3. Even less love as a posterior tilter of the scapula
4. Just about zero love for its impact on rib internal/external rotation.
Most importantly, you'll see that the upper fibers of the serratus anterior attach on the first rib - the very bone that's removed during thoracic outlet surgery.
Images by Anatomography - en:Anatomography (setting page of this image), CC BY-SA 2.1 jp, https://commons.wikimedia.org/w/index.php?curid=27010000
When the serratus fires, it depresses the first rib and clears space under the clavicle for important nerve and vascular structures to pass.
If you take a second to think about it while looking at the anatomy charts below, you'll appreciate that this attachment effectively makes serratus anterior an antagonist to the scalenes and subclavius, which both elevate the first rib.
This is one reason why a lot of the thoracic outlet syndrome cases you'll encounter aren't your classic kyphotic (hunchback) posture, but actually a lot of flat thoracic spine, heavy scapular downward rotation/depression, and horizontal clavicle presentations.
Getting serratus anterior going favorably impacts scapular upward rotation (which brings the clavicle up), first rib positioning, and the ideal convex-concave relationship between the rib cage and scapula.
Fun fact: serratus anterior also indirectly impacts contralateral thoracic rotation, but that's a post for another day!
If you're looking to learn more about how I assess, coach, and program for the upper extremity, be sure to check out Sturdy Shoulder Solutions.
Sign-up Today for our FREE Newsletter and receive a four-part video series on how to deadlift!
Today's guest post comes from Eric Schoenberg, the physical therapist at Cressey Sports Performance - Florida and a great resource to the entire CSP team. Enjoy! -EC
To get right to the heart of what I'm covering today, I think it's best that we start with a video:
So, as you can infer, the reason we're still talking about "down and back" is because we need to! Athletes are coming into the gym every week after multiple surgeries or drops in performance with postures and movement patterns that are faulty and easily correctible.
Obviously, the down and back concept is not the only reason for this, but the idea of driving our scapulae into maximal adduction (retraction), downward rotation, and depression is certainly something that we can control and improve upon.
To set the record straight, the only time an athlete should receive this cue is when their arms are by their side (Deadlifts, farmer’s walks, heavy dumbbell holds for lower body lifts). Once the humerus starts to move away from the side more than 20-30 degrees, the scapula needs to start moving in the appropriate direction to keep ball on socket congruency and reduce mechanical stress to the neighboring soft tissue structures (labrum, rotator cuff, neurovascular structures).
On the performance side of things, the “down and back” posture (scapular adduction, downward rotation, and depression) limit the ability to get the hand out in front or overhead. This has obvious implications in overhead athletes.
In the case of throwers, the difference in extension at ball release can vary by 3-4 inches depending on the position of the scapula. (as you can see in the comparison pics above and the video below).
When we don’t get full extension at ball release, any variety of downstream stresses can occur (aggressive elbow extension, lack of full pronation through the baseball) that result in increased injury risk and decreased performance.
As mentioned in the introduction video, we are bringing bad cues to good programming and it continues to result in faulty movement and injury. Even worse is when this “down and back” cue is brought into the rehabilitation setting and athletes that have already had surgery continue to experience symptoms similar to their pre-surgery presentation.
In conclusion, let’s continue to look at our cues and consider where the arm is in relation to the body when we decide to cue down and back. When the arms are by the side, then go ahead and cue the scaps down and back. However, when the arm is abducted to the side, overhead, layed back into ER, or out in front at ball release, we need to cue a degree of upward rotation and elevation to make sure the joint is aligned for success.
About the Author
Eric Schoenberg is a Physical Therapist and Strength Coach and the Owner of Diamond Physical Therapy located inside Cressey Sports Performance – Florida. Eric’s approach is to help athletes move more efficiently to reduce injury and improve performance. You can follow him on Twitter and Instagram at @csp_physicaltherapy, or email him at eric@diamondphystherapy.com.
Sign-up Today for our FREE Baseball Newsletter and Receive Instant Access to a 47-minute Presentation from Eric Cressey on Individualizing the Management of Overhead Athletes!
Not too long ago, I evaluated a baseball pitcher (left) and swimmer (right) back-to-back. It should serve as a reminder that not all overhead athletes are created equal - both in terms of the demands of their sports and the way they adapt to those demands.
The pitcher is a classic scapular depression example. Notice how “flat” the clavicle presentation is. He’s very lat dominant and struggles to get scapular elevation as part of upward rotation as the arms go overhead. He needs more upper trap activity.
Conversely, the swimmer is a scapular elevation presentation. Notice the significant upslope of the collarbone. He’s already so elevated that he struggles to get the rotational component of upward rotation. He needs more serratus anterior and lower trap, but less upper trap.
Three huge takeaways:
1. This is yet another reminder that you can’t just have a “rotator cuff program.” Both of these guys could present with the same pathology, but with completely different underlying movement diagnoses.
2. The same exercises might need to be coached differently for two different athletes
3. Whenever you see tightness, before you stretch it, ask why it’s there. With the pitcher in scapular depression, it’s a protective tension you don’t want to just stretch out. The swimmer could actually benefit.
Today's guest post comes from my good friend and Elite Baseball Mentorships colleague, Eric Schoenberg. Enjoy! -EC
In response to the tweet below and in preparation for the upcoming CSP Elite Baseball Mentorship in June, we decided to put together an article dedicated to the wall slide.
In this article, we will discuss the top 10 findings from a wall slide assessment. In addition, we cover examples of how different coaching cues can benefit the athlete not only in their sport, but more so, in a particular moment in their sport.
This leads to the thought of using the term movement or “moment-specific” training rather than the overused “sport specific” terminology.
Here is the Tweet/question (thanks, Simon). The direct answer will come at the end of the article.
Through many years of work and countless iterations, we have used and modified the pattern to allow for individualization of overhead activity in all body types and sports.
We use the wall slide as an assessment and an exercise every day with our athletes. It should be noted that the wall slide should serve as a bridge to any overhead activity (OH carries, landmine press, etc.) in your programming.
For each assessment finding using the Wall Slide Test, we use individual cues to assist the athlete in creating the desired movement correction. From there, we program the exercise into the warm-up or main program to help develop movement proficiency.
Here are ten reasons we use wall slides in our assessments:
1. Glenohumeral joint range of motion (ROM) – e.g. shoulder flexion
In the image below, we see Clint Capela and Andre Iguodala exhibiting adequate shoulder flexion, however, a slight lack of height, vertical jump, overhead strength, and timing may have resulted in the unfavorable result for AI.
2. Scapulo-thoracic joint ROM - e.g. scapular upward rotation and elevation
3. Cervical spine control – e.g. forward head tendency
4. Thoracic spine positioning – e.g. flat, extended vs. kyphotic, flexed
A clear illustration of the need to properly cue the Wall Slide and other overhead activities as it relates to the Thoracic Spine can be seen in the two pictures below.
a. OBJ’s catch shows elite thoracic extension in the overhead position. If Odell was an athlete that was more biased towards thoracic flexion, then his overhead mobility would be more limited and this iconic catch may have never happened. It is important to cue this pattern in the gym if it is required to happen on the field.
b. In contrast, CSP athlete and St. Louis Cardinals All-Star Miles Mikolas does not require thoracic extension when his hand is fully overhead. In fact, he needs to be in a position of thoracic flexion to help deliver the scapula, arm, and hand at ball release. This pattern must also be trained.
Note: This does not mean that Miles does not need thoracic extension to perform his job. It just means that he does not need to be trained into that position when his arm is fully overhead.
5. Lumbar spine positioning – e.g. excessive lumbar extension
6. Lumbo-pelvic stability – e.g. dropping into anterior pelvic tilt
7. Transverse plane alignment – e.g. spinal curvature or pelvic rotation
8. Lat length – e.g. athlete moves into humeral medial rotation at top of wall slide
In another example of the lat impacting overhead motion and movement quality, Rocky Balboa (not a CSP athlete, unfortunately!), shows a pattern of humeral medial rotation with overhead reaching. Interestingly, since his sport is not defined by vertical motion, but more so horizontal motion, Mr. Balboa does not require as much scapular upward rotation as a baseball player.
If we use the Pareto Principle (or the 80/20 rule), general fitness and athleticism should account for 80% of our training. However, the remaining 20% should be tailored to the movements, patterns, and positions that are unique to the athlete’s sport.
9. Motor Control - e.g. faulty scapulohumeral timing, inability to control scapulae eccentrically with arm lowering
10. Faulty activation patterns - e.g. overuse of upper trapezius vs. proper serratus and lower trapezius activation
In summary (and to answer the original question in the tweet above), the overhead reach (wall slide) is helpful to decrease upper trapezius involvement if the exercise is cued to do so. The ability to properly recruit serratus and lower trapezius to assist with scapular upward rotation will lessen the “need” for the upper trap to jump in too much. Remember, the upper trap does need to play a role in this movement, it just shouldn’t be doing all of the work.
As for the “extreme thoracic kyphosis” part…. It is important to first determine if this is a structural or functional issue. If it is structural, it will not change. In this case the wall slide can be used to train within this constraint to assist your client in finding solutions to get overhead. On the other hand, if the kyphosis is functional (meaning it can be changed), then the secret sauce is differentiating weakness, stiffness, shortness, and/or motor control issues as the reason for the kyphosis and difficulty getting overhead. The Wall Slide is a great tool to help tease that out to help your client.
If you want more information about this and many other aspects of the approaches that we utilize to manage the overhead athlete, please consider joining us June 23-25 at our Elite Baseball Mentorship program at CSP in Hudson, MA. The early-bird registration deadline is May 23.
This Cressey Sports Performance Elite Baseball Mentorship has a heavy upper extremity assessment and corrective exercise focus while familiarizing participants with the unique demands of the throwing motion. You’ll be introduced to the most common injuries faced by throwers, learn about the movement impairments and mechanical issues that contribute to these issues, and receive programming strategies, exercise recommendations, and the coaching cues to meet these challenges. For more information, click here.
About the Author
Eric Schoenberg (@PTMomentum) is a physical therapist and strength coach located in Milford, MA where he is co-owner of Momentum Physical Therapy. Eric is addicted to baseball and plays a part in the Elite Baseball Mentorship courses at Cressey Sports Performance. He can be reached at eric@momentumpt.com.
Sign-up Today for our FREE Baseball Newsletter and Receive Instant Access to a 47-minute Presentation from Eric Cressey on Individualizing the Management of Overhead Athletes!
Anyone who's followed this blog for any length of time knows that I'm a big fan of landmine presses for a number of reasons:
1. As a "free scapula" pressing exercise, they're an effective way to train scapular upward rotation.
2. They're much more shoulder friendly than overhead presses.
3. They provide a great core stability challenge.
4. You can implement a lot of variety in terms of stance (tall/half-kneeling, standing, split-stance, rotational, etc) and lower body contributions. This week's feature is a great highlight in this regard:
This drill fits well as a first exercise on a full body day and pairs well with horizontal or vertical pulling. I really like it late in the offseason when we're trying to keep sessions a bit shorter and get extra bang for our training buck. I'd do sets of 3-5 reps per side.
Sign-up Today for our FREE Newsletter and receive a four-part video series on how to deadlift!
If you've followed this blog for any length of time, you'll know that I'm a big fan of training the posterior chain and also working on getting serratus anterior firing to improve scapular upward rotation. So, you can imagine how excited I am to present to you an exercise of the week video that hits both. Thanks to Mets pitcher Noah Syndergaard for the demo:
I like this exercise as a first or second assistance exercise on a lower body day, or as part of a full body day. I love it when the late offseason rolls around and athletes have built up a solid foundation of strength, and are ready for more advanced arm care progressions. It's a game changer if you have an athlete who is heavily lordotic (arched back) with downwardly rotated/depressed shoulder blades and a flat thoracic spine (upper back). Enjoy!
Sign-up Today for our FREE Newsletter and receive a four-part video series on how to deadlift!
I recently started implementing the quadruped 1-arm trap raise to swimmer hover with some of our baseball guys, and it’s quickly become one of my favorites.
This drill addresses several important needs in a throwing population:
1. scapular posterior tilt
2. scapular upward rotation
3. tissue extensibility of the long head of the triceps and lat
4. the quadruped (all fours) position really reaffirms the good convex-concave relationship between the scapula and rib cage
You should not feel this at all in the front or top of the shoulder. Rather, the movement should be felt in the lower traps (mid back) and serratus anterior (add a full exhale at the top of each rep to intensify that activation). Some individuals will feel a good stretch through the triceps.
To learn more about how we assess, program, and coach at the shoulder girdle, be sure to check out Sturdy Shoulder Solutions.
Sign-up Today for our FREE Newsletter and receive a four-part video series on how to deadlift!
I see some of the lowest shoulders in history. This is a well-muscled guy who looks like his upper traps are non-existent because he sits in such significant scapular depression. Take note of the angle of his clavicles; normally, they should have an upslode from the sternoclavicular joint to the acromioclavicular joint, but in this case, they're actually downsloped. Wherever the scapula goes, the collarbone follows. In this presentation, expect to see tissue density in lats, subclavius, and scalenes (among other areas).
The most interesting discussion point, though, is what to do about that upper trap tightness. That tightness is protective tension: his body doing anything it possibly can to avoid dropping any lower into scapular depression. The upper traps are working to elevate the scapula against gravity all the time. If you give him a bunch of massage and stretching, it's like picking a scab; he'll feel better for 15 minutes, and then in rougher shape over the long haul. You never want to stretch out protective tension.
He'd had previous bouts of unsuccessful physical therapy, and while I had the benefit of hindsight here, it was clear that the unifying theme of these approaches was an emphasis on the one-size-fits-all "pull the shoulder blades down" cue that gets thrown around all too much and usually leaves this presentation in a tough spot while helping a lot of senior citizen rotator cuff pain cases. You can't one-size-fits-all cues because everyone moves differently.
We modified his training to avoid anything with heavy weights tugging the shoulders down (no deadlifts, walking lunges, farmer's walks, etc.) and instead trained the lower body with lots of front squat and goblet set-ups, plus sled work, glute-ham raises, and barbell supine bridges/hip thrusts. We cut back on lat dominant upper body work and instead chose drills like push-up variations and landmine presses that drove scapular upward rotation (and even prioritized elevation, which is borderline heresy in some rehab circles). We got his arms overhead more often during the warm-ups and integrated some manual therapy in the areas I noted earlier. I even encouraged him to do less unsupported sitting at work, too, because his upper traps were competing against gravity all the time (yes, there are actually times that standing desks make things worse).
Today, two weeks to the day after the evaluation, he's feeling significantly better - and training hard. Posture is the interaction of structure and function, and if you can't identify aberrant postures, you're simply guessing with how someone is going to respond to a given exercise.
Interested in learning more about what I look for when evaluating the upper extremity - and how my findings drive our programming and coaching cues? Check out Sturdy Shoulder Solutions (which is on sale for $50 off through Sunday at midnight) at www.SturdyShoulders.com.
Sign-up Today for our FREE Newsletter and receive a four-part video series on how to deadlift!
It's been a quiet week here on the blog because I'm still recovering from last week's Sturdy Shoulder Solutions product launch and the barrage of college athletes who are all starting up at CSP at the same time. Luckily, I do have some good content from around the 'net for you:
Pat Rigsby on Building Your Ideal Fitness Business - Pat Rigsby is the man. I got this email from Mike Robertson in my inbox this morning and cleared time in my schedule to listen to this podcast right away. He always has great business insights for fitness professionals.
Lessons Learned from a Bum Elbow - I posted this story on my Facebook page the other day, and there are a lot of lessons in here for fitness professionals and rehabilitation specialists, especially those who deal with throwing athletes.
Top Tweet of the Week
If the shoulder blade is going one way while the arm goes in the other direction, you're going to run into problems. This athlete's shoulder discomfort goes away when the shoulder blade is guided away from the spine and into upward rotation. Learn more: https://t.co/ZOKzZlG02epic.twitter.com/FaVKzWclmk
It's a rainy day in Massachusetts - which is the perfect time to compile some recommended reading for the week. Check it out:
Diagnosis and Treatment of Movement Impairment Syndromes - I'm throwing this one in there because it's probably been the single most influential book on my development as a coach. It was first published 17 years ago, but I still finding myself referencing it regularly - including this week. If you're in the fitness or rehabilitation worlds, give it a read.
Behold the Transformation of Noah Syndergaard - This was an excellent Sports Illustrated article that took a look at the pitch selection modifications that Cressey Sports Performance athlete and Mets pitcher Noah Syndergaard has made over the years.
We currently have 4 free agent LHPs who sit 91-93, 90-92, 92-95, & 93-96mph. 15 yrs ago, there probably weren’t 100 LHPs w/this much velo in the entire US at any level. Game has changed dramatically; velocity alone won’t get you to where you need to be. It’s just a prerequisite.
