Home Posts tagged "SLAP lesion"

Shoulder Mobility Drills: How to Improve External Rotation (if you even need it)

Last summer, a college pitcher came up to Cressey Performance from the South to train for a month before his summer league got underway. He was seven months post-op on a shoulder surgery (Type 2 SLAP) and had been working his way back. Unfortunately, his arm was still bothering him a bit when he got up to see us.

After the first few days at CP, though, he told me that his arm felt as good as it’s felt in as long as he could remember. He’d been doing a comprehensive strength and conditioning program, but the “impact” stuff for him had been soft tissue work, some Postural Restoration Institute drills, an emphasis on thoracic mobility, and manual stretching into internal rotation, horizontal adduction, and shoulder flexion. From all the rehab, his cuff was strong and scapular stabilizers were functioning reasonably well – which led me to believe that his issues were largely due to tissue shortness and/or stiffness.

This realization made me immediately wonder what he’d been doing in the previous months for mobility work for his arm – so I asked. He then demonstrated the manual stretching series that every pitcher on his team went through every day on the table with their athletic trainer. Each stretch was done for 2x20s – and two of those stretches took him into extreme external rotation and horizontal abduction. I was pretty shocked.

Me: “You’re probably not the only guy on your team rehabbing right now, huh?”

Him: “No; there are actually too many to count.”

Me: “Elbows, too, I’m sure.”

Him: “Yep.”

Want to irritate a labrum, biceps tendon, or the undersurface of the rotator cuff? Stretch a thrower into extreme external rotation and simulate the peel-back mechanism. This also increases anterior capsular laxity and likely exacerbates the internal impingement mechanism over the long-term. To reiterate, this is a bad stretch!

Want to make an acromioclavicular joint unhappy? Stretch a thrower into horizontal abduction like this (again, this is a BAD stretch that is pictured):

Want to irritate an ulnar nerve or contribute to the rupture of an ulnar collateral ligament? Make sure to apply direct pressure to the forearm during these dangerous stretches to create some valgus stress. This is a sure-fire way to make a bad stretch even worse:

These stretches are very rarely indicated in a healthy population – especially pitchers who already have a tendency toward increased external rotation. The shoulder is a delicate joint that can’t just be manhandled – and when you’re dealing with shoulders that are usually also pretty loose (both from congenital and acquired factors), you’re waiting for a problem when you include such stretches. In fact, I devoted an entire article to this: The Right Way to Stretch the Pecs.

Everyone thinks that shoulder external rotation and horizontal abduction alone account for the lay-back in the extreme cocking position.

In reality, though, this position is derived from a bunch of factors:

1. Shoulder External Rotation Range-of-Motion – and this is the kind of freaky external rotation you’ll commonly see thanks to retroversion and anterior laxity:

2. Scapular Retraction/Posterior Tilt

3. Thoracic Spine Extension/Rotation

4. Valgus Carrying Angle

So, how do you improve lay-back without risking damage to the shoulder and elbow?

1. Soft tissue work on Pec minor/major and subscapularis – Ideally, this would be performed by a qualified manual therapist – especially since you’re not going to be able to get to subscapularis yourself. However, you can use this technique to attack the pecs:

2. Exercises to improve scapular retraction/depression/posterior tilt – This could include any of a number of horizontal pulling exercises or specific lower trap/serratus anterior exercises like the forearm wall slide with band.

3. Incorporate specific thoracic spine mobility drills – In most pitchers, you want to be careful about including thoracic spine mobility drills that also encourage a lot of glenohumeral external rotation. However, when we assess a pitcher and find that he’s really lacking in this regard, there are two drills that we use with them. The first is the side-lying extension-rotation, which is a good entry level progression because the floor actually limits external rotation range-of-motion, and it’s easy to coach. I tell athletes that they should think of thoracic spine extension/rotation driving scapular retraction/depression, which in turn drives humeral external rotation (and flexion/horizontal abduction). Usually, simply putting your hands on the shoulder girdle and guiding them through the motion is the best teaching tool.

A progression on the side-lying extension-rotation is the side-lying windmill, which requires a bit more attention to detail to ensure that the range-of-motion comes from the right place. The goal is to think of moving exclusively from the thoracic spine with an appropriate scapular retraction/posterior tilt. In other words, the arm just comes along for the ride. The eyes (and head) should follow the hand wherever it goes.

Again, these are only exercises we use with certain players who we’ve deemed deficient in external rotation. If you’re a thrower, don’t simply add these to your routine without a valid assessment from someone who is qualified to make that estimation. You could actually make the argument that this would apply to some folks in the general population who have congenital laxity as well (especially females).

4. Throw!!!!! – Pitchers gain a considerable amount of glenohumeral external rotation over the course of a competitive season simply from throwing. Sometimes, the best solution is to simply be patient. I really like long toss above all else for these folks.

In closing, there are three important things I should note:

1. You don’t want to do anything to increase valgus laxity.

2. You’re much more likely to get hurt from being “too loose” than you are from being “too tight.” When it comes to stretching the throwing shoulder, “gentle” is the name of the game – and all mobility programs should be as individualized as possible.

3. Maintaining internal rotation is a lot more important than whatever is going on with external rotation. In fact, this piece could have just as easily been named "The Two Stretches Pitchers Shouldn't Do, Plus a Few That Only Some of Them Need."

To learn more about testing, training, and treating throwing shoulders, check out Optimal Shoulder Performance: From Rehab to High Performance.

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Long Toss: Don’t Skip Steps in Your Throwing Program

My good buddy Alan Jaeger has gone to great lengths to bring long tossing to the baseball world.  I discussed why I really like it and what some of the most common long toss mistakes are in two recent posts:

Making the Case for Long Toss in a Throwing Program
The Top 4 Long Toss Mistakes

However, one thing I didn't discuss in those previous blogs was the status quo - which is essentially that long toss distances should not exceed 90-120 feet.  These seemingly arbitrary numbers are actually based on some research discussing where a pitcher's release point changes and the throwing motion becomes less and less like what we see on the mound.  Alan looked further into the origins of the "120 foot rule," and informed me that these programs began in the late 1980s/early 1990s and were based on "post-surgery experience" of a few rehabilitation specialists.

Yes, we're basing modern performance-based throwing programs for healthy pitchers on 20+ year-old return-to-throwing programs that were created for injured pitchers.  It seems ridiculous to even consider this; it's like only recommending body weight glute bridges to a football player looking to improve his pro agility time because you used them with a football player who had knee or low back pain.  It might be part of the equation, but it doesn't improve performance or protect against all injuries.  Let's look further at how this applies to a throwing context, though.

A huge chunk of pitching injuries - including all those that fall under the internal impingement spectrum (SLAP tears, undersurface cuff tears, and bicipital tendinosis), medial elbow pain (ulnar nerve irritation/hypermobility, ulnar collateral ligament tears, and flexor/pronator strains), and even lateral compressive stress (younger pitchers, usually) occur during the extreme cocking phase of throwing.  That looks like this:

It's in this position were you get the peel back mechanism and posterior-superior impingement on the glenoid by the supra- and infraspinatus.  And, it's where you get crazy valgus stress (the equivalent of 40 pounds pulling down on the hand) at the elbow - which not only stresses the medial structures with tensile force, but also creates lateral compressive forces.

In other words, if guys are hurt, this is the most common spot in their delivery that they will typically hurt.

So, logically, the rehabilitation specialists try to keep them away from full ROM to make the surgical/rehab outcomes success - and you simply won't get full range of motion (ROM) playing catch at 60-120 feet.

Effectively, you can probably look at the "progression" like this:

Step 1: 60-120 ft: Low ROM, Low Stress
Step 2: 120+ ft: Medium ROM, Medium Stress
Step 3: 240+ ft: High ROM, Medium Stress
Step 4: Mound Work: High ROM, High Stress

In other words, in the typical throwing program - from high school all the way up to the professional ranks - pitchers skip steps 2 and 3.  To me, this is like using jump rope to prepare for full speed sprinting.  The ROM and ground reaction forces (stress) just don't come close to the "end" activity.

Only problem?  Not everyone is rehabbing.  We're actually trying to get guys better.

Long Toss.  Far.  You'll thank me later.

Want to learn more? Check out Alan's DVD, Thrive on Throwing, to learn more.  He's made it available to my readers at 25% off through this link.

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Lose Fat, Gain Muscle, Get Strong: Eric Cressey’s Best Articles of 2010

Show and Go: High Performance Training to Look, Feel, and Move Better - This was obviously my biggest project of 2010.  I actually began writing the strength and conditioning programs and filming the exercise demonstration videos in 2009, and put all the "guinea pigs" through the four-month program beginning in February.  When they completed it as the start of the summer rolled around, I made some modifications based on their feedback and then got cracking on writing up all the tag along resources.  Finally, in September, Show and Go was ready to roll.  So, in effect, it took 10-11 months to take this product from start to finish - a lot of hard work, to say the least.  My reward has been well worth it, though, as the feedback has been awesome.  Thanks so much to everyone who has picked up a copy.

Optimal Shoulder Performance - This was a seminar that Mike Reinold and I filmed in November of 2009, and our goal was to create a resource that brought together concepts from both the shoulder rehabilitation and shoulder performance training fields to effectively bridge the gap for those looking to prevent and/or treat shoulder pain.  In the process, I learned a lot from Mike, and I think that together, we brought rehabilitation specialists and fitness professionals closer to being on the same page.

Why President Obama Throws Like a Girl - A lot of people took this as a political commentary, but to be honest, it was really just me talking about the concept of retroversion as it applies to a throwing shoulder - with a little humor thrown in, of course!

Overbearing Dads and Kids Who Throw Cheddar - This one was remarkably easy to write because I've received a lot of emails from overbearing Dads asking about increasing throwing velocity in their kids.

What I Learned in 2009 - I wrote this article for T-Nation back at the beginning of the year, and always enjoy these yearly pieces.  In fact, I'm working on my 2010 one for them now!

What a Stressed Out Bride Can Teach You About Training Success - I wrote this less than a month out from my wedding, so you could say that I had a good frame of reference.

Baseball Showcases: A Great Way to Waste Money and Get Injured - In case the title didn't tip you off, I'm not much of a fan of baseball showcases.

Cueing: Just One Piece of Semi-Private Training Success - Part 1 and Part 2 - These articles were featured at fitbusinessinsider.com.  I enjoy writing about not only the training side of things, but some of the things we've done well to build up our business.

Three Years of Cressey Performance: The Right Reasons and the Right Way - This might have been the top post of the year, in my eyes. My job is very cool.

How to Attack Continuing Education in the Fitness Industry - Here's another fitness business post.

Want to Be a Personal Trainer or Strength Coach?  Start Here. - And another!

The Skinny on Strasburg's Injury - I hate to make blog content out of someone else's misfortune, but it was a good opportunity to make some points that I think are very valid to the discussion of not only Stephen Strasburg's elbow injury, but a lot of the pitching injuries we see in youth baseball.

Surely, there are many more to list, but I don't want this to run too long!  Have a safe and happy new year, and keep an eye out for the first content of 2011, which is coming very soon!

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Weight Training For Baseball: Best Videos of 2010

I made an effort to get more videos up on the site this year, as I know a lot of folks are visual learners and/or just enjoy being able to listen to a blog, as opposed to reading it.  Here are some highlights from the past year: The Absolute Speed to Absolute Strength Continuum - Regardless of your sport, there are valuable take-home messages.  I just used throwing velocity in baseball pitchers as an example, as it's my frame of reference.

Should Pitchers Overhead Press? - This was an excerpt from Mike Reinold and my Optimal Shoulder Performance seminar (which became a popular DVD set for the year).

Shoulder Impingement vs. Rotator Cuff Tears - Speaking of Mike, here's a bit from the man himself from that seminar DVD set.

Thoracic and Glenohumeral Joint Mobility Drills - The folks at Men's Health tracked me down in the lobby at Perform Better in Providence and asked if I could take them through a few shoulder mobility drills we commonly use - and this was the result.

Cressey West - This kicks off the funny videos from the past year. A few pro baseball players that I program for in a distance-based format created this spoof video as a way of saying thank you.

Tank Nap - My puppy taking a nap in a provocative position.  What's more cute?

Matt Blake Draft Tracker - CP's resident court jester and pitching instructor airs his frustrations on draft day.

1RM Cable Horizontal Abduction - More from the man, the myth, the legend.

You can find a lot more videos on my YouTube page HERE and the Cressey Performance YouTube page HERE.

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Weight Training for Baseball: Featured Articles

I really enjoy writing multi-part features here at EricCressey.com because it really affords me more time to dig deep into a topic of interest to both my readers and me.  In many ways, it's like writing a book.  Here were three noteworthy features I published in 2010: Understanding Elbow Pain - Whether you were a baseball pitcher trying to prevent a Tommy John surgery or recreational weightlifter with "tennis elbow," this series had something for you. Part 1: Functional Anatomy Part 2: Pathology Part 3: Throwing Injuries Part 4: Protecting Pitchers Part 5: The Truth About Tennis Elbow Part 6: Elbow Pain in Lifters

Strategies for Correcting Bad Posture - This series was published more recently, and was extremely well received.  It's a combination of both quick programming tips and long-term modifications you can use to eliminate poor posture. Strategies for Correcting Bad Posture: Part 1 Strategies for Correcting Bad Posture: Part 2 Strategies for Correcting Bad Posture: Part 3 Strategies for Correcting Bad Posture: Part 4

A New Paradigm for Performance Testing - This two-part feature was actually an interview with Bioletic founder, Dr. Rick Cohen.  In it, we discuss the importance of testing athletes for deficiencies and strategically correcting them.  We've begun to use Bioletics more and more with our athletes, and I highly recommend their thorough and forward thinking services. A New Paradigm for Performance Testing: Part 1 A New Paradigm for Performance Testing: Part 2 I already have a few series planned for 2011, so keep an eye out for them!  In the meantime, we have two more "Best of 2010" features in store before Friday at midnight. Sign-up Today for our FREE Newsletter:
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Friday the 13th: Muscle Imbalances, Stiffness, & Increasing Throwing Velocity

1.  I just realized that it's Friday the 13th.  Hopefully that epiphany doesn't jinx this blog and make it suck.  Prepare yourself either way.

epiphany

2. In case you missed it earlier this week, today is the last day you can save $50 off of Muscle Imbalances Revealed, a discount that is only in place for my readers through THIS LINK. As I noted in my Muscle Imbalances Revealed product review earlier this week, it's an excellent product and worth every penny. The sale lasts through tonight at midnight only.

muscle-imbalances-revealed-open-package-300x201

3. If you're a regular reader of this blog, you probably know that I'm a huge advocate of soft tissue work based on anecdotal evidence.  This week, however, I want to direct you to a great "case study" guest blog by physical therapist Trevor Winnegge over at Mike Reinold's blog.  Trevor writes about the importance of soft tissue release following SLAP 2 repairs.  This is great information for both clinicians and those looking to be advocates for themselves following shoulder injuries, so definitely check it out. 4. Check out this excellent blog post from Bret Contreras on stiffness.  A lot of folks think that being stiff is always a bad thing, but as Bret shows, there is a time and a place for everything - and it's crucial for successful athletic performance. 5. Cressey Performance athlete Andrew Chin had a nice interview published at ESPN Boston the other day, and talks about his training at CP in some detail. Check it out: Player Perspective: Andrew Chin.

chin

5. Tony's out of town for a lovely romantic weekend with his significant other.  He's planning to serenade her, so we did a little trial run at Cressey Performance the other night.  I think he did pretty well:

Hey, it beats techno, right?

6. One of my goals for the rest of 2010 is to really kick up the video content here at EricCressey.com.  To that end, I am tentatively planning a video series for the blog that is all about exercise technique and how we teach certain lifts.  I'm looking for ideas: what drills/exercises/lifts have been a struggle for you to learn?  Please post some suggestions as comments below and you might see it in this blog in the next few months with a ton of detail.  Thanks in advance for your ideas!

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Healthy Shoulders with Terrible MRIs?

In the same grain as Monday's post on lower back pain, today, I thought I'd highlight some of the common findings in diagnostic imaging of the shoulder, as these findings are just as alarming.

Do you train loads of overhead throwing athletes (especially pitchers) like I do?  Miniaci et al. found that 79% of asymptomatic professional pitchers (28/40) had "abnormal labrum" features and noted that "magnetic resonance imaging of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of 'nonclinical' findings."  Yes, you can have a torn labrum and not be in pain (it depends on the kind of labral tear you have; for more information, check out Mike Reinold's great series on SLAP lesions, starting with Part 1).

slap_lesion

This isn't just limited to baseball players, either; you'll see it in handball, swimming, track and field throwers, and tennis as well.  And, it isn't just limited to the labrum.  Connor et al. found that eight of 20 (40%) dominant shoulders in asymptomatic tennis/baseball players had evidence of partial or full-thickness cuff tears on MRI. Five of the 20 also had evidence of Bennett's lesions.

The general population may be even worse, particularly as folks age. Sher et al. took MRIs of 96 asymptomatic subjects, finding rotator cuff tears in 34% of cases, and 54% of those older than 60 - so if you're dealing with older adult fitness, you have to assume they're present in more than half your clients!

rtc-tear

Also, in another Miniaci et al. study, MRIs of 30 asymptomatic shoulders under age 50 demonstrated "no completely 'normal' rotator cuffs."  People's MRIs are such train wrecks that we don't even know what "normal" is anymore!

As is the case with back pain, these issues generally only become symptomatic when you don't move well - meaning you have insufficient strength, limited flexibility, or poor tissue quality.  For more information on how to screen for and prevent these issues from reaching threshold, check out Optimal Shoulder Performance from Mike Reinold and me.

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Baseball Showcases: A Great Way to Waste Money and Get Injured

Q: I read your blog here the other day about your "ideal competitive year" for a baseball player.  What's your take on showcases and college camps?  They always occur during the "down periods" you mentioned: fall ball and the early winter.  How do these fit in to a baseball player's development?

A: To be blunt, while there are some exceptions to the rule, they rarely fit into development. In reality, they usually feed into destruction - at least in the context of pitchers.  I openly discourage all our young athletes and parents from attending them almost without exception.

I know of very few showcase directors and college baseball coaches who legitimately understand anatomy, physiology, the etiology of baseball injuries, the nature of adolescent development, or motor skill acquisition.

Showcase directors specialize in promoting and running showcases.  College coaches specialize in recruiting players, developing talent, planning game and practice strategy, and winning games.  To my knowledge, understanding scapulohumeral rhythm and the contributions of a glenohumeral internal rotation deficit (GIRD) to SLAP lesions via the peel-back mechanism isn't all in a day's work for these folks.

nomo

The fundamental issue with these events is their timing.  As you noted, they almost always occur in the fall and winter months.  Why?

1.  It's the easiest time to recruit participants, as they aren't in-season with their baseball teams.

2. It's not during the college baseball season - so fields and schedules are open and scouting and coaching man-power is free.

You'll notice that neither #1 or #2 said "It's the time of year when a pitcher is the most prepared to perform at a high level safely."  It is just profitable and convenient for other people - and that occurs at the expense of many young pitchers' arms.

In 2006, Olsen et al. published a fantastic review that examined all the different factors associated with elbow and shoulder surgeries in pitchers by comparing injured pitchers (those who warranted surgery) with their non-injured counterparts.  Some of the findings of the study:

-Pitchers who eventually required surgery threw almost EXACTLY twice as many pitches as the control group (healthy pitchers) over the course of the year...from a combination of pitches per outing, total outings, and months pitched per year.  For those of you who think your kid needs to play on multiple teams simultaneously, be very careul; add a team and you instantly double things - at least acutely.

-The injured pitchers attended an average of FOUR times more showcases than non-injured kids.

-Interesting aside:  injured pitchers were asked what their coaches' most important concern was: game, season, or athlete's career.  In the healthy group, they said the coach cared about the game most in only 11.4% of cases. In the injured group, it was 24.2%!  These crazy little league coaches are often also the ones running the showcases...

The big problem is that these issues usually don't present until years later.  Kids may not become symptomatic for quite some time, or pop NSAIDs to cover up the issues.  They might even go to physical therapy for a year before realizing they need surgery.  It's why you see loads of surgeries in the 16-18 year-old population, but not very often in 15 and under age groups.

elbowsurgery

So why are appearances like these in the fall and winter months so problematic?  Well, perhaps the best way I can illustrate my point is to refer back to a conversation I had with Curt Schilling last year.

Curt told me that throughout his career, he had always viewed building up his arm each year as a process with several levels.

Step 1: Playing easy catch
Step 2: Playing easy catch on a line
Step 3: Building up one's long toss (Curt never got onto a mound until he'd "comfortably" long-tossed 200 ft.)
Step 4: Throwing submaximally off a mound
Step 5: Throwing with maximum effort off a mound
Step 6: Throwing with maximum effort off a mound with a batter
Step 7: Throwing with maximum effort off a mound with a batter in a live game situation
Step 8: Opening day at Fenway Park in front of 40,000+ people

curt-schilling1

Being at a showcase in front of college coaches and scouts with radar guns is Step 8 for every 14-16 year old kid in America.  And, it comes at the time of year when they may not have even been throwing because of fall/winter sports and the weather.  Just to be clear, I'll answer this stupid question before anyone asks it: playing year-round and trying to be ready all the time is NOT the solution.

I can honestly say that in all my years of training baseball players, I've only seen one kid who was "discovered" at a showcase.  And, frankly, it occurred in December of his junior year, so those scouts surely would have found him during high school and summer ball; it wasn't a desperate attempt to catch someone's eye.

I'll be honest: I have a lot of very close friends who work as collegiate baseball coaches.  They're highly-qualified guys who do a fantastic job with their athletes - but also make money off of fall baseball camps.  I can be their friend without agreeing with everything they do; there is a difference between "disagree" and "dislike."

Fortunately, the best coaches are the ones who go out of their way to make these events as safe as possible, emphasizing skill, technique, and strategy improvements over "impressing" whoever is watching.  So, it's possible to have a safe, beneficial experience at one of these camps.  I'd encourage you to find out more about what goes on at the events in advance, and avoid throwing bullpens if unprepared for them.

As far as showcases are concerned, I'd encourage you to save your money and go on a family vacation instead.

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Stuff You Should Read: 3/22/10

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

rugby-tackle

It is just another example of how our body has a great system of checks and balances.  When a passive structure is injured, the active restraints can pick up the slack. For related reading, check out Active vs. Passive Restraints.
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MRIs vs. Movement

As many of you know, earlier this week, I spent three days at a huge sports medicine conference organized by Mass General Hospital in conjunction with the Harvard University Medical School.  It was a great event geared toward sports orthopedists, radiologists, physical therapists, and athletic trainers; I was very humbled to have been invited to present alongside some of the brightest minds in the sports medicine world.  The discussions on surgical technique, physical examinations, etiology of injuries, biomechanics, rehabilitation, and return-to-play guidelines were absolutely fantastic.  The stuff that caught my attention the most, though, actually came in the discussion of imaging - MRIs, MRAs, and x-rays - by some of the best radiologists in the world. Several of these brilliant radiologists made specific points of commenting on how not every abnormality you see on diagnostic imaging constitutes a symptom-causing issues.  A perfect example would be a SLAP 1 (superior labrum fraying) in a baseball pitcher, which is completely normal for 79% of major league pitchers.  Just because the labrum is fraying doesn't mean that the pitcher is going to be in pain; it's a passive stabilizer, and the active restraints (rotator cuff, scapular stabilizers) can get stronger to pick up the slack.  Likewise, just because a player is having shoulder pain and he has a SLAP 1 lesion on imaging doesn't mean that the frayed labrum is the cause.  It could be coming from the biceps tendon or rotator cuff, for instance, and the labral issue is just "there." So what does that mean for strength and conditioning professionals?  Well, as I wrote in Inefficiency vs. Pathology, there isn't a whole lot we can do to effect favorable changes in what diagnostic imaging looks like, but we can go out of our way to ensure that clients and athletes move efficiently and have adequate muscular strength, stability, and tissue quality.

btea_set

This is actually my exact topic on the Perform Better tour (next stop is Long Beach at the end of July).  If you can't make it to Long Beach, I'd highly encourage you to check out these previous writings of mine: Inefficiency vs. Pathology (noted above) To Squat or Not to Squat An Interview with Dr. Jason Hodges The Proactive Patient
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