.
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Random Friday Thoughts: 3/19/10

1. I thought I'd kick this post off with a little technique troubleshooting.  Yesterday, one of the "guinea pigs" for my new project emailed this video to me and asked for some suggestions on bench press technique:

BP from Caleb Chiu on Vimeo. My suggestions to him were as follows: a. Your feet are antsy and jumping all over the place.  Get them pulled up a bit more under you so that they can't move around.  Then, focus on pushing them into the floor the entire set. b. Get more air in your belly.  Notice how the stomach sinks in?  That's because you don't have any air in it! c. Get a handoff.  The #1 reason guys flair the elbows out is that they lose scapular stability - and you lose that the second you hand off to yourself. 2. I'm headed to a Postural Restoration Institute Myokinematic Restoration Seminar this weekend up in Portland, ME - while my fiancee and my mother work on stuff for the wedding.  It is amazing what lengths guys will go to in order to escape wedding planning, huh? Just kidding; I'm actually really excited about it.  Neil Rampe of the Arizona Diamondbacks turned me on to the PRI stuff and it's really intrigued me from the get-go. 3. It's been a fun week around here with the start of the high school baseball season.  I got over to help out with some warm-ups and movement training with the Lincoln-Sudbury guys during tryouts on Mon-Tue.  In all, we saw 33 Lincoln-Sudbury high school baseball players - from freshman to seniors - this off-season, so it was pretty easy to pick up where we left off with them in the weight room.  There was great energy, and lots of excitement about the new season. 4. Here's a great feature on Blue Jays prospect Tim Collins and his training at Cressey Performance.

5. I was interviewed last week for an article about pitch counts.  It's now featured HERE.

6. Some feedback on Assess & Correct:

"I was pretty excited when I received an e-mail from Eric and Mike saying that I was getting an advanced copy of their new Assess and Correct product.  Mike and Eric have had a history of putting out top notch information and products and when I saw that Bill Hartman was also involved in this new product I knew that this was going to be even more special.

"Since I own a fitness facility, I'm always looking for cutting edge information that I can recommend to my trainers.  After viewing the DVDs and reading through the manuals, my first thought was, 'Wow, a home run!' "Finally, a product that I could wholeheartedly recommend to all of my trainers as an excellent go-to reference tool to enhance their abilities in assessing their clients needs; pinpointing their weakness &/or imbalances and then effectively addressing these findings to make sure their clients can achieve their goals safely." Joe Dowdell, CSCS - Founder & Co-owner of Peak Performance, NYC www.peakperformancenyc.com Click here to pick up a copy of Assess and Correct.

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7. Last, but certainly not least, CP athlete Danny O'Connor aims to run his professional boxing record to 11-o tonight with a bout at Twin River Casino in Rhode Island. Good luck, Danny!

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Optimal Shoulder Performance: Video Teaser #2 – Mike Reinold

A few weeks ago, I gave you a quick peek at an excerpt from one of my presentations in our new Optimal Shoulder Performance DVD set.  Today, I thought you might like to check out a bit from Mike Reinold, my collaborator on the project.  This DVD set should be out soon, so be sure to subscribe to my FREE newsletter if you want to be among the first notified.
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