Home Posts tagged "Shoulder Pain"

Should You “Balance” Your Pushes and Your Pulls?

Yesterday, I posted on social media about how I think the concept of balancing pushes with pulls in your programming is outdated. It received some hefty debate, so I thought I'd delve into the topic a bit further in today's video.

Also, just a friendly reminder that our entire Functional Stability Training series is on sale for 25% off through Cyber Monday at midnight. For more details, check out www.FunctionalStability.com. No coupon code is necessary.

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Simplified Shoulder Solutions

I've devoted a lot of my articles to shoulder assessment, training, and programming over the years. Some have been lengthy articles (like my lat strain feature), others have been quick hit posts (like this bear crawl vs. crab walk one), and some have been video technique tutorials and common mistakes, like this:

When you've been at something a long time, the natural tendency is to chase increasing complexity. The more complexity you chase, the more novelty you encounter - and that novelty is what keeps folks engaged when they "specialize" in the same joint over an entire career. One thing I've done well in this regard is to chase complexity in my own education, but kept our application of these principles simple in the way we evaluate and coach athletes. Because, at the end of the day, this is what it comes down to:

[bctt tweet="Shoulder health is about keeping the ball on the socket. Period."]

Keep in mind that we're speaking specifically to the glenohumeral (ball and socket) joint, when in reality the entire shoulder girdle is comprised of many different articulations). As I mentioned, though, the point of this blog is to simplify this discussion.

There are a lot of factors that impact how well one is able to do that. It could be cuff strength, scapular control, ligamentous laxity, previous injury, bony changes, faulty thoracic positioning, tissue density, core control, and a host of other issues. These things all - in one way or another - impact how the ball and socket interact.

As strength and conditioning and rehabilitation specialists, you still need to understand the most common injuries incurred at the shoulder. You must appreciate population specific norms. And, you need to understand the assessments that determine whether static posture and movement quality are where they need to be. However, you should never get away from always bringing these concepts back to the fact that they all have to do with ball-and-socket interaction.

As Einstein once said, "If you can't explain it simply, you don't understand it well enough." That's both the goal of this particular blog, and also my upcoming Shoulder Assessment, Corrective Exercise, and Programming seminar in New York City on August 20. Today is the deadline for getting the early bird registration rate, and I hope to see you there!

Also, I'll be delivering the same course near Washington, DC on September 17, if that's of interest. You can learn more HERE.

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Washington, DC Seminar Announcement: September 17, 2017

I just wanted to give you a heads-up on one-day seminar with me in Washington, DC on Sunday, September 17, 2017.

Cressey scapula

We’ll be spending the day geeking out on shoulders, as the event will cover Shoulder Assessment, Corrective Exercise, and Programming.  The event will be geared toward personal trainers, strength and conditioning professionals, rehabilitation specialists, and fitness enthusiasts alike.

Agenda

9:00AM-9:30AM – Inefficiency vs. Pathology (Lecture)
9:30AM-10:15AM – Understanding Common Shoulder Injuries and Conditions (Lecture)
10:15AM-10:30AM – Break
10:30AM-12:30PM – Upper Extremity Assessment (Lab)
12:30PM-1:30PM – Lunch
1:30PM-3:30PM – Upper Extremity Mobility/Activation/Strength Drills (Lab)
3:30PM-3:45PM – Break
3:45PM-4:45PM – Upper Extremity Strength and Conditioning Programming: What Really Is Appropriate? (Lecture)
4:45PM-5:00PM – Q&A to Wrap Up

Location

Beyond Strength Performance NOVA
21620 Ridgetop Circle
Suite 100
Dulles, VA 20166  

Continuing Education Credits

The event has been approved for 0.7 CEUs (7 contact hours) through the National Strength and Conditioning Association (NSCA).

Cost:

SOLD OUT! Please email ec@ericcressey.com if you'd like to be added to the waiting list in case a spot opens up.

Note: we'll be capping the number of participants to ensure that there is a lot of presenter/attendee interaction - particularly during the hands-on workshop portion - so be sure to register early, as the previous offering sold out well in advance of the early-bird registration deadline.

Looking forward to seeing you there!

Questions? Please email ec@ericcressey.com.

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New York Seminar Announcement: August 20, 2017

I just wanted to give you a heads-up on one-day seminar with me in New York on Sunday, August 20, 2017.

Cressey scapula

We’ll be spending the day geeking out on shoulders, as the event will cover Shoulder Assessment, Corrective Exercise, and Programming.  The event will be geared toward personal trainers, strength and conditioning professionals, rehabilitation specialists, and fitness enthusiasts alike.

Agenda

9:00AM-9:30AM – Inefficiency vs. Pathology (Lecture)
9:30AM-10:15AM – Understanding Common Shoulder Injuries and Conditions (Lecture)
10:15AM-10:30AM – Break
10:30AM-12:30PM – Upper Extremity Assessment (Lab)
12:30PM-1:30PM – Lunch
1:30PM-3:30PM – Upper Extremity Mobility/Activation/Strength Drills (Lab)
3:30PM-3:45PM – Break
3:45PM-4:45PM – Upper Extremity Strength and Conditioning Programming: What Really Is Appropriate? (Lecture)
4:45PM-5:00PM – Q&A to Wrap Up

Location

Solace NY
38 East 32nd St.
New York, NY 10016

Continuing Education Credits

0.7 CEUs (7 contact hours) through the National Strength and Conditioning Association (NSCA)

Cost:

SOLD OUT! Please email ec@ericcressey.com to get on the waiting list.

Note: we'll be capping the number of participants to ensure that there is a lot of presenter/attendee interaction - particularly during the hands-on workshop portion - so be sure to register early, as the previous offering sold out well in advance of the early-bird registration deadline.

Registration

SOLD OUT!

Looking forward to seeing you there!

Questions? Please email ec@ericcressey.com.

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How Bench Press Technique Impacts Shoulder Health

We often hear that an elbows-tucked bench press technique is more shoulder friendly than an elbows-flared approach. Nobody really ever seems to discuss why this is the case, though - so I thought I'd devote today's video blog to it:

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Making Sense of Exercise Contraindications

I've got a wonky shoulder. Actually, the term "wonky" probably doesn't do it justice. As of a MRI in 2014, here's what I've got:

"There is a high-grade partial thickness articular surface tear of the posterior fibers of the supraspinatus that measures 15 mm AP x 15 mm RL. The undersurface tendon fibers are delaminated and retracted 15
mm.

"There is a high-grade partial-thickness cartilage defect over the posterior medial aspect of the humeral head
(near the posterior-superior labrum) with cartilage flap formation that measures 8 mm SI x 5 mm AP."

That was about three years ago, and it may be worse now. The truth is that it started with internal impingement during my high school tennis career, and gradually progressed over the years. In comparing the 2014 MRI to one I'd had in 2003, you see that the damage has progressed (as expected), but the symptoms have actually gotten substantially better.

My (occasional) pain is your gain, though. You see, the symptoms (or lack thereof) can actually teach us a lot about how we view contraindicating exercises.

I can bench press as heavy as I want with zero issues. Pull-ups, rows, pullovers, overhead carries, landmine presses, Turkish get-ups are all completely asymptomatic. They're in my safe exercise repertoire.

And, as long as I don't go crazy with volume or intensity, I can throw a baseball just fine. I long-tossed out well over 200 feet with my pro guys consistently this offseason and it wasn't a problem.

Overhead pressing is weird for me, though. If I tried to push press 135 pounds, my shoulder would hate me for the next 6-8 weeks. Interestingly, though, if I keep the weight lighter, stick to dumbbells in the scapular plane, control the tempo, focus on perfect technique, and don't go crazy with volume, overhead pressing actually makes my shoulder feel better. I'll work it in as an assistance exercise every other month.

 

 

Thanks to a chronic partial thickness rotator cuff tear, overhead pressing is weird for me. If I tried to push press 135 pounds, my shoulder would hate me for the next 6-8 weeks. Interestingly, though, if I keep the weight lighter, stick to dumbbells in the scapular plane, control the tempo, focus on perfect technique, and don't go crazy with volume, overhead pressing actually makes my shoulder feel better. I'll work it in as an assistance exercise every other month. This reminds us that we shouldn't just contraindicate exercises, but rather specific SCENARIOS. You won't change a person's anatomy, but you can certainly change the training stimulus to accommodate that anatomy. Check out today's post at www.EricCressey.com/blog for more info. #cspfamily #rotatorcuff #overheadpress #shoulderpain #shoulderworkout

A post shared by Eric Cressey (@ericcressey) on

Interestingly, though, back squatting is what destroys my shoulder the most. This is consistent with an internal impingement diagnosis, but doesn't make a whole lot of sense when you consider that I can throw pain-free. Even if I just try to put a 45-pound barbell on my shoulders, it lights my shoulder up in a very bad way.

This weird collection of symptoms can actually teach us three really big lessons, though.

1. Everyone's symptoms and provocative patterns are completely different.  Two people might have a very similar medical diagnosis, but dramatically different safe exercise repertoires.

2. Too often, we contraindicate simply contraindicate exercises. In reality, we should be looking much broader, considering factors such as absolute loading, tempo, volume, and exercise technique.

[bctt tweet="We should contraindicate people from exercises, not exercises for people."]

3. An individual's "safe" exercise repertoire may evolve over time due to changes in movement quality, tissue quality, recovery capacity, and structural integrity. Our programming needs to evolve to accommodate those changes, too.

Certainly, some exercises are inherently bad and not worth the risk, but it's important to evaluate each individual and situation individually to make the determinations on all those "middle of the road" exercises that deliver great training effects and make strength and conditioning fun.

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Random Thoughts on Sports Performance Training – Installment 26

It's time for the January edition of Random Thoughts on Sports Performance Training. Before I get to it, though, just a friendly reminder that today is also the last day of the introductory $50 off sale on Cressey Sports Performance Innovations. Don't miss out on this chance to get our new resource at a great price. You can learn more HERE

CSPInnovations-02-2

Since my presentation is "Scapular Control: Implications for Health and High Performance," I thought I'd take an upper extremity approach to this month's cues.

1. If you want to relax the neck, talk or exhale.

One of the biggest mistakes I see athletes make when they're doing upper body work is aggressively recruiting the muscles surrounding the neck. In particular, we know that a hypertonic sternocleidomastoid (SCM) and scalenes can be implicated in not only neck pain, but also headaches and thoracic outlet syndrome.

tos3

In most cases, simply telling an athlete to relax or repositioning their head/neck will get the job done. However, another strategy you can employ is to have them exhale through the exertion phase, or simply talk during the set.  Both the scalenes and SCM are accessory muscles of inhalation and this forces them to relax a bit so that you can build tension where you really want it.

2. When it comes to scapular control, nothing beats kinesthetic awareness coaching cues.

As I've written at length in the past, I'm a big believer in categorizing all athletes by their dominant learning styles: visual, kinesthetic, and auditory.

Visual learners can watch you demonstrate an exercise, and then go right to it.

Auditory learners can simply hear you say a cue, and then pick up the desired movement or position.

Kinesthetic learners seem to do best when they're actually put in a position to appreciate what it feels like, and then they can crush it.

My experience with teaching scapular positioning has been that option #3 - actually putting someone in the position you want - is the quickest and easiest way to teach someone about scapular positioning. This is likely because:

a. The scapula is a unique bone with some unique movements (upward/downward rotation, anterior/posterior tilt) that aren't familiar to most people

b. You're always wearing a shirt when demonstrating drills, which makes it harder to see these subtle movements as they occur.

When in doubt, put a shoulder blade in the position you desire and then ask an individual to hold it and own it.

3. Uncontrolled end ranges are bad for the scapulothoracic joint, just like every other joint.

Here's something to consider...

We know that if you repeatedly flex and extend the spine to its end-ranges, you'll eventually wind up in trouble - whether it's a herniated disc, stress fracture, or some other pathology.

We also know that if you repeatedly hyperextend an elbow, you'll eventually wind up with loose bodies in the joint, early osteoarthritis, or a torn ulnar collateral ligament.

The point is that it's important to have sufficient range of motion - and stability in that ROM - but not excessive ROM. Hanging out at any end range probably isn't a good idea.

Interestingly, though, we overlook the fact that the scapulothoracic joint - the interaction of the shoulder blade with the rib cage - is subject to these rules. In particular, one issue that sometimes emerges is an excessive "military posture" of scapular adduction (toward the midline) and depression when folks are cued "down and back" without understanding what it really means.

adductedscap-300x162

These athletes often get neck/upper back flare-ups when they do a lot of deadlifting, carries, or even too much horizontal pulling. The shoulder blades are so far pulled back that it becomes a faulty stabilization strategy instead of a strong base from which to perform.

4. A PVC dowel is a super affordable way to do a lot of great things for your upper body work.

I was looking at a program I wrote for one of our pro guys yesterday, and realized that we used the PVC dowel for three different exercises in a single training day. That's as much as barbells and dumbbells - but you can buy the piece of PVC for around $1. You won't find a piece of training equipment that offers that kind of bang for your buck - and this realization made me think back to this video CSP coach Greg Robins filmed a few years ago. These options are really just the tip of the iceberg, too:

Have a great Sunday - and don't forget about the CSP Innovations sale that ends tonight! Learn more HERE

lineup-1   

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3 Tips for Improving Shoulder Health and Performance

Today's guest post comes from my good friend and Elite Baseball Mentorships colleague, Eric Schoenberg. Enjoy! -EC

It is well documented that shoulder pain/injury is a primary reason for lost time in the gym and on the baseball field. Often times, the culprit is not poor exercise selection, but instead poor exercise execution. Most high level performers are going to do the work that we ask them to do, the issue is whether they are practicing getting better or practicing getting worse.

The following three tips will be useful for any strength coach or physical therapist to help ensure optimal function of the shoulder.

1. Understand and Appreciate Relative Stiffness.

There are several examples of relative stiffness around the shoulder that can result in faulty movement, pain and/or decreased performance.

A primary culprit occurs when the relative stiffness of the deltoid is greater than the rotator cuff. The result of this will be superior translation of the humeral head.

55-deltoid-pull

This can lead to undersurface rotator cuff tears, biceps tendon irritation, cyst formation, inferior glenohumeral ligament tears, or humeral head abnormalities – all of which are common to throwers.

Consider this when attempting to strengthen the cuff. Check to see if the humerus is in extension, as demonstrated in this photo. This faulty "elbow behind the body" pattern will lead to over-recruitment of the posterior deltoid:

humeralextension

You also want to cue the athlete away from excessive horizontal abduction, as demonstrated in the next photo. Prone external rotation with no support results in increased use of deltoid to support the arm against gravity:

proneer1

Here it is corrected with support:

proneercorrected

More times than not, we see athletes doing the correct exercise with the wrong execution and getting poor results. We want to avoid allowing an athlete to practice getting better at moving incorrectly.

2. Stop rowing so much, especially if your rowing technique is incorrect!

Rowing variations are generally the safest and easiest upper body exercises to program. However, even though a row is usually pain free, it can sometimes lead to patterns that result in injury down the road.

For example: If the rhomboids and lats are too stiff, you will see limited upward rotation of the scapula. Regardless of how much you strengthen the serratus anterior and lower trapezius, these smaller muscles will never match the force production of the lats and rhomboids.

With this in mind, the best “fix” is to increase stiffness and muscle performance of serratus and lower trapezius while simultaneously decreasing the stiffness and use of the lats/rhomboids.

This can be done by modifying the way we row. In this great video, EC discusses how to correct the row and ensure the scapula is moving properly on the ribcage with both phases of the rowing pattern.

In addition, we should program pressing or reaching exercises such as landmines, kettlebell presses, overhead carry variations.

3. Don’t let good lower body days double as “bad” upper body days.

We sometimes see athletes come in complaining about an increase in symptoms following lower body days. They will report something like “I don’t know what I did to my shoulder; I lifted lower body yesterday.” 

By now we know that a common cause of shoulder pain is the scapula being too depressed and downwardly rotated.

ScapularDownwardRotation-300x225-2

If an athlete performed deadlifts, back squats, or any lower body exercise where the weight was held by their sides (DB reverse lunges, step ups, RDLs, Bulgarian split squats, etc.), chances are they were feeding the pattern of depression and downward rotation.

Taking this a step further, we commonly see these exercises resulting in postures and stabilization strategies that present with increased lumbar lordosis and anterior pelvic tilt. When this goes uncorrected, scapular alignment suffers. Here’s a look at a reverse lunge with excessive hip extension, lumbar extension, and anterior pelvic tilt:

revlunge

Remember, there is no “corrective’ in the world that will counteract the stress of carrying 120-pound DBs by your side while training on a lower body day. This does not mean that you shouldn’t program it; instead, it means that we should just be aware of the consequences.

The solution to this is to consider alternate loading strategies (such as a Safety Squat Bar, KB Goblet set-up, or weight vests) that will allow the shoulder girdle to be freed up and positioned more optimally.  If we pair this with consistent attention to proper alignment and movement strategies, we can use lower body days as another opportunity to enhance shoulder function.

Looking to learn more about our unique approach to assessing and managing throwing athletes? Check out the upcoming Elite Baseball Mentorship Upper Extremity Course on December 18-20. For more information, click here. Don't delay, though; the early-bird registration deadline is November 18.

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 Seminars at Cressey Sports Performance. He can be reached at eric@momentumpt.com.

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How Lower Body Exercises Can Impact Upper Body Function

A few months ago, I published a blog called Making the Case for Training in the Post-Surgery Period. In short, it discussed how we are almost always dealing with athletes who are training during their rehabilitation periods. In many cases, this is strictly working around the issues while they're going through physical therapy.

In writing these programs, one recognizes that it's actually far easier to write a program for a post-op lower body issue than it is for a post-op upper body scenario. Very simply, because most strength and conditioning exercise selections work "from the ground up," there are many more ways that lower extremity exercises can impact upper body drills than vice versa. Today, I'll outline some examples.

1. Grip work.

There is grip involvement in deadlifts, various dumbbell single-leg exercises, and even squatting exercises that require an athlete to grasp the bar. Particularly in the case of elbow issues, too much grip work can become a real problem. For example, in the 4-8 month period after Tommy John surgery, it's not uncommon for athletes to experience discomfort in the common flexor tendon region - and it usually has to do with the cumulative stress of gripping during strength training and rehab work on top of the intensification of the throwing program. Some doctors have surgical approaches that are a bit "rougher" on the flexor tendon, too. In these scenarios, you're best off working predominately with lower body drills that don't involve a lot of grip work.

2. Front rack position with acromioclavicular (AC) joint issues. 

When you want an AC joint issue to calm down, there are really three big rules: 

a. Avoid reaching across the body (horizontal adduction, like a cross-body stretch)

b. Avoid reaching behind the body (full extension, like in a dip)

c. Avoid direct pressure to the area (particularly because it has very little muscle mass to cushion it)

Gray326-4

With respect to "C," the front squat set-up is an absolute no-no. The pressure on the bar across the shoulder girdle can really take an upset AC joint and make it markedly worse. And, since this is in many cases an injury that we’re just “waiting out,” simply training through it will only makes things worse long-term.

HandsFreeRack

Therefore, deadlift variations, single-leg variations, and back squats (assuming no other related problems) are likely better bets. That said, we generally use the safety squat bar and giant cambered bar exclusively with those who present with AC joint problems.

3. Back squat position with internal impingement.

Internal impingement (also known as posterosuperior impingement) is a broad diagnosis most common in overhead throwing athletes. In the late cocking phase of throwing (or swimming, tennis, etc.) - which involves external rotation and abduction - the humeral head tends to translate superiorly (up) and anteriorly (forward) relative to the scapula.

layback

These issues are magnified by poor scapular control, weakness of the rotator cuff, insufficient thoracic mobility, loss of tissue extensibility around the shoulder girdle, and in some cases, structural changes. The end result is that the biceps tendon, labrum, rotator cuff, glenohumeral ligaments, or nerves that pass the anterior aspect of the shoulder get irritated. The term "internal impingement" really just explains the pain-provoking position, not the specific diagnosis. Generally speaking, the pain is purely mechanical in nature; it won’t bother an athlete unless the “apprehension” position (full external rotation at 90+ degrees of abduction) is created.

Just about every overhead athlete is constantly "flirting" with internal impingement problems, so my feeling is that it's best to just avoid this "at-risk" position in the weight room - and that's why we don't back squat any of our overhead throwing athletes. And, we certainly wouldn't use a back squat with anyone with symptomatic internal impingement.

backsquat

4. Giant cambered bar with scapular anterior tilt, humeral anterior glide, and forward head posture.

The giant cambered bar is an awesome option for avoiding the "at-risk" abducted, externally rotated position that often gives overhead athletes problems, but it can create a problem with athletes who are prone to scapular anterior tilt, humeral anterior glide, and/or forward head posture. Because of the positioning of the hands, the elbows are driven a bit behind the body, which can cause the shoulder blade to dump forward and "ball" to glide forward on the socket. You may also see the head shoot forward.

GCB

That said, these faults can be easily minimized with good cueing. However, I wouldn't recommend using this bar with an athlete who has a big predisposition toward any of the three issues.

5. Scapular depression from holding heavy weights in the hands.

The deadlift can be an awesome exercise for improving poor posture - but not in all cases. Specifically, whenever we have an athlete who sits in too much scapular depression and downward rotation (more info on that HERE), we'll avoid holding really heavy weights in the hands for lower body training.

ScapularDownwardRotation-300x225-2

Our goal is to teach the shoulder blades to sit a little higher at rest, and functionally get higher when the arms need to go overhead. We don't want all our lower body work competing against that. During this time period, it's best to go with squatting variations, barbell supine bridges/hip thrusts, DB/KB goblet set-ups, sled work, the front squat grip, glute-ham raises, and anything else your imagination yields - as long as it doesn't tug the shoulder blades down.

There are many more considerations for how lower body work impacts upper body function, but these are definitely the five I most frequently encounter that you should keep in mind.

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Chicago Seminar Announcement: July 31, 2016

I just wanted to give you a heads-up on one-day seminar with me in Chicago, IL on Sunday, July 31, 2016.

Cressey scapula

We’ll be spending the day geeking out on shoulders, as the event will cover Shoulder Assessment, Corrective Exercise, and Programming.  The event will be geared toward personal trainers, strength and conditioning professionals, rehabilitation specialists, and fitness enthusiasts alike.

Agenda

9:00AM-9:30AM – Inefficiency vs. Pathology (Lecture)
9:30AM-10:15AM – Understanding Common Shoulder Injuries and Conditions (Lecture)
10:15AM-10:30AM – Break
10:30AM-12:30PM – Upper Extremity Assessment (Lab)
12:30PM-1:30PM – Lunch
1:30PM-3:30PM – Upper Extremity Mobility/Activation/Strength Drills (Lab)
3:30PM-3:45PM – Break
3:45PM-4:45PM – Upper Extremity Strength and Conditioning Programming: What Really Is Appropriate? (Lecture)
4:45PM-5:00PM – Q&A to Wrap Up

Location

TC Boost Sports Performance
600 Waukegan Road
Unit 108 
Northbrook, IL 60062

tcboost

Continuing Education Credits

The event has  been approved for 0.7 CEUs (7 contact hours) through the National Strength and Conditioning Association (NSCA).

Cost:

$199.99

Note: we'll be capping the number of participants to ensure that there is a lot of presenter/attendee interaction - particularly during the hands-on workshop portion - so be sure to register early, as the previous offering sold out well in advance of the early-bird registration deadline.

Registration

Click here to register using our 100% secure server!

Looking forward to seeing you there!

Questions? Please email ec@ericcressey.com.

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