I received the following email the other day, and thought my response would make for a good Q&A here:
Q: I recently heard a national level gymnastics coach speak on how he believed shoulder dislocates with a dowel rod (working up to weighted dislocates) are a panacea for shoulder health and strength. I was wondering if you use them with your clients/players, and why or why not?
A: Thanks for your question. In short, the answer would be NO, I would never do shoulder dislocates with a throwing athlete. I discussed why in a previous video that goes into great detail, so rather than reinvent the wheel, here it is! Effectively, shoulder dislocates replicate some of the movements that I outline as problems here.
As a general rule of thumb, as a thrower, it's always better to be too tight than it is to be too loose. WIth that in mind, you always need to ask why you're stretching an area out. If the front of the shoulder feels "tight," it may be from a number of different causes:
1. Protective tension of the biceps tendon (secondary to rotator cuff weakness) - just stretching it out would remove what little anterior stability remains.
2. An injury to the anterior capsule, latissimus dorsi (humeral attachment point), subscapularis, supraspinatus, or biceps tendon - just stretching these areas out will likely exacerbate the injury.
3. Irritate of the nerves that run anterior to the humeral head - nerves don't like to be stretched.
4. True muscular shortness of pectoralis majoror another structure - Effectively, in doing shoulder dislocates, you're throwing all your eggs in this basket.
The only problem? Most throwers already have an insane amount of horizontal abduction and external rotation range-of-motion on their throwing shoulders. They aren't even close to having legitimate tissue shortness that would benefit from stretching. This is something we work hard to drill home in our Elite Baseball Mentorships as one of the most important takeaways from the events.
Now, if we're talking about a regular ol' desk jockey who doesn't throw a baseball (or other sporting implement), play tennis, or swim, then dislocates might have some merit. These individuals likely have some muscle/tendon stiffness that can be stretched out before they get to a point where they might crank on their joint capsule or nerves. I would never use it as a "blanket" recommendation for everyone, though. The only way to know is assess the individual and then plan accordingly.
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Here is this week's recommended strength and conditioning reading. As it turns out, you could call this the Assess and Correct edition, as it features the three of us who collaborated on this product:
The Secret to Ab Training - Mike Robertson did an awesome job introducing some movements you've probably never seen before. That said, we've been using them at Cressey Performance with great results for quite some time now.
It's time for another installment of my series on things you might overlook when assessing a new client or athlete. Here are three more things to which you should pay attention:
1. Shoulder Flexion Range of Motion - This is a valuable test to use in conjunction with a back-to-wall shoulder flexion test. If you can't effectively perform a back to wall shoulder flexion as in the video featured here, then we need to ask "why not?"
It might happen because you lack good stiffness in various places - anterior core, lower trapezius, upper trapezius, and serratus anterior, to name a few. Or, it might be because you're unable to overpower bad stiffness or shortness. Maybe you lack thoracic extension, are too rhomboid dominant, or simply can't get full shoulder flexion range of motion. To check for this last one, you'll want to put the individual in supine with the back flat and knees and hips flexed. They should be able to get the arms all the way down to the table - so this would be no good.
Shoulder flexion can be limited by a lot of things: short/stiff lats, teres major, long head of the triceps, and inferior capsule. Regardless of what limits it, though, you can't just take someone with this limited a ROM and plug them into overhead pressing. You're just waiting to chew up a rotator cuff, biceps tendon, labrum, or all of the above.
As a little bonus, this is my favorite drill for improving shoulder flexion ROM:
2. Scapular Upward (or Downward) Rotation - It goes without saying that scapular control - or the ability to position the shoulder blades appropriately - is absolutely essential to safe and effective upper extremity movement. In order for that to occur, though, the shoulder blades have to start in the right position. With respect to scapular rotation, "neutral" posture has the shoulder blades sitting at 5 degrees of upward rotation at rest. In the picture below, the black line represents where he should be in terms of upward rotation, but instead, you'll see that he sits in about 20-25 degrees of downward rotation (for the record, there are a number of other things wrong with this posture, so this is only a start!).
The problem with starting in this much downward rotation (or any downward rotation, at all) is that it's like beginning a race from 20 yards behind the starting line. When the arm starts to move up, the shoulder blade needs to rotate up to maintain the ball and socket congruency. If it starts too low, it can't possibly be expected to catch up - so the ball will ride up relative to the socket, regardless of how strong the rotator cuff is to try to prevent that superior migration. You'll wind up seeing irritation of the rotator cuff, biceps tendon, labrum, or bursa if it's left unchecked.
Step 1 is to simply educate people on where the scapula actually should sit, and step 2 is to work on training from that correct new starting position.
3. Constant stretching - I always take note of when I see a client who seems to be stretching "nervously" when they're just standing or sitting around. You'll often see people cranking on their shoulders, cracking their necks, touching their toes, or any of a number of things that make them "feel better.
The problem is that these people are often stretching out protective tension - or stiffness that's there because they lack stability elsewhere. This is often the case with those with significant joint hypermobility. They're already unstable, but the stretching is like picking a scab; it gives them temporary relief from the tightness, but only makes things worse in the long run. It might be hamstrings tightness in someone with crazy anterior pelvic tilt, biceps tightness in those with anterior shoulder instability, or any of a number of other presentations throughout the body. Unquestionably, though, the most common one is neck stretching in those with poor scapular control.
There is no one solution for everyone's problem, but I would encourage you to always ask, "Why is this tight?" And, don't even think about stretching until you know the answer.
2. Warm-ups for Sparing the Shoulders - This came as part of a post for Schwarzenegger.com.
3. Supine Alternating Shoulder Flexion on Doubled Tennis Ball - This upper back mobility/soft tissue drill was a big hit!
4. Fine-Tuning the Band Pullapart - This is a very popular exercise for shoulder health, but it's commonly performed incorrectly. Try these modifications!
5. Standing External Rotation Hold to Wall - This is an awesome warm-up that requires no equipment. We use it a lot with our throwers when they're on the field and don't have access to a table to do prone exercises.
As you can see, 2013 was the "Year of the Shoulder" at EricCressey.com! I'll be back soon with the top guest posts of 2013.
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Dreaming of a Title - In light of the World Series run by the Red Sox, CP's Elite Baseball Development Program was featured, with interviews with several of our pro guys. Check out this video.
Barbell shrugs have been labeled a "meathead" exercise by a lot of people, but with some quick modifications, you can make them really valuable inclusions in a strength training program, as not all shrugging is created equal. Check out this exercise of the week video to learn more:
As I mentioned, if you're looking for another variation that's unloaded, try including wall slides with overhead shrug in your warm-ups; they are a great teaching tool.
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A few years ago, I read What the Dog Saw, a collection of short stories from popular author Malcolm Gladwell.
In one particular short story, Gladwell introduces the concept of "risk homeostasis." Essentially, risk homeostasis refers to the fact that modifications that are designed to make things safer often eventually have a break-even effect on safety because of adaptations to those modifications. In other words, something that should protect us doesn't because new compensatory factors make things more dangerous.
As an example, Gladwell observers that taxi drivers who are given anti-lock brakes actually wind up with higher incidences of traffic violations and accidents. Presumably, this occurs because the drivers feel they can drive faster and more aggressively because of this added "protection."
In another case, a study showed that adding childproof lids to medicine bottles actually increased the likelihood that children would die from accidental overdose of consuming drugs not meant for them. The added “safety” leads to adults being less cautious with where they hide bottles of pills.
While watching an absolutely atrocious YouTube video with some of the worst box squat technique in history the other day, my thoughts flashed back to this concept of risk homeostasis from when I read Gladwell's work. There are actually some remarkable parallels in the world of strength and conditioning.
1. Wearing a belt.
When a lifter throws on a belt, he assumes that it will make an exercise safer for him. While the research isn't really in agreement with this assertion, we'll roll with this assumption.
In real life, most lifters throw on a belt because it helps them handle additional weights - and at these weights, their form usually deteriorates rapidly, and does so under additional compressive loading.
2. Popping anti-inflammatories and getting cortisone shots.
When a doctor gives you a cortisone shot or recommends oral anti-inflammatories, it's because he believes you have some level of inflammation, whether it's a bursitis, tenosynovitis, or other issue. This short course of anti-inflammatories will reduce that inflammation.
You rarely see these issues in isolation, though; they're usually accompanied by degenerative changes (e.g., tendinosis) or structural changes (e.g., bone spurs) that could also be causing your symptoms. Unfortunately, your anti-inflammatories don't know that; they just know they're supposed to kill off all your pain. They make you asymptomatic, but not necessarily "healthy."
Many individuals get a cortisone shot or take a few days of NSAIDs and assume they can just go right back to training hard with no restrictions because their pain is gone. A few weeks or months later (when the cortisone shot wears off), they're back in pain (and usually it's worse than before) because they've done nothing to address the underlying causes of the problem in the first place. They shut off the inflammation and pain, but kept the degeneration, structural changes, and stupid.
The anti-inflammatory intervention is supposed to be part of a treatment plan to make folks healthier, but actually gives them a false sense of security, which in turn makes an injury or condition worse.
3. Lifting alongside an "experienced" coach who has done stupid s**t for decades, but has never been hurt.
It's not uncommon to feel a sense of security when you train with a coach with tons of time "under the bar" himself. His training background - and reportedly clean injury history - gives you peace of mind and you buy into his system. And, you continue lifting heavier and heavier in poor form because he's proof that it works, right?
Unfortunately, he's a sample size of one.
His experience should make training safer, but instead, it just leads you to take more poorly calculated risks with your training.
As an example, I did this while goofing around a few years back, but I'd never let one of my athletes try it. There are enough ugly box jump videos out there on YouTube to appreciate that a lot of coaches don't have the same kind of self-restraint.
4. Wearing elbow sleeves and knee wraps.
Elbow sleeves and knee wraps are incredibly common in the world of strength sports, and with good reason: they can really help with getting or keeping a joint warmed-up.
The only problem is that most lifters use them just so that they can power through the exact exercises that caused the joint aches in the first place.
As an example, a lot of lifters lack the upper back and shoulder mobility to use a narrow grip position on the barbell when back squatting, and the medial (inside of the) elbow takes a beating as a result. Rather than doing some shoulder mobility drills, they just throw on a band-aid in the form of an elbow sleeve.
5. Picking "joint-friendly" strength exercises.
There are lots of ways to deload a bit in the context of strength exercise selection. Maybe you do some single-leg work instead of squatting. Or, maybe you do some barbell supine bridges in place of deadlifting. These substitutions usually make a strength training program safer.
That is, of course, unless you do them with horrendous technique. Sadly, this isn't uncommon. You see people who meticulously prepare for squatting and deadlifting and heavily scrutinize their technique with video analysis, yet they'll blow through other exercises with terrible form. They expect exercise selection alone to make their strength training program safer, but compensate for this added safety by butchering technique.
Of course, these are only five examples of how risk homeostasis applies to strength and conditioning programs, and there are certainly thousands more. Where do you see good intentions go astray in your training? I'd love to hear your thoughts in the comment section below.
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I'm out of town for a few days, but fortunately, Ben Bruno was kind enough to write up this guest blog. I enjoy Ben's writing - particularly his ability to constantly innovate - and I'm sure you will, too.
Common sense tells us that the one arm dumbbell bench press is an upper body exercise (duh!), but if you’ve ever done them with considerable loads, then you know that the legs aren’t just passive players in the mix. They don't just help to provide a little bit of leg drive; more importantly, they help to create a stable base so you don’t tip clear off the bench.
Don’t believe me? Try doing a set with your feet in the air and you’ll see exactly what I mean. Just make sure to put padding on the floor around you first.
To mimic this effect in a safer fashion, try one arm dumbbell floor presses with your legs straight.
You’ll find there’s a tendency for your torso to want to rotate towards the arm pressing the weight and for the contralateral leg to want to shoot up off the floor as the weight gets heavier or you get further into a set. As such, you have to be cognizant of that and squeeze your glutes and brace your core to prevent that from happening since you can’t rely on your feet to provide the base of support.
It’s a great exercise because it’s self-limiting and reflexively teaches you how to create total body tension—no cueing needed.
It’s also a nice shoulder-friendly alternative for people who might experience pain with full range of motion dumbbell pressing, or for people with lower-body injuries that won’t allow them to push through their feet.
Start with your legs wider and move them closer together as you feel more comfortable. Similarly, you can start with the non-working arm resting at the floor at first to give some additional stability, but work towards placing your hand over your abdomen as you improve.
You’ll need to start with a substantially lighter weight than you’d use for regular dumbbell presses (I’d say 60% would be a good starting point), but your numbers will climb back up quickly as you get the hang of it.
Give it a try!
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Over the weekend, I attended my third Postural Restoration Institute seminar, Impingement and Instability. I’ve written previously about how this school of thought has profoundly impacted the way that we handle many of our athletes – and this past weekend was certainly no exception. This weekend was also my first chance to meet and learn directly from Ron Hruska, the man initially responsible for bringing many of these great ideas to light.
While I am admittedly still processing all the awesome information from the weekend, I wanted to write today about one big “Ah-Ha” moment for me over the weekend. At some point on Day 2, Ron said something to the effect of (paraphrased):
“A superior acetabulum isn’t much different than an acromion on a scapula.”
My jaw practically hit the floor. I joked with the seminar organizer that I needed to go into the restroom to yell at myself for a few minutes for not thinking of this sooner. Let me explain…
Over the past few years, there has been a huge rise in hip injuries in athletes (I'd even written about it HERE in response to a New York Times article about number of hip injuries in baseball). Sports hernias, labral tears, and femoroacetabular impingement (FAI) are commonplace findings on the health histories that I see every day on first-time evaluations. In terms of FAI, you can have bony overgrowth of the femoral head (cam), acetabulum (pincer), or both (mixed), as the graphic from Lavigne et al. below demonstrates:
Many folks say that we’re getting better diagnostically and that’s why the prevalence has increased in recent years. Let’s be real, though, folks: if we’d had hip pain and dysfunction on this level for decades, don’t you think anecdotal evidence would have at least tipped us off? I find it hard that generations of athletes would have just rubbed some dirt on a painful hip, cowboyed up, and put up with it.
Consider those over the age of 60, though. Sher et al. reported that a whopping 54% of asymptomatic shoulders in this population have rotator cuff tears; that doesn’t even include those who actually have pain! Why does this happen? They impinge over and over again on the undersurfaced of the acromion process secondary to poor thoracic positioning, scapular stabilization, breathing patterns, and rotator cuff function. The end result is reactive changes on the acromion process that lay down more and more bone as the years go on. And, an anteriorly tilted scapula kicks that impingement up a notch. The “early” cuff irritation likely comes in those with Type 3 (beak-shaped) acromions, whereas the Type 1 (flat) and Type 2 (hook) acromions need time to lay down more and more bone for their anterior tilt to bring them to threshold.
Conversely, consider femoroacetabular impingement of the hip. You can get bony overgrowth of the acetabulum, femoral head, or both. It’s widely debated whether those with FAI are born with it, or whether it becomes part of normal development in some kids. Well, I guess it would depend on whether you consider playing one sport to excess year-round “normal.”
You know what? I’d estimate that over 90% of the femoroacetabular impingement cases I’ve seen have come in hockey, soccer, and baseball players. What do these sports have in common? They all live in anterior pelvic tilt – with hockey being the absolute worst. Is it any surprise that the incidence of FAI and associated hip issues has increased dramatically since the AAU generation rolled in and kids played the same sport all 12 months of the year?
Conversely, I’ve never seen a case of FAI in a field hockey player. Additionally, when I just asked my wife (who rowed competitively in college) if she ever saw any hip issues in her teammates in years of rowing, she joked that there weren’t any until they added distance running to their training. Field hockey players and rowers live in flexion (probably one reason why they have far more disc issues). And, taking it a step further, I’ve never seen an athlete with FAI whose symptoms didn’t improve by getting into a bit more posterior pelvic tilt.
Finally, a 2009 study by Allen et al. demonstrated that in 78% of cases of cam impingement symptoms in one hip, the cam-type femoroacetabular impingement was bilateral (they also found pincer-type FAI on the opposite side in 42% of cases). If this was just some “chance” occurrence, I find it hard to believe that it would occur bilaterally in such a high percentage of cases. Excessive anterior pelvic tilt (sagittal plane) would be, in my eyes, what seems to bring it about the most quickly, and problems in the frontal and transverse planes are likely to blame for why one side presents with symptoms before the other.
People have tried to blame the increased incidence of hip injuries on resistance training. My personal opinion is that you can’t blame resistance training for the incidence, but rather the rate at which these issues reach threshold. Quality resistance training could certainly provide the variety necessary to prevent these reactive changes from occurring at a young age, or by creating a more ideal pelvic alignment to avoid a FAI hip from reaching threshold.
Conversely, a “clean-squat-bench” program is a recipe for living in anterior tilt – and squatting someone with a FAI is like overhead pressing someone with a full-thickness cuff tear; things get ugly quickly.
Honestly, this probably isn’t revolutionary for folks out there – particularly in the medical field – who have watched the prevalence of femoroacetabular impingement rise exponentially in recent years, but Ron made a great point to reaffirm a thought I’d been having for years and strengthened the argument. And, more important than the simple “Ah-Ha” that comes with this perspective is the realization that an entire generation of young athletes have been so mismanaged that we’ve actually created a new classification of developmental problems and pathologies: femoroacetabular impingement, labral tears, and sports hernias.
Thanks, Ron, for getting me thinking!
For more information on appropriately managing kids during these critical development time periods, check out the International Youth Conditioning Association’s High School Strength and Conditioning Certification, which I helped to write.
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When it comes to corrective exercise programs, everyone simply wants to know "what" is and isn't included - and rightfully so. Picking the right strength exercises and mobility drills - and contraindicating others - is absolutely crucial to making sure you get folks to where they want to be.
However, very rarely will you hear anyone specifically discuss the "when" in these scenarios, and as I'll demonstrate in today's piece, it's likely just as crucial to get this aspect correct.
To begin to illustrate my point, I'm going to reuse a quote from an article I wrote a few weeks ago, Correcting Bad Posture: Are Deadlifts Enough?, on the Law of Repetitive Motion :
Consider the law of repetitive motion, where “I” is injury to the tissues, “N” is the number of repetitions, “F” is the force of each repetition as a percentage of maximal strength, “A” is the amplitude (range of motion) of each repetition, and “R” is rest. To reduce injury to tissues (which negative postural adaptations can be considered), you have to work on each of the five factors in this equation.
You perform soft tissue work – whether it’s foam rolling or targeted manual therapy – on the excessively short or stiff tissues (I). You reduce the number of repetitions (length of time in poor posture: R), and in certain cases, you may work to strengthen an injured tissue (reduce F). You incorporate mobility drills (increase A) and avoid bad postures (increase R).
What I failed to mention a few weeks ago, though, was that the sequencing of these corrective modalities must be perfect in order to optimize the training/corrective effect and avoid exacerbating symptoms. Case in point, we recently had a client come to us as a last resort with chronic shoulder issues, as he was hoping to avoid surgery. Physical therapy had made no difference for him (aside from shrinking his wallet with co-pays), and following that poor outcome, he'd had a similar result with soft tissue treatments twice a week for six weeks. In a single four-week program, we had him back to playing golf pain free. What was the difference?
In the first physical therapy experience, he'd been given a bunch of traditional rotator cuff and scapular stabilization exercises. There had been absolutely no focus on soft tissue work or targeted mobility drills to get the ball rolling. In other words, all he did was improve stability within the range of motion he already had. In the equation above, all he really worked on was reducing the "F" by getting a bit stronger.
In his soft tissue treatment experiences, he felt a bit better walking out of the office, but ran into a world of hurt when his provider encouraged him to "just do triceps pressdowns and lat pulldowns" for strength training. In other words, this practitioner worked on reducing "I" and increasing "A," but totally missed the boat with respect to enhancing strength (reducing "F") and increasing rest ("R") because of the inappropriate follow-up strength exercise prescription. Doh!
What did we do differently to get him to where he needed to be? For starters, he saw Dr. Nate Tiplady, a manual therapist at CP, twice a week for combination Graston Technique and Active Release treatments (reducing "I") at the start of his training sessions. He followed that up with a specific manual stretching, positional breathing, and mobility exercise warm-up program (increase "A") that was designed uniquely for him. Then, he performed strength training to establish stability (decrease "F") within the new ranges of motion (ROM) attained without reproducing his symptoms (decreasing "N" and increasing "R).
The sequencing was key, as we couldn't have done some of the strength exercises we used if we hadn't first gotten the soft tissue work and improved his ROM. He may have had valuable inclusions in his previous rehabilitation efforts, but he never had them at the same time, in the correct sequence.
This thought process actually closely parallels a corrective exercise approach Charlie Weingroff put out there much more succinctly in his Rehab = Training, Training = Rehab DVD set:
Get Long. Get Strong. Train Hard.
Keep in mind that there are loads of different ways that you can "get long." You might use soft tissue work (Active Release, Graston Technique, Traditional Massage, etc.), positional breathing (Postural Respiration Institute), mobility drills (Assess and Correct), manual stretching, or any of a host of other approaches (Mulligan, DNS, Maitland, McKenzie, etc). You use whatever you are comfortable using within your scope of practice.
When it's time to "get strong," you can do so via several schools of thought as well - but the important thing is that the strength exercises you choose don't provoke any symptoms.
It's interesting to note that this corrective exercise approach actually parallels what we do with our everyday strength and conditioning programs at Cressey Performance - and what I put forth in Show and Go: High Performance Training to Look, Feel, and Move Better. We foam roll, do mobility warm-ups, and then get cracking on strength and stability within these "acutely" optimized ranges of motion to make them more permanent.
