Home Posts tagged "Shirley Sahrmann"

Movement vs. Medical Diagnoses

Recently, during my weekly Instagram Q&A, I received this question:

"Have you ever dealt with valgus extension overload syndrome and how?"

My initial response was, "Absolutely - and with every single overhead throwing athlete I've ever encountered."

You see, "valgus extension overload" simply described the two most common injury mechanisms in throwers. Your elbow can get hurt at lay-back (max shoulder external rotation) or full elbow extension. This terminology doesn't describe a specific tissue pathology, nor an underlying movement competency that is insufficient and therefore allowing an individual to become symptomatic. To me, it's a completely incomplete "diagnosis." Let's dig deeper.

You have medical diagnoses and movement diagnoses. Both are important.

A medical diagnosis might be a rotator cuff tear, MCL sprain, or tibial fracture. These deviations speak directly to the damaged tissue and relate the severity of this structural change.

A movement diagnosis (popularized by physical therapist Shirley Sahrmann) might be scapular downward rotation syndrome, femoral anterior glide syndrome, or lumbar extension-rotation syndrome. These diagnoses speak to the deviation from normal movement that’s observed.

At times, both types of diagnoses are bastardized.

On the medical side, examples would include “shoulder impingement,” “shin splints,” and “valgus-extension overload.” All of these flawed medical diagnoses speak to a region of the body, but not a specific structure.

On the movement side, examples would be vague things like “weak posterior chain,” “scapular dyskinesis,” or “poor stability.” They don’t speak to the specific movement competencies that need to be improved.

I'm all for simplifying things as much as possible. However, diagnosis is an area where oversimplifying is completely inappropriate. Diagnosis is what establishes the road map for the journey you're about to begin - so make sure to eliminate any guesswork in this regard, whether it's on the medical or movement side of things.

Looking to learn more about how we assess and correct movement inefficiencies - and relate them to the rehabilitation and prevention of common medical diagnoses? Be sure to check out the Functional Stability Training series from Mike Reinold and me. It's on sale for 25% off through this Tuesday at midnight. Just head to THIS LINK and enter coupon code allstar2019cressey to get the discount.

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10 Reasons to Use Wall Slides

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.

The wall slide was born through the work of Shirley Sahrmann and outlined in her book – Diagnosis and Treatment of Movement System Impairments.

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.


Source: https://www.cbssports.com/nba/news/rockets-vs-warriors-clint-capela-meets-andre-iguodala-at-the-rim-with-incredible-two-handed-block/

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.


Source: https://ftw.usatoday.com/2014/11/odell-beckham-catch-new-york-giants-replay-youtube-vine-gif

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.


Source: https://www.albanyherald.com/sports/cardinals-sign-pitcher-miles-mikolas-to--year-extension/article_7c3fec36-4408-5ce6-a053-3659320329c1.html

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.


Source: https://www.phillyvoice.com/lesson-fake-news-faux-call-removal-rocky-statue/

 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.

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Exercise of the Week: Wall Slides with Upward Rotation and Lift-off to Swimmer Hover

With this week’s $50 off sale on Sturdy Shoulder Solutions, I wanted to introduce a new drill I’ve started using. The wall slide with upward rotation and lift-off to swimmers hover effectively blends two schools of thought: Shirley Sahrmann’s work and that of Functional Range Conditioning.

1. With the wall slide portion, we drive scapular upward rotation.

2. With the lift off portion, we get scapular posterior tilt and thoracic extension (as opposed to excessive arm-only motion).

3. With the swimmer hover, we lengthen the long head of the triceps and even drive a little bit more serratus anterior recruitment as the scapula rotated around the rib cage.

Get exposure to multiple philosophies and have an appreciation for functional anatomy, and the exercise selection possibilities are endless. Learn more at www.SturdyShoulders.com.

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Making Movement Better: Different Paths to the Same Destination

Lately, I've been posting more training pictures and videos on my Instagram page. The other day, I posted this video, and it led to some good discussion points that I think warrant further explanation:

One responder to the video asked the following:

You had an Instagram post the other day about an athlete not being able to differentiate between hip and lower back extension. I have a client with what seems to be a similar problem and just wondered how you generally go about teaching them the difference.

The answer to this question really just rests with having a solid set of assessments that help you to understand relative stiffness. I was first introduced to this concept through physical therapist Shirley Sahrmann's work. Relative stiffness refers to the idea that the presence or lack of stiffness at one joint has a significant impact on what happens at adjacent joints, which may have more or less stiffness. Without a doubt, if you've read EricCressey.com for any length of time, the most prevalent example of this is a shoulder flexion substitution pattern. 

In this pattern, the "bad" stiffness of the lats (among other muscles) overpowers the lack of "good" stiffness in the anterior core and deep neck flexors - so we get lumbar extension (arched lower back) and forward head posture instead of the true shoulder flexion we desire. Truth be told, you can apply these principles to absolutely every single exercise you coach, whether it's an 800-pound squat or low-level rotator cuff exercise.

As an example, when you cue a wall hip flexor mobilization, you're working to reduce bad stiffness in the anterior hip while cueing an athlete to brace the core and activate the trailing leg glute. That little bit of good stiffness in the anterior core prevents the athlete from substituting lumbar extension (low back movement) for hip extension, and the glute activation creates good stiffness that impacts the arthrokinematics of the hip joint (head of the femur won't glide forward to irritate the anterior hip during the stretch). 

In the upper extremity, just use this back-to-wall shoulder flexion tutorial as an example.The "reach" would add good stiffness in the serratus anterior. The shrug would add good stiffness in the upper traps. The "tip back" would add good stiffness in the lower traps. The double chin would add good stiffness in the deep neck flexors. The flat low back position would add good stiffness in the anterior core. Regardless of which of these cues needs the most emphasis, the good stiffness that's created in one way or another "competes" against the bad stiffness - whether it's muscular, capsular, bony, or something else - that limits overhead reaching.

Returning to our prone hip extension video from above, if we want to get more hip extension (particularly end-range hip extension) and less lumbar extension, from a purely muscular standpoint, we need more "good stiffness" in rectus abdominus, external obliques, and glutes - and less stiffness in lumbar extensors, lats, and hip flexors. As the question received in response to the video demonstrates, though, this can be easier said than done, as different clients will struggle for different reasons.

Sometimes, it's as simple as slowing things down. Many athletes can perform movements at slow speeds, but struggle when the pace is picked up - including when they're actually competing.

Sometimes, you can touch the muscle you want to work (tactile facilitation). Spine expert Dr. Stuart McGill has spoken in the past about "raking" the obliques to help create multidirectional spinal stability. I've used that cue before with this exercise, and I've also lightly punched the glutes (male athletes only) to make sure athletes are getting movement in the right places.

Sometimes, a quick positional change may be all that's needed. As an example, you can put a pad under the stomach to put the lumbar extensors in a more lengthened position. In fact, doing this drill off a training table (as demonstrated above) was actually a positional change (regression) in the first place; we'd ideally like to see an athlete do this in a more lengthened position where he can challenge a position of greater hip extension. Here are both options:

Sometimes, a little foam rolling in the right places can get some of the bad stiffness to calm down a bit. Or, you might need to refer out to a qualified manual therapist to get rid of some "tone" to make your coaching easier. I do this every single day, as I have great massage therapists on staff at both our Florida and Massachusetts Cressey Sports Performance facilities.

manual_therapy_page-300x206-2

Sometimes, a little positional breathing can change the game for these athletes, as it helps them to find and "own" a position of posterior pelvic tilt while shutting off the lats.

TRXDeepSquatBreathingWithLatStretch

The take-home point here is that there are a lot of different ways to create the movement you want; coaching experience and a working knowledge of functional anatomy and relative stiffness just help you get to the solutions faster and safer.

coachingtweet

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Preventing Pitching Injuries: You Get What You Train

Today's guest post comes from my friend and college, physical therapist Eric Schoenberg.  Eric is an integral part of our Elite Baseball Mentorships, and will be contributing more and more regularly here to outline some of the topics we'll cover in these mentorships.

As this great article from Tom Verducci at Sports Illustrated pointed out a few years ago, injuries cost MLB clubs $500 million dollars (an average of $16+ million/team) in 2011. In addition, over 50% of starting pitchers in MLB will go on the disabled list each year. Although there are many factors that contribute to these staggering numbers, an overwhelming majority of these injuries are due to five simple words:

"You Get What You Train."

This saying was made popular by the great physical therapist Shirley Sahrmann in her work at Washington University in St. Louis. This premise (in baseball terms) covers almost every issue that we encounter in the areas of injury prevention and performance enhancement. Here are some examples to illustrate the point:

  • If a pitcher is allowed to throw with bad mechanics (misuse), the result is a kid who is really good at throwing wrong and an increased risk of injury.
  • If high pitch counts (overuse) are allowed at a young age, the result is a pitcher throwing with fatigue, mechanical breakdown, and ultimately decreased performance and injury.
  • If a pitcher “throws with pain” (poor communication) due to pressure from coaches, parents, and teammates (culture of baseball), the result is compensated movement, decreased performance, and ultimately injury.
  • If a “one-size fits all approach” is rolled out in a strength and conditioning program or a pitching academy, then the result will be a program that doesn’t adequately “fit” anyone.
  • If performing “arm care programs” and long toss programs incorrectly before a game or practice is the norm, then the result will be athletes that are improperly “tuned” neurologically and fatigued before they even step on the mound for their first pitch.
  • If a hypermobile athlete performs a stretching program to “get loose”, then the result will be an athlete that has more instability than he can handle ultimately will get injured.
  • If we teach an athlete to get his shoulder blades “down and back” when his throwing shoulder is already depressed and downwardly rotated, then what we get is more strength in a dysfunctional position.
  • If we don’t teach proper movement, then we will get exactly what we train. The correct exercise performed incorrectly is a bad exercise.

This point is illustrated in the videos below. In the first video, the only instruction given to the athlete was to hold the top of a pushup on the elevated surface. As you can see, there is clear dyskinesia in the scapulae which if repeated without correction would result in reinforcement of the faulty movement pattern. Without actually seeing the shoulder blades (shirt off) or at the least putting your hands on the athlete, this faulty pattern is missed and the athlete will get worse.

In the next video, the athlete is instructed to get into the same position, however the athlete is cued to “engage the shoulder blade muscles and don’t let the shoulder blades come off your ribcage”. This simple cue can be coupled with some manual correction to activate the proper muscles to achieve a proper movement pattern.

In summary, both of these videos can be called a “pushup hold” or “elevated plank,” but only one achieves the desired movement and activation pattern.

This concept of “you get what you train” becomes a bigger problem when you realize that baseball players rarely play for the same coach or in the same “system” for more than a year or two (different leagues/levels, coaching changes, etc.). In addition, it takes a while before faulty movements and overuse reach the threshold where an athlete becomes symptomatic. As a result, there is no direct cause and effect and no “blame” to assign. A coach that overuses a kid in his 13 year-old season is never identified to be the actual cause of that same kid’s UCL tear in his 16 year-old season. This lack of accountability is a huge factor in the injury epidemic across all levels of baseball.

The goal of the Elite Baseball Mentorships is to bring together leaders in the baseball and medical communities in an effort to be proactive and share ideas to help improve the overall health of the game of baseball and its players.  We'd love it if you'd join us for one of these events; please visit www.EliteBaseballMentorships.com for more information.

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Fitness Professionals: Figuring Out Your Learning Style

One of the more profound realizations any fitness professional can make is that not all clients and athletes learn the exact same way.  Some athletes simply need to be told what to do.  Others can just observe an exercise to learn it. Finally, there are those who need to actually be put in the right position to feel and exercise and learn it that way.  And, you can even break these three categories down even further with more specific visual, auditory, and kinesthetic awareness coaching cues.

These learning styles aren't specific to the athletes' training experience, demeanor, intelligence, injury history, or previous coaching experiences.  I've had professional athletes and very inexperienced athletes from various walks of life in each categorization.  People are just wired the way they're wired, and you're better off working with that, as opposed to changing it.

Every good fitness professional gets to this realization eventually on the coaching front, but I'm constantly amazed at how individuals never stop to consider how it might apply to their own learning.  In other words, just like you can make faster fitness progress when you have the right cues, you can also acquire a lot more knowledge as a coach when you appreciate your own unique learning style.  Let me explain.

I'm an auditory and visual learner.  I can watch a DVD, read a book, or listen to a presenter and retain information very well.  I find hands-on sessions at seminars to be far less productive than lectures.  I don't get excited about going to seminars that are just full days of exercise; I'd rather just read the handouts or watch a DVD of the event at 8x fast-forward (yes, I often watch DVDs in fast forward).  This makes me dramatically different than most fitness professionals, though.  In my experience, far more than half of attendees at seminars thrive in the hands-on components, and struggle to learn and apply knowledge from reading book chapters.

What does this mean for you?  Very simply, you need to figure out what your learning style is and then plan your continuing education accordingly. 

If you do well with hands-on learning, attending a workshop with 1,500 attendees probably isn't going to be a great learning experience for you. A 600-page book would probably bore you to death. You'd be better off seeking out a more intimate learning experience like a mentorship - or even just hiring a personal trainer you respect to coach you through something you'd like to learn.

If you're more like me and do well with just reading or listening, a lecture-based experience might work great, even with a larger crowd.  And, books might be a much more affordable option for continuing education, as you can get a ton of information without travel expenses.

If you're an observational learner, make sure that you get to seminars (like the Perform Better tour) that have practical components to complement the lectures.  Pick up DVDs and order webinars in lieu of buying books.  And, make trips to visit other gyms to learn; we have trainers come to visit us at Cressey Sports Performance all the time, for example.

cspfamily

The great thing about technology in today's society is that it's made the same great information available via multiple mediums.  If you want to learn Shirley Sahrmann's methods, for instance, you can read her books, watch her DVDs, go take a course with her, or study in a fellowship until a therapist who has trained under her.  And, you can even pursue all of these avenues with someone who has previously learned from her, but figured out how to relate information in a manner that might be more user-friendly for you. 

The sky is the limit; you just need to figure out what works best for you.

This is one reason why I'm so proud of the resource we've put together with Elite Training Mentorship.  It combines in-service lectures, articles, exercise demonstrations, sample programs, and case studies all in one place; there is something for everyone.  If you haven't checked it out already, I'd encourage you to do so.

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15 Static Stretching Mistakes

One of the most debated topics in the strength and conditioning world in recent years has been whether or not static stretching is necessary and, if so, when it should be implemented.  While I don't think everyone needs it, and that there are certainly are times when it is a bad idea to utilize, I'm still of the mindset that it can have some solid benefits when implemented properly. 

Unfortunately, like all training initiatives, some people do it all wrong. To that end, I wanted to devote today's article to covering the top 15 static stretching mistakes I encounter.

Mistake #1: Stretching through extreme laxity.

This is the most important and prevalent one of all, so it comes first.  When I see someone doing this, this is pretty much how I feel:

We're all have a different amount of congenital laxity.  Basically, this refers to how much "give" our ligaments have.  Some folks have naturally stiff joints, and others have very loose joints.  This excessively joint laxity is obviously much higher in females and younger populations, but, as Leon Chaitow and Judith DeLany discuss in Clinical Applications of Neuromuscular Techniques: Volume 1, it is also much higher in folks of African, Asian, and Arab origin.

When you take someone who is really lax and implement aggressive static stretching, it's on par with having someone with a headache bang his/her head against a wall.  It makes things worse.

This is a tricky thing to understand, though, because many of these "loose" individuals will comment on how they feel "tight."  Usually that tightness is just them laying down trigger points as a way for the body to create stability in areas where they are chronically unstable.  They'd be better off working on stability training to get back to efficient movement.

I think yoga has a tremendous amount of applications and we borrow from the discipline all the time, but I think this is where many modern yoga classes fall short; they have everyone in the class go to the same end-range on certain exercises. Folks with serious joint laxity should not only contraindicate certain yoga poses, but also modify others so that they're training stability short of the true end-range of their joints. Unfortunately, most of the people you'll see in yoga classes are hypermobile women; you see, they like to do the things they're good at doing, not necessarily what they need to do.

How do you know if you're lax, though? I like to use the Beighton hypermobility scale to assess for both generalized congenital laxity and specific laxity at a joint. The screen consists of five tests (four of which are unilateral), and is scored out of 9:

1. Elbow hyperextension > 10° (left and right sides)
2. Knee hyperextension > 10° (left and right sides)
3. Flex the thumb to contact with the forearm (left and right sides)
4. Extend the pinky to >90° angle with the rest of the hand (left and right sides)
5. Place both palms flat on the floor without flexing the knees

Beighton_Score

One of the biggest problems I see in today's strength and conditioning world is that we assume all "big, strong" athletes are tight and need aggressive stretching.  As an example, take a look at this high Beighton score in a 6-3, 240-pound athlete.  We do very little static stretching with him - and absolutely none in the upper body.

If someone is really lax, nix the static stretching and instead spend more time on stabilization work.  If they still feel like they need to "loosen up," tell them to do some extra foam rolling.  They'll transiently reduce some of the stiffness they're feeling, but they won't be working through harmful end-range joint range-of-motion in the process.

Mistake #2. Substituting knee hyperextension for hip flexion in hamstrings stretches.

This comment piggybacks a little bit on mistake #1, as lax individuals (who probably shouldn't be stretching their hamstrings, anyway) are the most likely to have problems with this.  Because the hamstrings are two-joint muscles (knee and hip), folks will often allow the knee to "give" extra because they are subconsciously trying to avoid an uncomfortable stretch at the hip - or they simply aren't paying attention.  These are the same folks who have terrible hip hinges on toe touch tests, yet can touch their toes without a problem; they just go to knee hyperextension to make it happen.  As an example, this particular athlete scores really high on the Beighton hypermobility score, and he can actually put his palms flat on the floor with little to no posterior weight shift (the wall blocks him). 

How does he do it? Knee hyperextension. 

We'd much rather get a good hip hinge without resorting to excessive joint range of motion at the knee. You get good at what you train, so if you're always doing your static stretching in a bad position, you're going to be more likely to wind up in knee hyperextension on the field - and that's where ACL injuries occur.

Mistake #3: Not creating stiffness at adjacent joints.

In a previous post, I talked about why stiffness can be a good thing, in spite of the negative connotation of the word.  Stiffness is a crucial part of keeping us healthy and enhancing athleticism.  "Good" stiffness allows us to overpower "bad" stiffness that's occurring in the wrong places, and it helps to transfer force as part of the kinetic chain.  Static stretching can either be an opportunity to foster good stiffness or develop bad habits.

You see, we static stretch to transiently reduce stiffness (or true tissue shortness).  However, if we don't stabilize (stiffen up) adjacent joints, it defeats the purpose. Let me give you an example.

Let's say that I want to stretch my hamstrings in the supine position with not just a neutral position (center), but also a bias toward internal rotation/adduction (left) and external rotation/abduction (right).


 



 

 

Now, let's see what happens to these stretches if one doesn't engage the lateral core to prevent the pelvis from rolling toward the direction of the stretch on the ones that go out to the sides.

Mistake #4: Irritating the medial aspect of the knee with 90/90 hip stretches.

Most folks are familiar with doing 90/90 hip stretches or cradle walks as a way to improve hip external rotation in a position of hip flexion.  This is the position I commonly see people using at the point of maximal stretch:

The problem is that many folks crank excessively on the medial aspect of the knee by rotating the tibia (lower leg) instead of the femur (upper leg).  This actually parallels what happens during a McMurray's Test for medial meniscus pathology:

It's a pretty safe bet that static stretching into a position that replicates a provocative test is never a good idea - and it's one reason we use 90/90 stretches very sparingly.  If you are going to use this stretch, however, I recommend that individuals grab the quadriceps on the stretching side to ensure that the majority of the pull into external rotation and flexion comes from the femur and not the tibia.  The opposite hand is simply there to support the weight of the lower leg.

Mistake #5: Substituting valgus stress at the knee for hip adduction/internal rotation stretching.

It's really important than folks have adequate hip internal rotation, as a loss of hip internal rotation has been correlated with low back pain, and it can certainly predispose individuals to hip and knee issues as well. The knee-to-knee stretch is a popular approach for maintaining and improving hip internal rotation, and it's also my chosen method for demonstrating how incomplete my goatee was at the time of this picture.  

lyingkneetoknee

As you can see from the picture, this position can also impose some valgus stress at the knees if it isn't coached/cued properly.  So, instead of thinking of letting the knees fall in, I tell athletes to actively internally rotate the femurs (upper leg).  The stretch should occur at the hips, not the knees.

In folks with a history of medial knee issues, we won't use this static stretch.  Rather, we'll use a kneeling glute stretch, which still gets a bit of stretch into adduction, which will still stretch several of the hip external rotators indirectly.

Lastly, keep in mind that the knee-to-knee isn't a stretch most females will ever have to utilize because of their tendency toward a knock-knee posture (wider hips = greater Q-angle) at rest.

Mistake #6: Not monitoring neutral spine during hip stretching.

This point really works hand-in-hand with #3 from above, which talked about establishing stiffness at adjacent joints.  Certainly, maintaining neutral spine falls under the category of "good stiffness," but because it's such a common mistake, it deserves attention of its own.  When the hip flexes, you shouldn't go through lumbar flexion. For this split-stance kneeling adductor stretch, notice the correct on the left and the incorrect on the right:

And, when it extends, you shouldn't go through lumbar extension.  Again, the correct is on the left, and incorrect (hyperextended) is on the right:

Mistake #7: Not monitoring neutral spine during standing stretches.

Again, this is another point that piggybacks off of establishing good stiffness, but I see a lot of people doing upper extremity stretches - overhead triceps, lats, pecs - in terrible spine posture.  Perhaps the best example is the overhead triceps stretch with the lumbar spine in hyperextension, plus forward head posture further up.

Mistake #8: Stretching your lower back.

There may be times when a qualified manual therapist might want to do some mobilizations on your lower back. The rest of you really shouldn't be stretching your spine out. Stretch your hips, and mobilize your thoracic spine (upper back), where it's much safer for you to move. Focus on building up some core stability.

Mistake #9: Stretching your calves – and then wearing high heels the rest of the day.

There's nothing wrong with the "stretching your calves" part; it's the high heels part that makes me want to bang my head against the wall. Talk about a dog chasing its tail!

Mistake #10: Stretching a throwing shoulder into extension and/or external rotation (and creating valgus stress at the elbow in the process).

I devoted an entire video to this topic last week in my baseball-specific newsletter:

Mistake #11: Stretching through pain or neurological symptoms.

I honestly can't think of a single reason why anyone should ever stretch oneself through pain. Sure, there may be times when physical therapists may push a post-operative joint through some uncomfortable ranges of motion, but that's a trained professional making a educated decision.  You stretching yourself through pain is just throwing a bunch of s**t on the wall to see what sticks.  Don't do it.

Sometimes, an indirect approach is better.  As an example, there is research demonstrating that core stability exercises can transiently and chronically improve hip internal rotation - even without stretching the joint.  If you're hurting while stretching, see a qualified medical professional to help you devise a plan to work around the issue while reducing your symptoms.

On the topic of neurological symptoms, as an example, intervertebral disc issues with radicular symptoms into the legs may be exacerbated by stretching the hamstrings.  Similar issues can come about if folks with thoracic outlet syndrome perform aggressive upper body stretching. If nerves aren't gliding the way that they need to be, the last thing you want to do is yank on them.

Mistake #12: Not tightening the glutes during hip flexor stretches.

I've written previously at length about how anterior (front) hip irritation is often caused the head of the femur (ball) gliding forward in the acetabulum (socket) during hip extension.  This femoral anterior glide syndrome (described in detail here), was originally introduced by physical therapist Shirley Sahrmann.  Effectively, the hamstrings have a "gross" hip extension pull - meaning that they don't have a whole lot of control over the head of the femur.  Therefore, we need to have great gluteus maximus contribution to hip extension, as the glute max posteriorly pulls the femoral head back during hip extension so that the anterior hip capsule doesn't get irritated.

What we don't consider, however, is that if we stretch a hip into hip extension (osteokinematics), we also need that glute contribution to control the glide (arthrokinematics) of the femoral head.  This is a definite parallel to what I described earlier with respect to stretching a throwing shoulder into extension or external rotation; you don't just want to do it carelessly. As such, whenever you stretch the hip into extension, make sure that you tighten up the glute:

Mistake #13: Stretching into a bony block.

There are a lot of things that may limit range of motion at a joint.  It could be muscular shortness/stiffness, capsular tightness, muscular bulk, swelling, or guarding due to injury.  In many cases, though, it simply has to do with the congruency of the bones (or lack thereof) at a joint.

In the case of a "fresh" bone spur or loose body at the posterior aspect of the elbow, aggressively stretching into extension could easily provoke symptoms.  Conversely, I've seen some elbows with flexion contractures that are a combination of bony blocks and subsequent tissue shortening and capsular tightening that can be stretched until the cows come home with no problem. 

Each case is unique - but at the end of the day, remember that you're better off being too tight than too loose.  In other words, if you're unsure about something, don't stretch it.

Beyond just reactive changes like bone spurs and loose bodies, we also have folks who simply have different congenital or acquired bone structures.  Many individuals have retroverted (externally rotated) or anteverted (internally rotated) femoral carrying angles.  Those in retroversion will lack hip internal rotation no matter how much you stretch them, and those in anteversion aren't going to be gaining external rotation no matter what you do.  Trying to power through these bony blocks will likely create hip discomfort as well.

We also see retroversion as an adaptation in throwing shoulders, where bones "warp" to allow for more lay-back during the extreme cocking phase of throwing.  This is why most throwers will have significantly less internal rotation on the throwing shoulder than on the non-throwing shoulder in-spite of the fact that they have symmetrical total motion (IR + ER) from side to side; they simply shift their arc.

Before you stretch, you better find out if it's bone or soft tissue that is limiting you at end-range.  If it's bone, you're better off leaving things alone.

Mistake #14: Putting the band behind your head during hamstrings stretching.

This one drives me bonkers.  It screams "I know stretching isn't hard to do, but I'm still too lazy to put any semblance of effort into doing it correctly."  Why create forward head posture and neck stress when stretching the hamstrings?

Mistake #15: Not monitoring your breathing.

Nowadays, I'd say that we do just as much "positional breathing drills" as we do actual stretches. The more I learn (particularly from the Postural Restoration Institute school of thought), the more I realize that breathing in specific positions can have a dramatic effect on reducing tissue stiffness. For instance, here is one that many of our right-handed pitchers do. 

The left femur is internally rotated and adducted, the left rib flare is "tucked," right thoracic rotation is encouraged, the lumbar spine is flat, and the right shoulder blade is fully upwardly rotated with a bit of upper trap activation. We cue the athlete to inhale through the nose without allowing the rib cage to "fly up," and then encourage him to exhale fully, allowing the ribs to "come down."

We stretch to reduce tone, not increase it - and most athletes are in a constant state of inhalation, which corresponds to a big anterior pelvic tilt and lordotic curve. 

APT-250x300

When the rib cage flies up like this, we lose our Zone of Apposition (ZOA), a term the PRI folks have coined to describe the region into which our diaphragm must expand to function.

Zone-of-Apposition-300x220

In this extended posture, rather than effectively use their diaphragm, athletes will overuse supplemental respiratory muscles like lats, sternocleidomastoid, scalenes, and pec minor - and these are all areas where we're always trying to reduce tone.

Teaching athletes how to control their breathing during stretching - and paying particular attention to fully exhaling on each breath - goes a long way to help reduce sympathetic nervous system stimulation, get rid of unwanted tone in the wrong places, effective favorable changes to posture, and make the most of the stretches you're prescribing.  I think the folks in the yoga and Pilates worlds have done a good job of drawing attention to the importance of breathing, and we should appreciate that with respect to how static stretching and dynamic flexibility drills are implemented.

Conclusion

There are really only 15 mistakes that were right on the tip of my tongue - to the tune of 2,800 words!  To reiterate, I have a lot of clients/athletes who do absolutely no static stretching, but that's not to say that it can't be of benefit to a good chunk of the population.  Just remember that each body is unique, so no two static stretching programs should be alike in terms of exercise selection and coaching cues. 

If you benefited from this article, please share it via Facebook or Twitter, as this is a very misunderstood topic in the world of health and human performance.  Thanks for your support!

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What the Strength and Conditioning Textbook Never Taught You: Synergists and Antagonists

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.

glutemax

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.

sahrmann

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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Down on Lumbar Flexion in Strength Training Programs? Enter the Reverse Crunch.

The other day, I got an email from another fitness professional saying that he really liked my Maximum Strength training program, but that he'd have left out the reverse crunches if it was his strength training program because he "doesn't use any lumbar flexion work" in his programming anymore.

Given that the book was published in 2008, I'd gather that he is under the assumption that I've jumped on board the anti-flexion bandwagon that's been piling up members in droves over the past 3-4 years.  That perception certainly has backing.  Afterall, if you want to herniate a disc, go through repeated flexion and extension at end range.  If you want to see a population of folks with disc herniations, just look at people who sit in flexion all day; it's a slam dunk.

And, you certainly don't want to go into lumbar flexion with compressive loading.  As far back as 1985, Cappozzo et al. demonstrated that compressive loading on the spine during squatting increased with lumbar flexion.

These points in mind, I'm a firm believer that you should avoid:

a) end-range lumbar flexion

b) lumbar flexion exercises in those who already spend their entire lives in flexion

c) lumbar flexion under load

It seems pretty cut and dry, right?  Don't move your lumbar spine and you'll be fine, right? Tell that to someone who lives in lumbar hyperextension and anterior pelvic tilt.  Let me make that clearer:

Flexion from an extended position to "neutral" is different than flexion from "neutral" to end-range lumbar flexion.

In the former example, we're just taking someone from 20 yards behind the starting line up to the actual starting line.  In the latter example, we're taking someone from the starting line, through the finish line, and then violently through the line of people at the snack shack 50 yards past the finish line as nachos and Italian ice fly everywhere and the spectators scurry for cover.  You get a gold star if you take out the band, too.

If you're someone who trains predominantly middle-aged to older adult clients, by all means, nix flexion exercises.  However, I deal with loads of athletes - most of whom live in lumbar extension and anterior pelvic tilt.

Now, I'll never be a guy who has guys doing sit-ups or crunches, as they can shorten the rectus abdominus, thereby pulling the rib cage down when we're working hard to improve thoracic extension and rotation.  Additionally, most athletes absolutely crank on the neck with these - and that leads to a host of other problems.

For reasons I outlined in a recent post, Hip Pain in Athletes: The Origin of Femoroacetabular Impingement, we need to work to address anterior pelvic tilt and excessive lumbar extension - which can lead to a "pot belly" look even in athletes who are quite lean.

Enter the reverse crunch, which selectively targets the external obliques over the rectus abdominus.  As Shirley Sahrmann wrote in Diagnosis and Treatment of Movement Impairment Syndromes, "The origin of this muscle from the rib cage and its insertion into the pelvis are consistent with the most effective action of this muscle, that is, the posterior tilt of the pelvis."

We utilize the reverse crunch as part of a comprehensive anterior core strengthening program that also includes progresses from prone bridging variations to rollout variations and TRX anterior core work (and, of course, anti-rotation exercises to improve rotary stability).  And, I can say without hesitate that this addition was of tremendous value to an approach that got cranky baseball hips and spine healthier faster than ever before at Cressey Performance.

In summary, remember that flexion isn't the devil in a population that lives in extension. Contraindicate the person, not the exercise.

To learn more about our comprehensive approach to core stabilization, be sure to check out Functional Stability Training of the Core.

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Stuff You Should Read: 3/28/11

I am getting back late tonight from my trip, so here's a list of recommended reading to hold you over in my absence. The #1 Cause of Inconsistent Pitching Velocity - With the high school baseball season about to get underway, this seemed like a good time to "re-up" this article. Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines, by Shirley Sahrmann - This is what I've been reading on the beach the past week.  Lengthy title, but super high quality book, if you're a geek like me.

Packing in the Neck - This is an old one, but a good one from Charlie Weingroff.  Charlie talks about proper neck positioning while lifting - a topic that I think gets really overlooked in discussions of appropriate lifting technique.  In case you can't tell from this deadlift technique, I'm in full agreement with Charlie.

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