Injury Treatment Article Archives

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3 Popular Exercises I Am No Longer Using

It’s almost 10 years since I wrote one of my most popular articles on this website, My Top 5 LEAST Favorite Exercises.

I still dislike all of those exercises, and today I wanted to share 3 more exercises that I am not going to use anymore. These are pretty popular exercises, so I expect many to disagree with me. I actually have no problem with you using these exercise, I just wanted to share some reasons why I have started to critically assess the value of them, and have considered not performing them anymore

 

Side Planks

Woah, I’m starting by throwing out a haymaker! Side planks?!? But everyone needs side planks!

Side planks are actually a great exercise for the core, and fairly common staple in people’s core programs. But over the years I have found that many people have complained about the impact the side plank position has on their shoulders.

So I would modify their programs. And then it would happen with someone else. And someone else.

I think the position has the shoulder abducted slightly below 90 degrees of abduction and then puts full body weight through the joint in a super orientated force vector:

So I’ve added side planks as an exercise I’m not going to be using much in the future. There are variations that may work that place less strain on the shoulder, like the feet-off-the-bench variation, but other functional activities like weighted carries can likely provide a similar treatment or training effect, while not irritating the shoulder.

Now, realize I am biased. I work with a lot of people with shoulder pain and hypermobility. So perhaps my population tend to not handle them as well. But if my population doesn’t, maybe your population won’t either.

 

TRX Y’s

Next up is the TRX Y. I love the TRX, and the TRX Rip Trainer, two great devices. But I’ve always felt uncomfortable when performing a shoulder Y exercise using the TRX.

The shoulder Y is designed to incorporate upward rotation of the scapula, protraction, and posterior tilt of the scapula. It’s a great exercise for the lower trapezius.

However, when performed on the TRX, the Y exercises is drastically different, involving more scapular retraction and upward shrugging. Plus, the Y exercise is much more subtle, using your body weight, even at an angle, simply overloads the exercise and causes compensation. I think this promotes poor habits.

Just because two exercises may look the same, like the TRX Y and the Prone Y, doesn’t mean they have the same effect on the body.

 

Hip Flexor Stretch

My 3rd exercise is the wall hip flexor stretch. I’ve been pretty vocal on the fact that many people do this stretch poorly, hyperextending their back and placing more stress on their anterior hip capsule than on their hip flexors.

I popularized the use of the True Hip Flexor Stretch to help people shift focus on the right structures.

But even I sometimes felt that some people were Ok to do the standard wall stretch if they were “loose enough.”

You know what, I think those loose people actually just compensated more, like in the below video. So if we are really working on the flexibility of the hip flexors or on anterior pelvic tilt, I think we should all probably be sticking to a variation of the true hip flexor stretch and maybe just leaning forward more, than going back to the wall.

 

I really want to hear what you think, hit the comments below and let me know if you agree, disagree, or have more to add to this list! I don’t hate these exercises for everyone, but for now, these are a few I’m going to use less frequently.

 

 

Working with the Hypermobile Athlete

The latest Inner Circle webinar recording on Working with the Hypermobile Athlete is now available.

Working with the Hypermobile Athlete

This month’s Inner Circle webinar is on Working with the Hypermobile Athlete. In this presentation, I’m joined with my colleague at Champion, Dave Tilley, to discuss our approach to working with hypermobile athletes.  Dave works with a lot of gymnasts, so has a great perspective on the topic.

This webinar will cover:

  • How do you assess for hypermobility, rather than just flexibility or soft tissue mobility
  • How does rehabilitation differ for the hypermobile athletes
  • The role of fatigue and capacity in working with hypermobility athletics
  • How we manage the fine line between hypermobility and instability

 

To access this webinar:

5 Ways to Get More Out of Self Myofascial Release

With the popularity of self myofascial release skyrocketing over the last decade, we’re seeing people rolling all over the place.  And for good reason…

Foam rolling helps you feel and move better.

Foam rollers are great, and I have talked about other self myofascial release tools that I highly recommend you try.  But it’s not always just about WHAT you are using to roll out, it’s also about HOW you are performing self myofascial release that is important.

If you combine some of our basic understanding of functional anatomy with our understanding of movement, we can really enhance how you perform self myofascial release to get even better results.

5 Ways to Get More Out of Self Myofascial release

To illustrate this concept, I wanted to share 5 videos demonstrating how you can enhance how you perform self myofascial release.

Reduce the Surface Area

My first video discusses the concept of reducing the surface area while rolling.  Again, foam rollers are great.  But depending on the tissue you are focusing on when rolling, you may want to reduce the surface area.

When you get used to foam rolling and are looking for a deeper sensation, putting the same amount of body weight on a smaller surface area will obviously increase the applied pressure.

This is also helpful when you are foam rolling an area that is hard to place full body weight on the roller, like the calf, as you will be able to apply more pressure.

 

Roll in 360 Degrees

In the next video, I discuss the ability to use a mobility sphere to be apply to easily alter the direction of rolling, instead of just back and forth using a foam roller.  This is one of my favorite progressions.

 

Hold a Spot

Often times when rolling, you’ll find one spot that is really tender.

Once you find a tender spot, combine our treatment technique of sustained pressure on the area.  Stop rolling and hold pressure on that spot for 10-30 seconds.  The goal is not to crush the spot, but rather to gentle hold and increase pressure as the tenderness subsides.

You’ll be surprise how the spot will decrease in tenderness after holding the spot.

 

Add Active Motion

The next variation is also a simulation of our treatment techniques, this time a pin and stretch.  Again, when you find a tender spot, hold it for a duration, then add some active motion of that muscle group.

Focus on slowly moving the muscle through full range of motion while sustain pressure.

Move Another Muscle

On a similar note, you can also pin one muscle and stretch an adjacent muscle.  The example I use in the video below is the hamstring and adductor group.  You can pin the adductor and slowly flex and extend the knee to move the hamstring.

 

These examples are just 5 of the many ways we enhance self myofascial release with our patients and clients at Champion.  I’d love to hear what you do as well.  By combining some of our treatment concepts, we think you can really get a lot more out of your self myofascial release.

If you like this type of content, be sure to follow me on Instagram and Facebook, I’ve been sharing a lot of videos like this:

 

Dry Needling for Scapular Winging

This week’s article is a guest post from Michael Infantino.  Michael reached out to me on Facebook and sent me the below videos of a patient’s improvement in scapular winging after dry needling the serratus anterior.

I wanted to share the below article that Michael wrote showing the videos, but also talk about how trigger points may be involved.

I’m not sure what to make of these videos, if trigger points are involved, or exactly how dry needling the serratus anterior helped this patient’s winging.  But I am sure that I was impressed with the results.  I wish we knew more about the reasoning and mechanism, but in the meantime I’m happy we can help people feel and move better.

Dry Needling for Scapular Winging

Can we correct scapular winging in a matter of minutes?  This obviously depends on the cause of the scapular winging.

It is well documented that injury to the long thoracic nerve or cervical spine may lead to medial border scapular winging or dyskinesia of the scapula (Meininger, 2011). These are always challenging.  Ruling out neuromuscular cause can be done with a nerve conduction velocity test or EMG.  

But a recent patient of mine, made me think…

Research has continually shown that muscles with trigger points demonstrate the following:

  • Altered muscle activation patterns on EMG (Lucas, 2010; Wadsworth, 1997)
  • Reduced muscle strength (Celik, 2011)
  • Accelerated muscle fatigue (Ge, 2012)
  • Reduced antagonist muscle inhibition (Ibarra, 2011)  
  • Increased number of trigger points on the painful side (Alburquerque-Sendin, 2013; Bron, 2011; Fernandez-de-las-Penas, 2012; Ge, 2006; Ge, 2008)

Appreciating these findings would lead most to conclude that treatment of trigger points could improve scapular mobility and timing. This was my immediate thought when I noticed a significant medial border scapular winging while watching my patient raise and lower his arm.

It wasn’t until I read this research that I began using dry needling to do more than just manage pain. The results seen following dry needling to the serratus anterior were remarkable.

After seeing this amount of scapular winging, I dry needled his serratus anterior muscle.  Note the remarkable improvement:

How Trigger Point Dry Needling May Impact Scapular Winging

It is well documented that appropriate muscle activation patterns (MAP) surrounding the shoulder is necessary for efficient and pain free mobility (Lucas, 2003). Lucas and group actually gauged the effect of trigger point dry needling on MAP in subjects with latent trigger points (LTrP).

“Latent myofascial trigger points (LTrPs) are pain free neuromuscular lesions that are associated with muscle overload and decreased contractile efficiency” (Simons et al., 1999, p. 12). MAP’s of the upper trapezius, serratus anterior, lower trapezius, infraspinatous and middle deltoid were compared in a group with LTrP’s and one without. Following surface EMG, the LTrP’s were treated with trigger point dry needling. Surface EMG was performed after treatment as well.

Findings from this study were as follows:

  • Muscle activation of the upper trapezius in the LTrP group pre-treatment.
  • Early activation of the infraspinatous in the LTrP group pre-treatment.
  • Increased variability of muscle activation in all muscles assessed in the LTrP group pre-treatment compared to the control group.  
  • Altered MAP of distal musculature (infraspinatous and middle deltoid) were consistent with co-contraction, a finding that has been attributed to increased muscle fatigability (Chabran et al., 2002).
  • Improved muscle activation times in the LTrP group following dry needling.
  • Significant decrease in the variability of muscle activation in the LTrP group following dry needling, except for the serratus anterior.
  • The serratus anterior and lower trapezius showed increased variability in both the control and LTrP group, which may be why the results did not reach significance. This is also consistent with the latest research in JOSPT that found dyskinesia to be normal in asymptomatic populations. (Plummer, 2017).

Based on the both my clinical experiences and the research presented in this paper, it would seem highly valuable to focus on the treatment of trigger points to restore muscle activation patterns surrounding the shoulder complex.

Being able to press the “reset button” on a muscle is important for re-establishing normal muscle activation patterns prior to exercise. Inclusion of other manual therapy and exercise techniques is important for optimizing function of the local musculature (range of motion, hypertrophy, strength and endurance).

No research that I am familiar with has compared dry needling to other manual therapy techniques for restoring MAP in muscles adjacent to the shoulder. Future research that compares various trigger point treatments for restoration of normal MAP would be beneficial.

 

About the Author

Dr. Michael Infantino, DPT, is a physical therapist who works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.

References

  • Alburquerque-Sendin, F., Camargo, P.R., Vieira, A., Salvini, T.F., 2013. Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: a blinded, controlled study. Clin. J. Pain 29 (6), 478e486.
  • Bron, C., de Gast, A., Dommerholt, J., Stegenga, B., Wensing, M., Oostendorp, R.A., 2011a. Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial. BMC Med. 9, 8.
  • Chabran, E., Maton, B., Fourment, A., 2002. Effects of postural muscle fatigue on the relation between segmental posture and movement. Journal of Electromyography and Kinesiology 12, 67–79.
  • Celik, D., Yeldan, I., 2011. The relationship between latent trigger point and muscle strength in healthy subjects: a double-blind study. J. Back Musculoskelet. Rehabil. 24 (4), 251e256.
  • Cummings, T.M., White, A.R., 2001. Needling therapies in the management if myofascial trigger point pain: a systematic review. Archives of Physical and Medicine and Rehabilitation 82, 986–992.
  • Ge, H.Y., Arendt-Nielsen, L., Madeleine, P., 2012. Accelerated muscle fatigability of latent myofascial trigger points in humans. Pain Med. 13 (7), 957e964.
  • Ge, H.Y., Fernandez-de-las-Penas, C., Arendt-Nielsen, L., 2006. Sympathetic facilitation of hyperalgesia evoked from myofas- cial tender and trigger points in patients with unilateral shoul- der pain. Clin. Neurophysiol. 117 (7), 1545e1550.
  • Ge, H.Y., Fernandez-de-Las-Penas, C., Madeleine, P., Arendt- Nielsen, L., 2008. Topographical mapping and mechanical pain sensitivity of myofascial trigger points in the infraspinatus muscle. Eur. J. Pain 12 (7), 859e865.
  • Hillary A. Plummer, Jonathan C. Sum, Federico Pozzi, Rini Varghese, Lori A. Michener. Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without Shoulder Pain. J Orthop Sports Phys Ther:1-25.  
  • Ibarra, J.M., Ge, H.Y., Wang, C., Martinez Vizcaino, V., Graven- Nielsen, T., Arendt-Nielsen, L., 2011. Latent myofascial trigger points are associated with an increased antagonistic muscle activity during agonist muscle contraction. J. Pain 12 (12), 1282e1288.
  • Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166
  • Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166Meininger, A.K., Figuerres, B.F., & Goldberg, B.A. (2011). Scapular winging: an update. The journal of The American Academy of Orthopaedic Surgeons, 19(8), 453-462.
  • Simons, D.G., Travell, J.G., Simons, L.S., 1999. The Trigger Point Manual, Vol 1, 2nd Edition. Williams and Wilkins, Baltimore, USA.
  • Wadsworth, D.J.S., Bullock-Saxton, J.E., 1997. Recruitment patterns of the scapular rotator muscles in freestyle swimmers with subacromial impingement. International Journal Sports Medicine 18, 618–624.

 

5 Reasons Why I Don’t Use the Sleeper Stretch and Why You Shouldn’t Either

Ah, the sleeper stretch.  Pretty popular right now, huh, especially in baseball players?  Seems like a ton of people are preaching the use of the sleeper stretch and why everyone needs to use it.  It’s so popular now that physicians are asking for it specifically.

I don’t like the sleeper stretch and I rarely use it, in fact I haven’t used it in years.  I don’t think you should use it either.

There, I said it, I felt like I really had the get that off my chest!

Every meeting I go to, I see more and more people talking like the sleeper stretch is the next great king of all exercises.  Then I get up there and say I don’t use it and everyone looks at me like I have two heads!  Call me crazy, but I think we probably shouldn’t be using it as much as we do.

In fact, I actually think it causes more harm than good.

 

5 Reasons Why Shouldn’t Use the Sleeper Stretch

I haven’t used the sleeper stretch in over a decade and have no issues restoring and maintaining shoulder internal rotation in my athletes with safer and more effective techniques.

If you have followed me for some time, you know that I rarely talk in definitive terms, as I always strive to continue to learn and grow.  I know my opinions will change and things aren’t black and white.  However, over the years my stance on NOT using the sleeper stretch has only strengthening.  As I learn more and grow, I actually feel more strongly that we shouldn’t be using this common stretch.

So why don’t I use the sleeper stretch?  There are actually several reasons.

 

It’s Often Performed for the Wrong Reason

The sleeper stretch is most often recommended for people with a loss of shoulder internal rotation.  When a person has a loss of internal rotation, it can be from several reasons, including:

  1. Soft tissue / muscular tightness
  2. Joint capsular tightness
  3. Joint and boney alignment of the glenohumeral joint and scapulothoracic joint
  4. Boney adaptations to repetitive tasks, such as throwing a baseball and other overhead sports

You must assess the true cause of loss of shoulder motion and treat accordingly.

Of the above reasons, you could argue that only joint capsular tightness would be an indication to perform the posterior capsule.  But see my next point below…

Performing the sleeper stretch for the other reasons could lead to more issues, especially in the case of boney adaptations.  The whole concept of glenohumeral internal rotation deficit (GIRD), is often flawed due to a lack of understanding of the normal boney adaptations in overhead athletes.

I can’t tell you how many people think they have GIRD that I evaluate and that they in fact do NOT have GIRD.  Click here to learn more about how I define GIRD.

 

It Stretches the Posterior Capsule

If you have heard me speak at any of my live or online courses, you know that I am not a believer in posterior capsule tightness in overhead athletes.  Maybe it happens, but I have to admit I rarely (if ever) see it.  In fact, I see way more issues with posterior instability.  Please keep in mind I am talking about athletes.  Not older individuals and not people postoperative.  They can absolutely have a tight posterior capsule.

But for athletes, the last thing I want to do is make an already loose athlete looser by stretching a structure that is so thin and weak, yet so important in shoulder stability.

Urayama et al in JSES have shown that stretching the shoulder into internal rotation at 90 degrees of abduction in the scapular plane does not strain the posterior capsule.  However, by performing internal rotation at 90 degrees of abduction in the sagittal plane, like the sleeper stretch position, places significantly more strain on the posterior capsule.

Based on the first two points I’ve made so far, if you have a loss of shoulder internal rotation, you should never blindly assume you have a tight posterior capsule.

Assess, don’t assume.

But be sure you know how to accurately assess the posterior capsule.  Many people perform it incorrectly.  Click here to read how to assess for a tight posterior capsule.

 

It is an Impingement Position

This one cracks me, check out the photos below, if you rotate a photo of the Hawkins-Kennedy impingement test 90 degrees it looks just like a sleeper stretch.  I personally try to avoid recreating provocative special tests as exercises.

sleeper stretch impingement reinold

 

This is a provocative test for a reason, by performing internal rotation in this position, you impinge the rotator cuff and biceps tendon along the coracoacromial arch.  If you actually had a tight posterior capsule, you’d get subsequent translation anteriorly during this stretch and further impingement the structures.

So based on this, even if you have a tight posterior capsule, I wouldn’t use the sleeper stretch.  I would just perform joint mobilizations in a neutral plane.

 

People Often Perform with Poor Technique

So far we’ve essentially said that people often perform the sleeper stretch for the wrong reasons and can end up torquing the wrong structure (the posterior capsule) and irritating more structures (the rotator cuff and biceps tendon).

Even if you have the right person with the right indication, the sleeper stretch is also often performed with poor technique, which can be equally as disadvantageous.

People often roll too far over onto their shoulder or start in the wrong position.  If you are going to perform the sleeper stretch, at least follow my recommendations on the correct way to perform the sleeper stretch.

 

People Get WAY too Aggressive

Despite the above reasons, this may actually be the biggest reason that I don’t use the sleeper stretch – people just get way too aggressive with the stretch.  The whole “more is better” thought process.  Being too aggressive is only going to cause more strain on the posterior capsule and more impingement.  You may actually flare up the shoulder instead of make it better.

I always say, if you have a loss of joint mobility, torquing into that loss of mobility aggressively is only going to make it worse.

 

When the Sleeper Stretch is Appropriate

There are times when the sleeper stretch is probably appropriate.  But it’s not as often as you think and it’s most often not in athletes.  The older individual with adhesive capsulitis or a postoperative stiff shoulder may be good candidates for the sleeper stretch.  But I honestly still don’t use it in these populations.  There are better things to do.

But of course, there are good ways to perform the sleeper stretch and there are bad ways, technique is important.

For more information on some alternatives to the sleeper stretch, check out my article on sleeper stretch alternatives.

 

How to Choose the Right Medicine Ball

Medicine balls are commonly used for plyometric and power development drills.

The two most common types of medicine balls can be categorized by how well they bounce, high bounce or low bounce.

There’s a time and need for both, but choosing the right medicine ball can easily make or break the effectiveness of the exercise.

A medicine ball that bounces can effectively trigger the stretch-shortening cycle of a plyometric exercise, while a medicine ball with low bounce will place the emphasis on the concentric power output.

How to Choose the Right Medicine Ball

In this video, I discuss this more and show the different emphasis that different medicine balls will produce:

Get More Performance Therapy Tips

I’ve really been publishing a ton of great videos on social media lately, including this series of “Performance Therapy Tips.”  Be sure to follow me on Instagram and Facebook to get them all!

 

The Science of Plyometrics

If you want to learn more, check out my Inner Circle presentation that overviews the neurological basis, phases, and science of plyometrics:

To access this webinar:

 

The Right Way, and Wrong Way, to Do Plyometrics

Plyometric exercises have been used for decades in both the rehabilitation and sports performance settings.

I love how plyometrics can effectively be used for power development, but are also valuable in the rehabilitation setting to gradually apply load to healing tissue while working on both force production and dissipation.

To truly perform plyometric exercises and get the most out of them, you must understand the science behind the stretch-shortening cycle.  I talk about this in detail in an Inner Circle presentation on the Science of Plyometric Exercises.

To fully maximize the benefit of the stretch-shortening cycle, you have to quickly transition from the eccentric loading phase to the concentric explosion phase of the drill.

If you perform the drills to slow, you’ll reduce the effect of the stretch-shortening cycle and decrease the efficacy of the plyometric exercise.

 

The Right Way, and Wrong Way, to Do Plyometrics

Watch the quick video below to see what I mean:

The Science of Plyometrics

If you want to learn more, check out my Inner Circle presentation that overviews the neurological basis, phases, and science of plyometrics:

To access this webinar:

The Science of Plyometrics

The latest Inner Circle webinar recording on The Science of Plyometrics is now available.

 

The Science Behind Plyometrics

The Science of Plyometrics

This month’s Inner Circle webinar is on The Science of Plyometrics.  In this presentation, I overview the foundation behind plyometric training so that you can perform them effectively,

This webinar will cover:

  • The goals of plyometric training
  • How the muscles spindles and golgi tendon organs interact
  • The 3 phases of plyometric exercises
  • The right way, and wrong way, to perform plyometric exercises

To access this webinar: