Home Posts tagged "Thoracic Outlet Syndrome"

Random Thoughts on Sports Performance Training – Installment 24

With only a few days to spare, here is the November 2016 edition of randomness!

1. Don’t let bad movement become cemented joints.

As I presented in Functional Stability Training of the Upper Body, mobility can be restricted for a lot of reasons.

One thing I didn't note in this video is that if you have muscular, capsular, or alignment issues that persist for an extended period of time, you'll eventually develop changes to the joint (bony overgrowth). In a 2013 study, world-renowned hip specialist Marc Phillipon examined how the incidence of femoroacetabular impingment (FAI) - bony overgrowth at the hip - changed across various stages of youth hockey. At the PeeWee (10-12 years old) level, 37% had FAI and 48% had labral tears. These numbers went to 63% and 63% at the Bantam level (ages 13-15), and 93% and 93% at the Midget (ages 16-19) levels, respectively. The longer one played hockey, the messier the hip – and the greater the likelihood that the FAI would “chew up” the labrum.

fai
Source: Lavigne et al. 2004

It's imperative for strength and conditioning coaches to understand these issues. On evaluation, if an athlete already has changes to the joint, we need to create training programs to deliver a training effect while working around these issues. If you squat an entire team of football players even though you know 4-5 of them already have significant FAI and associated pathologies in their hips, you're probably going to be funding some hip surgeon's retirement. Work on deadlifting and single-leg work instead, though, and you'll probably kick the can down the road for those athletes.

Conversely, if your assessment reveals that an athlete is out of alignment and has some tissue density and core control issues that are preventing quality hip flexion and internal rotation, you need to design a program to get to work on those problems before they can develop bony blocks at the hip. As my buddy Mike Reinold often says, "Assess, don't guess." 

2. We might be seeing the end of the versatile strength and conditioning coach.

One thing I've noticed in the strength and conditioning field over the past decade is an increased tendency toward specialization among coaches. Over the years, there have some been really bright coaches - Al Vermeil, Mike Boyle, and Bob Alejo come to mind - who've had success across multiple sports at the highest levels. They were few and far between, but it was still something that was feasible if someone was educated and motivated enough. I think that's changing and this versatility will be obsolete very soon.

We're seeing a much bigger focus on analytics in all professional sports; the focus on minute details has never been greater. In college sports, we are seeing more "baseball only" and "hockey only" guys to build on the years of the football strength and conditioning coach typically not working with other teams. At every level, specialization among strength coaches (and rehabilitation specialists, for that matter) is increasing. As a result, if a coach tries to venture out into another sport at a high level, it takes longer to get up to speed. 

If a guy leaves basketball to go to baseball, he's got to learn about thoracic outlet syndrome, ulnar collateral ligament injuries, and lat strains; these just don't happen very often in hoops. He won't have to worry much about humeral retroversion in his programming for shooting guards, either - but it has a huge influence on how he manages functional mobility in pitchers.

 

Today is Day 12 of #30DaysOfArmCare. Thanks to #Tigers pitcher @adamrav12 for the assist! Key takeaways: 1. Retroversion is a common finding and throwing shoulders. It gives rise to greater lay-back at max external rotation. 2. The more passive range of motion you have, the more consistently you must work to maintain active stability of that ROM. ROM without stability is injury risk. 3. Perform your cuff work in the positions that matter - and keep in mind that individual differences in passive ROM may be present. 4. Don't stretch throwers into external rotation, especially if they already have this much lay-back! Follow #30DaysOfArmCare and @cresseysportsperformance for more tips to keep throwing arms healthy. #cspfamily #armcare #baseball #mlb

A video posted by Eric Cressey (@ericcressey) on

Likewise, just because I have a solid handle on managing shoulders in overhead athletes doesn't mean that I'm equipped to handle the metabolic demands that swimmers encounter.

Versatility is still important; a well-rounded professional will never go hungry. However, at the higher levels, I just see fewer and fewer professional teams and colleges valuing it highly when the quickest option is to seek out specialists in specific realms.

3. Create context not only to improve coaching, but also to improve adherence.

Recently, I saw a professional pitcher who noted that his team had commented on how limited his extension on each pitch was. For those who aren't familiar, in recent years, teams have started tracking the actual release point of various pitchers. Basically, if two pitchers both throw 95mph, but one releases the ball closer to the plate, the one with more extension is actually releasing the ball closer to the plate, so it "gets on" the hitter faster. All things considered, a higher extension is generally better. You can view it as part of the Statcast panel on each MLB pitchers' page; here's CSP athlete Steve Cishek's, as a frame of reference. Steve's extension is well above MLB average, so the perceived velocity of his pitches are over one mph higher than their actual velocity.

cishekextension2

Returning to the pitcher I evaluated recently, he commented that although his fastball velocity is among the best in the minor leagues and he has quite a bit of movement, he doesn't strike a lot of guys out. While there are a lot of reasons for this, one consideration has to be physical limitations that don't allow him to get extension out in front. In his case, on evaluation, we saw a pseudo military posture; his shoulder blades were tugged back into adduction, and he lacked the upward rotation to effectively "get out front."

adductedscap

Additionally, in the lower extremity, he had significant bilateral muscular/alignment limitations to hip internal rotation. If you don't have sufficient hip internal rotation on your back leg, you aren't going to ride your hip down the mound very far. If you don't have internal rotation on the front hip, you won't be able to accept force on the front leg, so you'll effectively cut off your deceleration arc, also shortening your extension out front. These are usually the guys who "miss" up-and-armside, or cut balls off in an attempt to correct the issue.

If I had just told him he needed to fix these for the sake of fixing them - or even just to prevent injury - it probably wouldn't hold much water. However, by relating these movement inefficiencies back to aspects of his delivery with which he struggles, the buy-in is a lot higher. Striking guys out is a lot "sexier" than avoiding injury or conforming to some range-of-motion norm. 

4. This is a great weekend to be an up-and-coming fitness professional or rehabilitation specialist on a limited budget.

Black Friday/Cyber Monday might be annoying if you're in stores and dealing with a bunch of crazy Moms who are fighting over the last Tickle-Me-Elmo, but in an online context, it's pretty darn awesome - especially if you're an aspiring coach looking to get your hands on some quality educational material.

I did my undergraduate education at a smaller Division 3 school in Southern Maine. We didn't have a varsity weight room where I could observe or volunteer, and there weren't tip top internship opportunities right down the road where I could've found opportunities like that. Looking back, I realize that one of the main reasons I got on the right path was that I was willing to search high and low for those learning opportunities. I spent hours reading T-Nation and hard copy books I'd bought, not to mention driving to whatever seminars I could find.

Nowadays, education is much, more more accessible. Instead of driving nine hours to Buffalo or dropping $1,000 on a plane right, hotel, rental car, and seminar registration, you can spend 10% of that amount and get an awesome education - and you can pick and choose what you want to learn. This weekend, you can do it super affordably, too.

Want a crash course in relative stiffness? Check out my presentations in Functional Stability Training: Optimizing Movement (on sale for 20% off with coupon code BF2016). 

Looking to patch up the holes in your college anatomy course by learning about functional anatomy instead? Pick up Building the Efficient Athlete from Mike Robertson and me (20% off this weekend; no coupon code needed).

Need some cutting-edge hip mobility strategies? Watch Dean Somerset's presentations in The Complete Shoulder and Hip Blueprint (on sale for $30 off through Monday).

Interested in taking a peek into the mind of a successful NFL strength and conditioning coach? Soak up Joe Kenn's knowledge in Elite Athletic Development (20% off this weekend; no coupon code needed).

It's an amazing age in strength and conditioning; short of actual hands-on coaching experience, all the information you need to be successful is at your fingertips in a digital medium - and this is the weekend to get it at the best price.

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Strength and Conditioning Stuff You Should Read: 10/25/16

Before we get to the recommended content for the week, can we talk about how awesome it is to have a Cubs/Indians World Series match-up?!?! With four Cressey Sports Performance (CSP) guys in this series, you can bet that I won't miss a single pitch. I'm flying out today for Game 1 in Cleveland, but before I do, here's some strength and conditioning reading to hold you over for a few days!

Long-Term Success: What You Can Learn from Corey Kluber - With CSP athlete Corey starting Game 1 of the World Series, it seemed like a good time to reincarnate this article I wrote for Gabe Kapler's website back in 2014. Yesterday's article (here) on MLB.com reaffirmed my thoughts even more.

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Why Nutrition Science is So Confusing - Dr. John Berardi has a knack for making the complex seem simple, and in this infographic, he discusses why things have gotten so complicated on the nutrition front in the first place.

How to Write Better Youth Warm-ups - At our Massachusetts facility, Nancy Newell heads up the CSP Foundations program, which is geared toward 7-12 year-old athletes. They have an absolute blast and it has a lot to do with Nancy's contagious energy and fun programming.

Top Tweet of the Week:

Top Instagram Post of the Week:

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Strength and Conditioning Stuff You Should Read: 9/12/16

Happy Monday! Well, at least it is for me. I'm pumped about the Patriots' season opening win on the road against the Cardinals last night! Let's keep the good vibes rolling with some recommended reading from around the 'Net over the past week:

3 Laws to Master Coaching Young Athletes - Cressey Sports Performance coach Nancy Newell does an awesome job with our CSP Foundations (7-12 year-old) class, and this blog shows why. The kids have a blast and learn a ton in large part due to her enthusiasm and fun approach to coaching. 

Performance Metrics in Professional Baseball Players Before and Surgical Treatment for Neurogenic Thoracic Outlet Syndrome - In light of the rise in TOS surgeries in professional baseball, I thought it'd be good to link to this recent publication from Dr. Robert Thompson's group in St. Louis. It's important to note that the case studies in question were performed between 2001 and 2014, and they've actually improved the surgery and rehab in the two years since then. I'd venture a guess that outcomes are even better now.

3 Tips for Transitioning Your Training Model to Semi-Private - When folks come to observe at one of the CSP facilities, invariably, they wind up asking the question, "How can I do this with my clientele?" In this blog, Pete Dupuis provides a thorough answer.

Elite Training Mentorship - Just a friendly reminder that the CSP staff uploads content to this resource every month, and the September update includes an awesome webinar, "Coaching, Cueing, and Performance," from Miguel Aragoncillo.  

Top Tweet of the Week:

 

Top Instagram Post of the Week

 

To think, this all started with a handful of HS baseball players during the summer of '07... #cspfamily #elitebaseball #CSPpitching

A photo posted by Cressey Sports Performance (@cresseysportsperformance) on

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6 Saturday Shoulder Strategies

In light of the recent announcement of my upcoming shoulder course in Colorado, I thought I'd use today's post to throw out some thoughts on training the shoulders.

1. In the upper extremity, the assessments are often the solutions, too.

Imagine you're assessing an athlete, and their squat pattern is absolutely brutal. Usually, the last thing you're going to do is go right to a squat as part of their training. In other words, simply coaching it differently usually won't improve the pattern immediately. Rather, you typically need "rebuild" the pattern by working with everything from ankle and hip mobility to core control, ultimately progressing to movements that replicate the squatting pattern.

Interestingly, the upper extremity is usually the opposite in that the assessment might also be the drill you use to correct the movement. For instance, an aberrant shoulder flexion pattern like this...

...might be quickly corrected with some of these three cues on a back to wall shoulder flexion pattern.

This is also true of push-up assessments and shoulder abduction and external rotation tests we do; funky patterns are usually cleaned up quickly with some subtle cueing. This just isn't the case as much in the lower body, though. Why the difference?

My theory is that because we're weight-bearing all day, the lower extremity is potentially less responsive to the addition of good stiffness in the right places. Conversely, a little bit of stiffness in serratus anterior, lower trap, or posterior cuff seems to go a long way in quickly improving upper extremity movement. My experience with the Postural Restoration Institute also leads me to believe that creating a good zone of apposition can have lead to a more pronounced transient movement in the upper extremity than it does in the lower extremity. This is likely because the rib cage is directly involved with the shoulder girdle, whereas the relationship with the lower extremity (ribs --> spine --> pelvis) is less direct. 

Zone-of-Apposition-300x220

These differences also seem to at least partially explain why upper extremity posture is much easier to change than lower extremity positioning. It's far more common to see a scapular anterior tilt change markedly than it is to see an anterior pelvic tilt substantially reduced.

Just thinking out loud here, though. Fun stuff.

2. Anterior shoulder pain usually isn't "biceps tendinitis."

First off, true tendinitis is actually quite rare. In this landmark paper, Maffulli et al. went to great lengths to demonstrate that the overwhelming majority of the overuse tendon conditions we see are actually tendinOSIS (degenerative) and not tendinITIS (inflammatory). It may seem like wordplay, but it's actually a very important differentiation to make: if you're dealing with a biceps issue, it's probably tendinosis.

shoulder

Second, if you speak with any forward thinking orthopedic shoulder specialist or rehabilitation expert, they'll tell you that there are a lot of differential diagnoses for anterior (front) shoulder pain. It could be referred pain from further up (cervical disc issues, tissue density at scalenes/sternocleidomastoid/subclavius/pec minor, or thoracic outlet syndome), rotator cuff injury or tendinopathy, anterior capsule injury, a lat strain or tendinopathy, labral pathology, nerve irritation at the shoulder itself, arthritis, a Bankart lesion, osteolysis of the distal clavicle, AC joint injury, and a host of other factors.

3. Thoracic outlet surgery really isn't a shoulder surgery.

Over the past few years, each time a professional pitcher gets thoracic outlet surgery, you see many news outlets call it "shoulder surgery." Sorry, but that really isn't the case unless you have a very expansive definition of the word "shoulder."

With this intervention, the surgeon is removing the first (top) rib to provide "clearance" for the nerves and vascular structures to pass underneath the clavicle.

Gray112thoracicoutlet

Additionally, surgeons usually opt to perform a scalenectomy, where they surgically remove a portion of the anterior scalenes, which may have hypertrophied (grown) due to chronic overuse. Again, this is not a "shoulder" procedure.

Finally, more and more surgeons are also incorporating a pec minor release as part of the surgical intervention. This is because the nerve and vascular structures that may be impinged at the scalenes or first rib can also be impinged at the coracoid process of the scapular if an individual is too anterior-tilted. While the coracobrachialis and short head of the biceps both attach here, the pec minor is likely the biggest player in creating these potential problems.

pecminor

This, for me, is the only time this becomes somewhat of a "shoulder" surgery - and it's an indirect relationship that doesn't truly involve the joint. We're still nowhere near the glenohumeral (ball-and-socket) joint that most people consider the true shoulder.

All that said, many people consider the "shoulder girdle" a collection of joints that includes the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic articulations. In this case, though, the media just doesn't have a clue what they're trying to describe. With that in mind, hopefully this turned into somewhat of an educational rant.

4. Medicine ball scoop tosses tend to be a better than shotputs for cranky shoulders.

Rotational medicine ball training is a big part of our baseball workouts, and it's something we try to include as an integral part of retraining throwing patterns even while guys may be rehabilitating shoulder issues. When you compare rotational shotputs with rotational scoop tosses...

...you can see that the scoop toss requires far less shoulder internal rotation and horizontal adduction, and distraction forces on the joint are far lower at ball release. The shotput is much more stressful to the joint, so it's better saved for much later on in the rehab process.

5. Adequate rotator cuff control is about sufficient strength and proper timing - in the right positions.

To have a healthy shoulder, your cuff needs to be strong and "aware" enough to do its job in the position that matters. If you think about the most shoulder problem, there is pain at some extreme: the overhead position of a press, the lay-back phase of throwing, or the bar-on-your back position in squatting. For some reason, though, the overwhelming majority of cuff strength tests take place with the arms at the sides or right at 90 degrees of elevation. Sure, these positions might give us a glimpse at strength without provoking symptoms, but they really don't speak much to functional capacity in the positions that matter. 

With that in mind, I love the idea of testing rotator cuff strength and timing in the positions that matter. Here's an example:

Eric-Cressey-Shoulder_OS___0-300x156

Obviously, you can make it even more functional by going into a half-kneeling, split-stance, or standing position. The point is that there are a lot of athletes who can test pretty well in positions that don't matter, but horribly in the postures that do.

6. Pre-operative physical therapy for the shoulder is likely really underutilized.

It's not uncommon to hear about someone with an ACL tear going through a month or so of physical therapy before the surgery actually takes place. Basically, they get a head start on range-of-motion and motor control work while swelling goes down (and, in some cases, some healing of an associated MCL injury may need to occur).

I'm surprised this approach isn't utilized as much with shoulder surgeries. It wouldn't be applicable to every situation, of course, but I think that in some cases, it can be useful to have a pre-operative baseline of range-of-motion. This is particularly true in cases of chronic throwing shoulder injuries where regaining the right amount of external rotation is crucial for return to high level function. Adding in some work on cuff strength/timing, scapular control, and thoracic mobility before hopping in a sling for 4-6 weeks probably wouldn't hurt the case, either. And, as an added bonus, if this was more common, I think we'd find quite a few people who just so happen to become asymptomatic, allowing them to cancel their surgeries. It's probably wishful thinking on my part, but that's what these random thoughts articles are all about.

For more information on my June 24 seminar in Colorado, please click here.

Have a great weekend!

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Register Now for the 3rd Annual Cressey Sports Performance Fall Seminar!

I’m psyched to announce that on Sunday, September 28, we’ll be hosting our third annual fall seminar at Cressey Sports Performance.  As was the case with our extremely popular fall event over the past two years, this event will showcase both the great staff we're fortunate to have as part of our team.  Also like last year, we want to make this an affordable event for everyone and create a great forum for industry professionals and fitness enthusiasts alike to interact, exchange ideas, and learn.

CP_monogram_ol.eps

Here are the presentation topics:

Thoracic Outlet Syndrome: A "New" Diagnosis for the Same Old Problems - Presented by Eric Cressey

More and more individuals - both athletes and non-athletes alike - are being diagnosed with thoracic outlet syndrome. In this presentation, Eric will explain what it is, how it's treated, and - most importantly - what fitness professionals and rehabilitation specialists can do to prevent it from occurring in the first place.

Making Bad Movement Better – Presented by Tony Gentilcore

Tony will cover the most common technique flaws he sees on a daily basis, outlining both coaching cues and programming strategies one can utilize to improve exercise technique. He'll also cover progressions and regressions, and when to apply them.

Paleo: The Good, The Bad, and The Ugly – Presented by Brian St. Pierre

Paleo: possibly the most hyped nutritional approach to come along since Atkins. This, of course, begs the question: do the results match the hype? Is it right for everybody? Do we really need to avoid dairy, legumes and grains to achieve optimal health? Do all clients need to take their nutrition to this level? In this presentation, Brian explores the pros and the cons, the insights and the fallacies of the Paleo movement. And, he'll discuss the accumulated wisdom from coaching over 30,000 individuals, and what that teaches us about which nutritional camp to which should really "belong."

Trigger Points 101:  – Presented by Chris Howard

In this presentation, massage therapist Chris Howard will discuss what trigger points are, why they develop, where you'll find them, and - of course - how to get rid of them! He'll pay special attention to how certain trigger points commonly line up with certain issues clients face, and how soft tissue work can play an integral in improving movement quality while preventing and elimination symptoms.

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How Bad Do You Want It? – Presented by Greg Robins

In this presentation, Greg will discuss the factors that govern how individuals stick to (or abandon) their training and nutrition goals. He'll introduce real strategies to help people make changes by focusing on the most important variable: themselves.

Finding the Training Potential in Injury – Presented by Andrew Zomberg

Don't let a setback set you or your clients back in the weight room. Injuries happen, but that doesn’t mean that you can’t still achieve a great training effect. Andrew will discuss the most common injuries/conditions individuals encounter, and how the fitness professional can aid in sustaining a training stimulus during the recovery phase. This will include exercise selection tips, coaching cue recommendations, and programming examples.

Location:

Cressey Sports Performance
577 Main St.
Suite 310
Hudson, MA 01749

Cost:

Regular Rate – $149.99
Student Rate (must have student ID at door) – $129.99

Date/Time:

Sunday, September 28, 2014
Registration 8:30AM
Seminar 9AM-5PM

Continuing Education:

0.6 NSCA CEUs pending (six contact hours)

Click Here to Sign-up (Regular)

or

Click Here to Sign-up (Students)

We’re really excited about this event, and would love to have you join us! However, space is limited and each seminar we’ve hosted in the past has sold out quickly, so don’t delay on signing up!

If you have additional questions, please direct them to cspmass@gmail.com. Looking forward to seeing you there!

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Assessments You Might Be Overlooking: Installment 4

I always tell up-and-comers in the strength and conditioning field, "If you aren't assessing, you're just guessing."  It's not as simple as just doing a sit-and-reach test and having someone hop on the scale for you, though. This series is devoted to highlighting some of the most commonly overlooked components of the assessment process - and here are three more evaluations you might be missing:

1. Previous Athletic/Training Workload - If you're trying to help a client get to where they want to be, it's important to realize where they've been.  For example, someone who has a history of overworking themselves might respond really well to a lower volume program.  Or, an athlete looking to gain muscle mass who has never trained with much lifting volume might be well-served to add some "backoff" sets and additional assistance work.

This is an incredibly important discussion with our professional pitchers, too.  Starting pitchers who have a high workload (some in excess of 200 innings pitched in the previous 8-9 months) need to wait longer to start throwing than relief pitchers who may not have thrown more than 40 innings in a season.  The former group might not start an off-season throwing program until January 1, whereas the latter group might already have eight weeks of work in by that point.

600px-Corey_Kluber_on_June_27,_2013

Discussions of building work capacity get a lot of love in the strength and conditioning field, but I think we often lose sight of the fact that sporting coaches are also looking to build work capacity in the context of the athletes' actual sports.  Now, these two things don't have to be mutually exclusive, but if everyone is always pushing high volume all the time, things can go downhill fast.

2. Quad and Adductor Length - Let's face it: a huge chunk of the population doesn't exercise enough, and even most of those who do exercise regularly don't pay attention to mobility needs. As a result, their entire exercise program takes place in a very small amplitude; they never get through significent joint ranges of motion. Two areas in which you see this probably rearing its ugly head the most are quad and adductor length. 

Your quads are maximally lengthened when your heel is on your butt.  How often do you see someone encounter this position in their daily lives?

IMG_8805

Adductors are stretched when the hips are abducted.  When was the last time you hit this pose in your daily activities - outside of a fall on the ice?

NeutralRockBack

If you want to do a quick and easy assessment of where you stand on these, try these two (borrowed from Assess and Correct):

Prone Knee Flexion: you should have at least 120 degrees of active knee flexion without the pelvis or lower back moving.

pronekneeflexion

Supine Abduction: you should have at least 45 degrees of abduction without lumbar or pelvis compensation, or any hip rotation.

supineabduction

I generally just check these up on the training table when people get started up, but these should provide good do-it-yourself options for my readers who aren't fitness professionals.  Also, if you find that you come up short on these tests, get to work on the two stretches pictures at the start of this bulletpoint.

3. Taking the Shirt Off - This is a tricky one, as you obviously can't do it with female clients, and even when male clients, you have to be sensitize to the fact that it might not be something in which they'd like to partake.  That said, you'd be amazed at how many upper extremity dysfunctions can be obscured by a simple t-shirt.  As an example, this left-handed pitcher's medial elbow pain was diagnosed with ulnar neuritis, and he was prescribed anti-inflammatories for it and sent on his way without the doctor even having him take his shirt off to evaluate the shoulder and neck.

lowleftshoulder

Needless to say, he sits in heavy scapular depression on the left side, and it wouldn't be a "stretch" (pun intended) at all to suspect that his ulnar nerve symptoms would be originating further up the chain.  Take note on how the brachial plexus/ulnar nerve runs right under the clavicle as it courses down toward the elbow.

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Crank the scapula and clavicle down, and you can easily compress the nerve (and vascular structures) to wind up with thoracic outlet syndrome, a very common, but under-diagnosed condition in overhead throwing athletes.  The more forward-thinking upper extremity orthopedic surgeons are diagnosing this more and more frequently nowadays; elbow problems aren't always elbow problems!

The lesson is that you can see a lot when you take a shirt off.  If it's the right fit for your client/athlete, work it in.

I'll be back soon with more commonly overlooked assessments.  In the meantime, I want to give you a quick heads-up that to celebrate National Multiple Sclerosis Awareness week and help the cause, Mike Reinold and I have put both Functional Stability Training of the Core and Lower Body on sale for 25% off through tonight (Saturday) at midnight - with 25% of proceeds going to MS charities. Just use the coupon code msawareness to apply the discount at the following link: www.FunctionalStability.com.

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