November Hits

1)  Down and back isn't always right for our shoulder patients.  In fact, some people need the opposite.  This months article goes over how to assess and treat someone for overhead shoulder exercises.2) This is awesome - slow-mo clean & jerk video with analysis from olympic lifting coach Jim Schmitz.3) A new knee ligament?  Researchers have found an Anterolateral Ligament (ALL) in the knee.  Is this a profound advancement in anatomy?  Or is this just a carved out fascial thickening?4) Great perspective on hamstring tightness.  Mike Reinold discusses how a tight hip flexor can pull the pelvis into an anterior pelvic tilt, thus decreasing the contralateral straight leg raise.  You could use the 90-90 active posterior chain test in hooklying to further determine if it's true posterior tissue extensibility.  The hooklying position takes out the hip flexors and anterior pelvic tilt.  Just understand that with ankle dorsiflexion it would be more of a neural bias and keeping the foot in neutral would be more of a soft tissue bias.5) The Subjective Examination.  Patients recall from memory the events and factors the influence their injury.  But how accurate is it?  Watch this interesting TED talk on memory.6) Mike Robertson put together a great guide for learning and correcting the front squat.7) If you're interested in performance you should check out this post on the different types of speed.  "To evaluate an athlete properly, several options exist to discovering the fitness and speed of an athlete. "8) Don't forget to train your upper dorsimus.9) Erson's 5's - Mistakes He's Learned From.   A great and humble post with some valuable clinical advice.  I recently have been learning from my mistake of thinking I can fix everyone.  I have a hard time "giving up".  This sometimes causes patients treatment duration to last longer than it should.  After 10+ visits of no significant change a lot of bad things can happen.  I am on board with Erson's rule of referring out if there are no change after 4-6 visits /1 month.10) “Graded Motor Imagery changes the brain’s neurosignature,” says Robert Johnson.  Here's a quick article explaining GMI.11) Activating the T-Spine extensors and lower trapezius is often a difficult task (especially in the patients that love to hinge at their TL junction).  I find this exercise very helpful for this problem.  The deep squat posture locks out the lumbar spine, thus forcing the thoracic extensors and lower traps to do all the work.12) Moseley's 4 Key Points to Understand Pain

1. Pain does not provide a measure of the state of the tissues;
2. Pain is modulated by many factors from across somatic, psychological and social domains
3. The relationship between pain and the state of the tissues becomes less predictable as pain persists
4. Pain can be conceptualized as a conscious correlate of the implicit perception that tissue is in danger

13) I think the SFMA should include this in their stability breakouts     [subscribe2]   

The New Overhead Concept (Part II)

In Part I you learned the concepts behind upward rotation and the overhead shoulder.  This article builds off of these concepts and will show you how to properly assess and treat for the overhead shoulder.I cannot emphasize enough how important a thorough assessment is before prescribing overhead shoulder exercises.  Without an assessment to determine any impairments or movement dysfunctions you will not be able to properly prescribe the correct exercises.  Before someone starts overhead movements you should make sure they're clear in all of the overhead shoulder characteristics (Part I).  Failure to do so could result in injury.However, a full biomechanical assessment is beyond the scope of this article.  Only general shoulder type and posture will be addressed in the assessment.

Assessment

Once you have cleared their shoulder biomechanics you can start to look back at the movement and shoulder type.There are several ways to assess the scapula position and shoulder type.  The Kibler Scapula Classification is one of the more common assessments.However, as we learned in part I, the scapula is only part of the kinetic chain.You need to also look globally.  And lucky for us, one of the best ways to assess global shoulder types is by simply looking at posture.

Posture

Don't just look at the glenohumeral joint, or even just the scapula.  You need to start at the center and work your way out.  Each level will determine what part of overhead training the patient will need to focus on.

Lumbar Spine: Look for the degree of their lordosis/anterior pelvic tilt.  If someone is hyperextended and hinges at the T-L junction you will need to address their anterior core before going overhead.

Thoracic Spine: You will usually either see a kyphotic thoracic spine or a flat thoracic spine.  Both cases will have difficulty stabilizing their scapula.  This needs to be addressed so that the scapula can move efficiently.  The scapula can be viewed like the patella; "it's not the train that needs fixin', its the tracks".

Clavicle: Due to its attachments, it will be a giveaway for the scapula.  You want to see a 6-20° upslope.

Scapula: This is the biggest giveaway.  The scapula is the "liaison" between the arm and the trunk.  But remember it moves in many planes, not just forward in back.

• Anteriorly or Posteriorly Tilted (Sagittal)• Upward or Downwardly Rotated (Frontal)• Elevated or Depressed (Frontal)• Internally Rotated (Winged) or Externally Rotated (Transverse)

Even a quick global view will give you a good indication.  For example, look at the picture to the left.Mr. Burns is a mess.  All his time obsessing about money and abusing his employees has left his shoulders depressed and his thoracic spine kyphotic.On the other hand, Juggernaut's uncontrollable rage has left his shoulders so high he appears to have no neck.These two would respond completely differently to an overhead program and require completely different exercises and cues.

Shoulder Flexion / Abduction

Once you have a good postural/static assessment you can then assess how they move dynamically when going overhead.  This movement pattern assessment will be a very valuable insight to their compensatory strategies.Have the patient flex and/or abduct their arms all the way overhead.  Look for fluid motion.  It shouldn't be a struggle for someone to get their arm overhead.You want to look for similar things that you do during the postural assessment, but you can focus on 3 things.

1. Centrated Spine (lack of rib flare)
2. Full Scapular Upward Rotation (55-60°).
3. Level Hands in Full Flexion

Intervention

After your assessment you will have a better idea of what your patient needs.  Their needs and movement patterns displayed in the assessment will dictate where to start.My progression usually starts with the anterior core integration, then goes to unloaded overhead, then to loaded overhead.  I know this is vague, but its more about making sure you aren't missing a step in the process.  Going to a loaded press without assuring correct unloaded movement patterns or anterior core stability is a dangerous way to treat.

Compensations / Substitutions

Before you start pressing away, it's important to know what common compensations occur with overhead shoulder movement.  Here is a list of the most common strategies I see (this is not conclusive, some people find amazing ways to compensate).

• Rib Flare
• Lumber Hyperextension
• Cervical Protusion
• Inadequate Upward Rotation
• Elbow Flexion
• Scapular Protraction/Anterior Tilt
• Trunk Lateral Shift

Cues

It is important to have the right cues to prevent compensations.  Each individual will require a different cue depending on their movement patterns and potential compensations/substitutions.Eric Cressey uses 4 Different Cues depending on the athlete:

1) For Lumbar Hyperextension / Lordosis / Rib Flare = cues to engage antere core and keep ribs down

2)For Kyphotic "Desk Jockeys" = cues to keep chest up (posteriorly rotate rib cage, not lumbar extension)

3) For Depressed Sloping Shoulder Blades = cues to shrug as arms go overhead (not before) to get full upward rotation

4) For Upper Trap Dominant = cue posterior tilt of the scapula

The Exercises

Basic Anterior Core Integration

I always find it advantageous to start with some basic anterior core integration.  Many people have difficulty with this concept.  If you skip this step and start training scapular upward rotation on a weak/inhibited core you will only be setting them up for failure in the future.  Without the core, the shoulder has to do twice as much work.The reachback / pullover exercise is a great place to start.  If the patient has difficulty getting their ribs down, you may need to regress the exercise a simple breathing drill (full exhale helps achieve "down" position and engages core).http://www.youtube.com/watch?v=blJcjYIRiokOn the other side of the difficulty continuum, the standing anti-extension exercise is a great way to integrate the core with shoulder flexion.  I find this exercise very challenging when done correctly.http://www.youtube.com/watch?v=nxkawQ_sanc

Unloaded Overhead Training

After you integrate the core it's time to start training overhead.  But before you load it up you want to make sure your movement patterns are clean.  Start "greasing the groove" without resistance or load first.  These are also great warm-ups for advanced patients.

• Unloaded PNF D2 Patterns (supine, half/tall-kneeling, quadruped, standing)

• Reach, Roll, & Lift

• Prone Y's & ILY's

• Wall Slides

• Back-to-Wall Shoulder Flexion

• Bilateral Shoulder Flexion in Deep Squat

3 Loaded Overhead Training Progressions

• 1. Static Load in Full Flexion

Often times when people have difficulty squatting or deadlifting we start from the bottom and/or shorten the range (i.e. box squats, FMS corrective squat, rack pulls).  We can apply the same logic to the same with the press.  We can start from the top and shorten the range.The top down press (Rack Press) is essentially working from the full overhead position and progressing your way down.  This allows the patient to reap the benefits of the overhead position without going through the provocative motions to get there.  Remember from Part I, this loaded full overhead position is where you reap all of the benefits (core, scapula, t-spine, RTC, etc.).http://www.youtube.com/watch?v=EZAIDV7vMOIThe emphasis for the rack press should be the static loaded hold in full flexion.  I usually have my patients hold this position for at least 3 breaths per repetition.  The more time in this position, the better.Other exercises include:

Bottoms-Up Kettlebell Overhead Hold / Farmers Walk

Reactive Neuromuscular Training (RNT) with Lower Extremity (the possibilities are endless)

• 2. Progressive Angles

Another great way to progress loaded overhead training is with progressive angles.  I learned this one from Eric Cressey.  Starting with angled presses/pulls decreases the provocative positions while allowing for overhead adaptation.

Landmine Press (Angled Press)

Angled Pull-Down

Resisted PNF D2 Flexion

1/4 Turkish Get-Up (to elbow)

• 3. Full Range Overhead Training

Once your patient is able to handle all the exercises above it is safe to progress to full overhead training.  From this point it is more about the SAID principle and maintaining clean movement.

Yoga Push-Up (at 2:10 in this video)

Full Turkish Get-Ups

Resisted Y's (TRX Y's)

Kettlebell Overhead Press

Push-Press

Barbell Overhead Press (OHP)

Pull-Ups (eccentric → concentric)

Bottom Line

Sometimes just mentioning overhead shoulder work makes people cringe and grab their shoulders.  It is often avoided in rehab and is performed/progressed incorrectly in performance training.Everyone should be able to get their arm overhead.  This position is incredible for the human body.  With this article series you should be able to better assess and prescribe exercises for overhead shoulder work.

Dig Deeper

Eric Cressey - Upward Rotation in Athletes - Why You Struggle to Train Overhead & What to Do About itLudewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000;80:276-91Johnson G, Bogduk N, Nowitke A.  Anatomy and actions of the trapezius muscles.  Clinical Biomechanics.  1994;9:44-50.Struyf F, Nijs J, Meeus M, Roussel NA, Mottram S.  Does Scapular Positioning Predict Shoulder Pain in Recreational Overhead Athletes?  Int J Sports Med. 2013 Jul 3; --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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October Hits

1) The poor upper trapezius.  It might be the most understood muscle in the body.  It's not a major shoulder elevator and it isn't a big problem in shoulder patients.  In fact it's usually the opposite.  Check out this months post to learn more.2) "Thought viruses" are a big problem in rehab.  Sometimes patients come in with them, other times PT's give them to their patients.  We need to stop using harsh pathoanatomical diagnoses (use movement instead).  I've seen it way too often; a patient comes in with some shoulder pain and leaves with subacromial bursitis, RTC tendonitis, and impingement syndrome.  Don't plant diagnoses into patients minds.  It can cause centralization, it's unfair, and maybe even unethical.  Check out some Erson's pet peeves on thought viruses.3) Cressey has some great advice on how to deadlift forever.  Hint: don't have setbacks!4) The great Pavel writes about the benefits of the 5x5 training program.  If you are trying to get stronger or training to get someone stronger you should pick a lift and give it a try.5) Reciprocal pelvis and thorax motion in gait is extremely important.  Both for mechanical and central mediated neurological factors.  The Gait Guy's talk about it in this article.  "The hip must pass through the internal rotation phase before it starts into hip extension.  This means that the opposite shoulder must do the same thing."6) Fascia is more important than just tensegrity.  "Fascia nevertheless is densely innervated by mechanoreceptors which are responsive to manual pressure. Stimulation of these sensory receptors has been shown to lead to a lowering of sympathetic tonus as well as a change in local tissue viscosity. Additionally smooth muscle cells have been discovered in fascia, which seem to be involved in active fascial contractility. Fascia and the autonomic nervous system appear to be intimately connected. A change in attitude in myofascial practitioners from a mechanical perspective toward an inclusion of the self-regulatory dynamics of the nervous system is suggested." -Robert Schleip (Fascial Plasticity, 2003)7) More Erson's Friday Fives - This is a great one on mobility problems hiding stability problems.  I'm always amazed when someone's cervical patterns will become FN after some core or scapula activation.8) Paul Bach-Y-Rita: “We see with our brains, not with our eyes.”.  Todd Hargrove gives an excerpt from his upcoming book on the difference between sensation and perception.  Great read.9) This is both an assessment and an exercise.  When my patients can do this it usually correlates with pain free return to activities.10) Mike Reinold writes about a problem with the medical professions.  "We have created this “paralysis-by-evidence” situation where some people think you can’t do anything unless it has strong evidence suggesting it is effective.  This approach is challenging and ultimately unrealistic."11) Gray Cooks 3 R's: Reset, Reinforce, Reload.  I've been using this with every patient for every treatment since I first heard about it a couple years ago.  It makes a huge difference and is a great way to treat (regardless of your approach).

Reset: Passive, Reduce Pain & Inflammation, Make Change in System

Reinforce: Behavioral, Lifestyle Changes, Conservative Management, Taping

Reload: Active, Therapeutic/Corrective Exercises, Movement, Motor Pattern Training

12) Dogs will always be better at yoga. [subscribe2]

The New Overhead Shoulder Concept (Part I)

Traditional Down & Back

At this point we all know the importance of a stable and strong scapula for shoulder function.  Almost every PT, athletic trainer, and personal trainer trains the shoulder with a "down and back" cue.  This cue allows for a better stable position of the scapula and enables the rotator cuff to work more effectively.  Kolar has summed this concept up in a single sentence:

• "The muscle may not be weak in itself, but it may not function well because its attachment point is insufficiently fixed."

New Upward Rotation Emphasis

However, in my experience there have been many patients that don't seem to get back to their full function after a shoulder injury despite the scapula strengthening and the down and back shoulder packing.  In my search for answers I came across Eric Cressey's blog several times.  Where most clinicians are terrified of allowing a shoulder to elevate due to the Upper Trap/Lower Trap ratio that we were taught to fear, Cressey advocates the opposite.  He trains many of his clients in an overhead position with an emphasis on upward rotation using the trapezius.

• "We may have ruined a whole generation of athletes with the cue back and down" - Eric Cressey

Does the statement above bother you?  Bring up some defensive arguments?  It did for me when I first heard it.  I've been cueing people with "back and down" for years.  However, once I got past my ego and opened up to this concept my shoulder patients started to get MUCH better.

Overhead/Upward Rotation/Upper Trap Concept

While this upper trap/overhead concept may not be brand new or fully original to Eric Cressey (I know Sahrmann is an advocate of this); he is the first I've heard to discuss it with such clarity and clinical relevance.  Most of the time when you hear about a new concept it's really just somebody trying to sell something or someone just offering an interesting perspective with no clinical solutions.  However, Cressey not only helps to define this paradigm shift, but he also offers detailed strategies to address it (for free!).Much of this post series, especially the assessment & intervention (part II), is based upon Cressey's work.It's important to note that this isn't just a protocol you blindly apply to everyone.  It's a detailed concept that requires an individualized assessment to determine if they need more upward rotation (and where they need to get it from).

Why is Overhead Position Important?

We're Losing It

Our current species of the hominin is starting to de-volve.  To understand this, we have to look at where we came from.  First when we used to live in the trees our shoulders were oriented upward and forward.  Then when the climate changed and we were forced to our bipedal states in the savanna, our shoulders re-oriented less upward and more forward to manipulate objects.  Next, to increase our hunting prowess our shoulders re-oriented more laterally facing to allow us to throw objects at our prey.  Now, with all the use of technology and poor postures our shoulders are starting to regress back to facing more forwrard.

Displays Optimal Shoulder Function

The FMS/SFMA had it right with the overhead squat assessment.  For more reasons than I realized.Being able to get both arms overhead without compensatory patterns is a sign of great shoulder function.  If you have any pain, restrictions, weaknesses, or dysfunctional movement patterns you will not be able to do this.  The same cannot be said for non-overhead shoulder positions.

People Like to Use it

Even if you don't buy into the last two, you can't argue with this one.  Most of our patients love to participate in recreational activities and exercise.  For these patients to return to such activities they need to display good overhead shoulder mechanics.  You can't just have them doing sidelying ER and expect them to go out and hit a tennis serve without problems.Even if they're not athletes they'll need it for everyday tasks of putting dishes away, washing your hair, hailing a cab, slapping someone taller, etc.

What is Required for the Overhead Shoulder Position?

Before you can assess and correct the overhead shoulder, you first must truly understand what goes into an overhead shoulder.  Each of these things have their own complexity and should not be underestimated.

What You Get When You Train Overhead?

A cascade of events occur when you lift your arm to the full overhead position with a proper movement pattern.  From a simple perspective it strengthens the upward rotators and lengthens the downward rotators.  Full scapula upward rotation is paramount (increased GH congruency in overhead position).  However, it's much more complex than just upward/downward rotation.First it's important to understand that most people only have about 170 degrees of pure shoulder flexion.  Often time they'll cheat with lumbar/T-L junction hyperextension to get to the full 180.  But if you can teach your patients not to cheat and to actively get to a stable compensatory free full overhead shoulder position, a lot of good things will occur.So what happens when you try to go for the full 180?  A cascade of events occurs leading to a stable shoulder position with activated thoracic extensors, scapula stabilizers, rotator cuff, and anterior core.Load this position with a weight and a ton of great things happen.  The simple physics of it:Long Lever + High COG over Small BOS = Inherent Instability = Reactive Stability.Plus, adding a compressive load gets the reflexive stabilization of the RTC and scapula in this great position.

Is the Upper Trapezius Really a Problem?

The poor upper trap.  It gets blamed for everything.  People often say that it's too tight and too active.  Historically many people have tried to decrease the upper trapezius tone by spending a ton of manual therapy and stretches to "loosen" them up.  Then they try force the little lower trapezius and serratus anterior to do all of the upward rotation work.The problem is that the upper trapezius should be considered with the opposite point of view.  We should look at it as an important shoulder muscle that needs to be strengthened.This concept should be agitating for anyone that went to physical therapy school, as we learned about UT/LT ratio's and how much of a problem the UT can be.To accept and utilize this paradigm shift you have to understand the true function of the upper trapezius.

2 Aspects of the Upper Trap Function

1) The UT is an important part of scapular upward rotation.  Many people know this, but tend to spend all their time on the LT & SA.  If you only focus on the LT and SA then you are missing out on  33% of the upward rotators.  How can you get someone back to full function by only strengthening 66% of their muscles?2) Almost all the fibers of the UT attach to the posterior boarder of the distal third of the clavicle (Johnson et al, 1994).  This would mean the fiber orientation would actually cause medial rotation of the clavicle, compress the sternoclaviculalr joint, posteriorly tilt of the scapula, elevate the lateral clavicle, and increase upward rotation.

So have we been completely wrong all along?

Yes and no.Yes, there can be an excessive elevation during the initial stages of shoulder flexion.  So there is a movement dysfunction.But no, the UT isn't capable of elevation with the arm at the side.  The UT works synergistically with the LT and SA after the shoulder has started to flex/abduct.  The excessive elevation is from the levator scapula (the main scapula elevator with the arm at the side).To make matters worse, when the upper trap is weak the levator scapulae will jump in and try to make up for this weakness.  Unfortunately the LS doesn't upward rotate, so it just pulls on the cervical spine, jacks up the scapula, and throws off all force couples.

Bottom Line

The down and back traditional treatment of shoulders may not be the best approach for all patients.  Not to mention there is a great deal of benefit from training in full scapular upward rotation (i.e. increased subacromial space, UT/SA/LT strengthening, downward rotator lengthening, t-spine extension, anterior core stability, etc.).After reading this article you will have the necessary understanding to better assess and treat the overhead shoulder (part II).

Dig Deeper

Eric CresseyWarren Hammer - Dynamic ChiropracticAdam Meakins - Upper Trapezius James Speck - UT Doesn't Fire IndependentlyLudewig PM, Cook TM. Alterations in shoulder kinematics anda ssociated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000;80:276-91Johnson G, Bogduk N, Nowitke A.  Anatomy and actions of the trapezius muscles.  Clinical Biomechanics.  1994;9:44-50. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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September Hits

1) Kettlebells are becoming more and more common in fitness and rehab.  If you don't use them, you should.  Here's this months article on my expirience at the premier kettlebell workshop.2) Erson goes over 5 things to look for in runners.  "Running is one sport that arguable needs more symmetry than most. I tell my runners it's because you're doing the same thing over and over for 1000s of steps until you stop!"3) Habits are regularly tendencies that become automated by the brain.  James Speck goes over how to form good habits.  This is something we need to teach all of our patients.  Some great points: habits take 60 days to develop, tap into subconscious willpower by visualizing & planning goals, reward yourself, start small, be consistent, and make it measurable.4) Mike Robertson has a great article on life long lifting.  This is a must read, because unless your a vampire, we all get older everyday.5) Yoga or Doga?6) Eric Cressey gives you a solid base for a medicine ball workout.  These provide a great functional workout.  Great gem here: "When performed correctly, medicine ball exercises serve as an outstanding way to "ingrain" the mobility you've established with a dynamic warm-up prior to training."7) Andreo Spina describes the important difference between mechanical tightness vs. neurological tightness.  Chasing neurological tightness with interventions such as static stretching, joint mobs, or ART are unlikely to yield good results.  Instead you should try PNF, slow fascial release (for parasympathetic response), and breathing techniques.  Another important consideration is pain.  Pain changes everything.  Often neurological tightness is a protective mechanism to avoid pain.8) Having trouble teaching the squat?  The Goblet Squat is the best way to start.  Progression: Goblet Squat, Front Squat, Back Squat.9) Here's an interesting perspective on the psychological benefits of yoga.  "I came to realize that yoga works not because the poses are relaxing, but because they are stressful.  It is your attempts to remain calm during this stress that create yoga's greatest neurobiological benefit."  Make sure your patients don't forget that there's supposed to be a mind attached to the body they workout.10) The elbow is a more complicated joint than most people realize.  Eric Cressey has a great series on elbow pain (Part 1, 2, 3, 4, 5, 6).  He also has an article on 13 ways to take care of your elbows.[subscribe2]

Course Review - StrongFirst Kettlebell Workshop

On June 1st I had the pleasure of participating in a StrongFirst Kettlebell Workshop with Phil Scarito.  It was a 1-day course that went over the intricacies of the basic kettlebell movements (Deadlift, Swing, TGU, Goblet Squat, Press).  The theory is that it's better to master the fundementals than to be average at a bunch of different lifts.  Plus, it's these basic KB movements that that have the greatest impact on improving one's physical abilities and movement patterns.Phil Scarito was the instructor for the course.  He is extremely knowledgable on many levels and was able to translate his concepts to everyone from physical therapists to personal trainers to your average gym rat.  Phil is able to go into the greatest details of each movement to truly help you understand the movement at a different level.  He has a great YouTube page with tons of detailed instructional videos.Along with some posterior chain soreness, I learned quite a few things.  Here's some things I learned in one day with Phil Scarito and the StrongFirst instructors.

General

1) Your clients/students/patients will do what you do.  Make sure you can execute the move perfectly and they will too.2) Training barefoot is extremely important.  It allows you to maximally "root" your feet into the ground and give you more power.  Shoes deprive you of that important sensory information.3) Lose big toe contact = lose power4) Fast & Loose - keep moving during your training and use active rest5) Tactical Frog is a great mobility warm up6) Fix the deadlift.  When someone is having difficulty with a movement, often times going back and fixing their deadlift will resolve the problem.  "Don't fix the swing, fix the dealift" - Brett Jones7) "Try to make the light weight feel heavy, and make the heavy weight feel light" - Marty Gallagher8) Breathing is extremely important to develop stability.  Coordinate breathing with movements (biomechanical breathing).9) Think about driving your feet into the ground and pushing the earth away.10) Active Negatives are a great way to learn movement.  It also spares the agonist of eccentric load, allows for successive induction, trains the antagonist, and helps to "grease the groove".11) Always keep the wrists in neutral.  Don't let it bend to accommodate the bell.12) All you need for programming is TGU's and Swings.  Do those everyday and you will make tremendous gains.  (paraphrased Pavel advice)

Hip Hinge/Deadlift/Swing

1) The hip hinge is the basis for the deadlift.  The deadlift is the basis for the swing.2) "Rooting" feet into the ground is extremely important for power transfer.3) Reach down and stay tall before you pick up the bell.  This packs the shoulders while maintaining proper posture.4) It's important to start the swing off right.  This helps activate the lats to develop tension, increases power generation, and properly starts the movement with the right momentum.5) If you let the weight go at the bottom of the swing it should fly backwards, not down.6) Avoid the "high hip hinge".  Don't get lazy and start doing partial range swings.7) Timing is extremely important.  There should be a delay going up (KB "float") and a delay going down ("playing chicken with the KB").8) Don't over think quick lifts.9) Don't be so afraid of flexing your trunk forward.  Many people will bend at the knees to try to keep their torso upright instead of hinging at the hips.10) Make sure to "snap" your hips forward.  Finish the lift tall.http://www.youtube.com/watch?v=_z3T1CwP5bg

Turkish Get-Up (TGU)

1) You can take the TGU and turn it into a million different exercises.  Break it up, practice small parts of it, add a few TGU movements into other exercises.2) The TGU takes you through a full neurodevelopmental progression.  No other exercise can do that.3) Starting position will determine the success of the rest of the movement.4) The legs and arms should be parallel in the starting position, much like a starfish (or at 45 degree angles).5) You should be "rolling" to your elbow, not sitting up to it.6) When you get to your hand "think of wedging yourself between the bell and the floor" - Phil Scarito7) The "2 Lines" to look for:

• In Sitting Phase: Hand, Hip, and Oppoite Foot in line

• In First Kneeling Phase: Hand, Knee, and Foot in Line (same side)

8) Most people do the TGU too fast.  Should be a slow movement with at least a couple seconds in between movements.http://www.youtube.com/watch?v=RkVaQMi9wTQ

Goblet Squat

1) After your hips go below your knees it is all on the glutes to get back up.2) Don't get out of the bottom position too fast.  You want to go slow to prevent the hips from shooting up.3) Pull yourself into the bottom position with your hip flexors (active negative).4) Keep your feet pointed straight ahead and the exercise will naturally prevent valgus collapse at the knee.5) Don't sacrifice form for depth (avoid excessive lumbar flexion).6) A common fault is sitting forward into the knees.  Most people will need to focus on sitting back into their hips.http://www.youtube.com/watch?v=ZnG3Z7Zgpzs

Strict Press

1) You can't press with a hyper-extended wrist.  There's no power.2) Don't reach up.  Instead, think of pushing the whole body away from the KB.3) The plank and the military press are very similar exercises.4) Don't let the ribs flair and hyperextend the lumbar spine.5) Actively pull the bell back down (active negative).http://www.youtube.com/watch?v=WTmR-Qr32dg

Summary

More and more people are becoming interested in kettlebells.  As a clinician this means we have to have a better baseline level of knowledge so that we can assess, train, or refer out when we have patients that are using this equipment.Remember the rule with all exercises:

• Make sure you are competent with the movements before you prescribe or assess someone else.

The kinesthetic learning of this course cannot be matched by anything other than performing the movements while being coached by professional.  I highly recommend taking one of these workshop courses with StrongFirst if you have any interest in kettlebells.

Dig Deeper

Strong FirstPhil Sacrito - Website - YouTubePaul GormanGray Cook & Brett JonesKettlebell Studies

McGill

Jay K

Jay K et al

 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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August Hits

1) Our profession and our society has become so afraid of lumbar flexion that it's almost a phobia.  This obsession of avoiding lumbar flexion has allowed another problem to slip by - excessive lumbar extension.  I've been noticing more lumbar extension dysfunction in the clinic.  Read about it in this months post here.2) The more I practice the more I start to think the most important aspect of PT is the patient's mindset.  I look for 2 things in the eval to see where their mindset is: 1) Pt wants to know why they hurt 2) Pt wants to take an active role in getting better.  The ones that come in with these 2 questions get better much faster.  If not, try Eric Cressey's 6 Tips on the "Buy-In".3) This is an incredible library of resources from North American Sports Medicine Institute & Advances in Clinical Education.  And here is their great journal club to follow to keep up on the latest research.4) JOSPT added some more research to the pain/expectations paradigm shift.  Expectations have a great influence on outcomes.  They mentioned one study that injected saline solution into 2 groups: the first group was told that it was a great analgesic, the second group was told that it intensifies their pain.  The exact same intervention was given, yet the two groups had a significant difference in pain (correlated with expectations - 1st group decreased, 2nd group increased).5) Apparently our ability to throw fastballs "evolved roughly two million years ago as a way of improving our hunting prowess".  Interesting article on the evolution of the human shoulder.6) Of course Wolverine deadlifts!7) I've recently had a lot of hip patients whose main complain is posterior hip pain with prolonged sitting.  This study showed that the most common referred pain from the hip joint is in the posterior hip.  When patients are sitting for prolonged periods of time they are just jamming their femur into the superior of their acetabulum.  This can aggravate a labrum or a bony impingement, thus causing referred pain into the posterior hip.  Of course it's important not to chase pain, but it's also important to try to understand where it might be coming from.8) We're 3 months away from the NYC Marathon.  Posterior chain extensibility is extremely important in runners.  I have most of them doing this exercise.  I learned this one from Chris Johnson - he has many more great exercises for runners here.9) Gray Cook is one of the most influential physical therapist our time.  On his website he has a section called "Gray Cook Radio".  It has short 10-15 minute discussions about some great concepts.  I usually load them on to my iPhone and listen to them while I take my crazy dog for a walk.10) Erson's Friday Five's - here's 5 good things you should add to your practice.  I've just started using the compression wraps myself.  They can make a significant difference in edema and ROM.11) This is a long read, but it makes a great point about our current Evidence Based Medicine (EBM) obsession.  It discusses how we aren't robots treating a chemical reaction or defective anatomical structures.  We are clinicians treating people.  Empirical-based humoral pathology has been around for 2,000+ years, why throw it away for protocols and algorithms?

"In order to keep to a healthy course and avoid enslavement, there are other E’s which medicine must respect in full besides EBM – eminence, empiricism, experience, economy, ethics, and emotion-based medicine. None of them can be prioritized because they overlap each other. We must start by following the empirically acquired knowledge of our teachers (i.e. empiricism and eminence-based) and gradually factor in our own trial and error (experience-based), where possible comparing this with publications and, often, with economic limits (evidence-/economy-based)." - Pavel Kolar

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Lumbar Extension Dysfunction

Low back pain is one of the most common injuries we see.  Traditionally you always hear a lot of information regarding excessive lumbar flexion.  And with the amount of information readily available in our society, many patients already know this as well.  This has caused some therapists and patients to walk around terrified that the next time they bend over their L5-S1 disc will splatter against the wall behind them.  But what about the other direction?  What about the potential problems in extension patterns?We've concerned ourselves so much about "blowing out a disc" with flexion that we've completely overlooked extension problems.

Over Extension

Maybe it's because I practice in NYC where people are constantly on the move and always going 1,000 miles per hour.  Maybe it's because our society is spending more time sitting down and plugged in.  Maybe this excessive stress leads to a state of inhalation (PRI concept) which would increase lumbar extension.  Maybe it's our footwear.  But whatever the reason, I'm seeing ALOT more patients with a lumbar extension dysfunction.

When it Happens?

Most of the time the lumbar extension error doesn't present itself until you get the patient moving.  This is something subtle that they are repeatedly doing throughout the day as they move.  It's a micro-trauma that accumulates until they shoot over their pain threshold.You may be able to guess that it will be a problem when you assess their posture and see that you rest a glass of water on their sacrum because they're so anterior tilted.  But most of the time it won't come out until you look at their movement patterns and challenge them with loads.

Why it Happens?

Like all kinds of movement dysfunction, this extension fault is different for every individual.  To say conclusively that it happens for one particular reason would be overlooking the complexity of the individual.  A full assessment will give you a better picture of what's going on.Even if you don't know the exact reason, focusing on movement will allow you to correct the dysfunction without having to know the exact structural culprit.  And if you can correct the dysfunctional movement, then who cares what the exact pathoanatomical cause was?  Pathomechanics always trumps pathoanatomy in our field.So how do you explain the pathomechanics?  This dysfunction is easy to understand if you have a mobility restriction, but what if their SFMA is fairly clean and the breakouts all lead to stability/motor control dysfunction (no mobility impairments)?Since it often only presents itself with movement and load, it is a compensatory mechanism to stabilize.  Why go into extension?  Because the muscles don't have to work as hard in this position.  The closed packed position of joints is a stable position.  The body can rely on static osseous stability instead of dynamic myofascial stability.So what's happening is that these patients are relying on their lumbar facets for stability.  Instead of creating efficient core stability and transferring torque from their hips, they just compress and hang out on their facet joints.  Doing this over and over throughout the day and with load in the gym would make anyone's back hurt.

Assessment

As mentioned above, you may see an excessive anterior pelvic tilt (hyperlordosis) and the patient may complain of pain with extension activities.  This is a good start to your hypothesis, but you need to prove that they have a dysfunctional compensatory movement pattern before you blindly attack it.  I find the best assessment system for movement patterns to be the SFMA.9 times out of 10 someone with this dysfunction will fail the multi-segmental extension pattern.  When you break it out and find it's not a mobility issue, then you can rest assure that they probably have an extension stability/motor control problem.  This directs you towards rolling and a developmental stability assessment.Another key to this assessment is seeing how they move with the hip hinge.  This tests their ability to stabilize their spine and create torque from their hips.  If they can't control their lumbar spine and hips then they will hyperextend onto their facet joints for stability.  And this usually reproduces their pain.The video below shows a patient who has an extension stability/motor control dysfunction.  She is hypermobile and has no mobility restrictions.http://www.youtube.com/watch?v=I9xBxpJeYfQ

How to Fix It

If you're lucky and it's a mobility problem you will be able to resolve their restrictions and easily train the movement pattern back to normal.However, if it isn't a mobility problem then it isn't going to be an easy fix.  You can't just give them planks and dying bugs and expect the movement pattern to resolve.  While working on their anterior core and breathing will help, you will have to do one of the more difficult things in our profession...coach them out of it.  You have to fix their movement pattern.

Torque & the 1-Joint Rule

Kelly Starrett often talks about creating torque and the one-joint rule in his book "Supple Leopard".  These are great concepts you can use to assess and treat movement dysfunction.Our body moves (and stabilizes) from the torque that muscles create on our bones.  So it makes sense that some patients will benefit from verbal cues and education on how to create it.Kelly describes the one-joint rule as the general principle that "you should see flexion and extension movement happen only at the hips and shoulders, not your spine."  This of course doesn't mean that your spine shouldn't move, it just means that during high-load or high-velocity tasks your 2 ball & socket joints (hips/shoulders) should be moving while your spine stabilizes to transfer the forces.Using these rules as a blue-print to teach patients to stabilize their spine and create torque through their extremities can pull them out of the gumby like stability problem.  In the video below, Kelly takes someone from an extension dysfunction to a normal movement pattern simply by using verbal cues.http://www.youtube.com/watch?v=mjbvf0P0bas

Bottom Line

We traditionally concern ourselves (and our patients) about the dangers of lumbar flexion.  However, any excessive and misused movement is dangerous.  Lumbar extension is no different and is a common problem in many low back pain patients.This post also provides an example of how I have integrated Kelly Starrett's work with Gray Cook's SFMA approach.Sometimes clinicians can limit themselves by following only one system religiously.  By doing so you can miss out on some great aspects of other approaches.  I'll admit that I am biased towards the SFMA, but that doesn't prevent me from using other systems as well.  In fact I've found that adding other approaches in to your practice benefits you as a clinician, and more importantly it benefits your patient.Bruce Lee said it best: "Absorb what is useful, discard what is not, add what is uniquely your own." --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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July Hits

1) I think exercise programs like crossfit and P-90X are great.  They get more people moving and interested in their health.  And in today's society, decreasing the amount of sedentary people is very important.  However, when exercises are performed past failure a ton of things go wrong.  A new study showed there is a deterioration of lower extremity biomechanics when fatigue hits.  This causes a dangerous cascade of events: compensations, inefficient movement, substitution movement patterns, and an increased risk for injury.  While many of us already know this, many of our patients don't.  Educate them.2) Infographics are a great way to educate patients.  We sent this high heel infographic out in our monthly email.3) Here's a nice review on motor learning from the MovNat concept by Jaime Guined.4) More research supporting the mobility before stability concept -  Impaired ankle DF ROM leads to poor balance.5) In the past couple years I've been hearing about the importance of low vs high-threshold strategies.  However, I could never find anything that fully described this concept.  So I decided to try to create a post that put it all in one place.  This is something we should have learned in PT school.6) Proof that the hip is a ball and socket joint.7) "If you think strength training is dangerous, try being weak.  Being weak is dangerous."  This is a hilarious article from Bret Contreras.8) One of the downsides of research is that it breeds "that guy".  The guy that pessimistically challenges everything through a lens of EBP because he's too afraid to try new things.  This stalls our profession and even worse, it prolonges patient care because they're only receiving what's in peer-reviewed articles instead of what simply works best for that specific individual.  Next time you encounter "this guy", point them towards this article and tell them to sign up for it.9) University of Deleware Protocols.  Check them out and see if you can improve your post-op plan of care.10) I've been using this exercise with a lot of shoulder patients.  It causes reflexive stabilization of the glenohumeral joint, dynamic scapula stabilization, and core integration.  Plus, the bottoms-up kettlebell position causes the patient to grip harder, which leads to increased RTC activation.11) University of Texas has an incredible site reviewing neuroscience.  Here's a few of many gems:

"One of the major principles of the motor system is that motor control requires sensory input to accurately plan and execute movements."

"The adaptiveness of spinal reflexes can change depending on the behavioral context; sometimes the gain (strength) or even the sign (extension vs. flexion) of a reflex must be changed in order to make the resulting movement adaptive. The descending pathways are responsible for controlling these variables."

"Unconscious processes allow higher-order brain areas to concern themselves with broad desires and goals, rather than low-level implementations of movements."

"The motor system must constantly produce postural adjustments in order to compensate for changes in the body’s center of mass as we move our limbs, head, and torso. Without these automatic adjustments, the simple act of reaching for a cup would cause us to fall, as the body’s center of mass shifts to a location in front of the body axis."

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