How to Perform Lower Body Plyometrics

The latest Inner Circle webinar recording on How to Perform Lower Body Plyometrics is now available.

How to Perform Lower Body Plyometrics

This month’s Inner Circle webinar is on How to Perform Lower Body Plyometrics.  In this presentation, I demonstrate the different types of plyometric exercises you can perform for the lower body and show some of my favorite progressions.

This webinar will cover:

  • The different types of plyometric exercises you can perform for the lower body
  • How I progress from two leg to one leg drills
  • How I progress different planes of motions
  • The keys to choosing the best exercise for your goal

To access this webinar:

 

Should We Delay Range of Motion After a Rotator Cuff Repair Surgery?

Over the last several years, there has been a trend among orthopedic surgeons to delay the start of rehabilitation, specifically range of motion exercises, following rotator cuff repair surgery.

It’s my opinion that this trend started in response to the research that has been reported in the past that show issues with tendon healing rates and a large percentage of rotator cuff repairs are not intact at follow up examination.

For example, I previously discussed the outcomes of arthroscopic rotator repairs and noted that at the one year follow up after surgery, 68% had an intact rotator cuff. 32% had a full thickness tear again.

So physicians did what they tend to do… They started to get more conservative and delayed the start of rehabilitation. I’ve discussed a similar to approach to rehabilitation following total shoulder replacement.

But does delaying the start of range of motion after rotator cuff repair surgery even help improve outcomes?

Does immobilization after rotator cuff repair increase tendon healing?

A systematic review was published in the Archives of Orthopaedic and Trauma Surgery that looked at 3 randomized control trials comparing immediate versus delayed range of motion follow rotator cuff repair surgery.

The authors reported a few findings.

Most importantly, there was no difference in tendon healing rate, showing that early range of motion is safe to perform and not the reason why people may retear.

Range of motion improved earlier in the immediate range of motion group, but was similar at the year mark. This is consistent with many past studies. Again physicians read into this and use this stat to favor delayed range of motion, stating that patients are all the same at 1 year postoperative. However, as we all know, restoring motion is key to the patient’s’ subjective and functional outcomes. Similarly, functional outcomes were achieved sooner in the immediate range of motion group.

Based on this systematic review, I would continue to recommend performing control range of motion following rotator cuff repair surgery as it appears to be safe and effective at restoring motion and function sooner than if we delay rehabilitation.

Learn More About How I Evaluate and Treat the Shoulder

I’m pretty excited to announce I have revised my acclaimed online program teaching you exactly how I evaluate and treat the shoulder to now include a lesson on the arthritic shoulder! If you want to learn more about how I work with rotator cuff repairs, and everything else related to the shoulder, you’re going to want to take my online course.

 

Should We Delay Range of Motion After a Total Shoulder Replacement?

Total shoulder replacement surgery is being performed more and more each year.  Our current patients were more active in sports in their youth, potentially increasing the chances of developing an arthritic shoulder.  They also want to remain active as they age, potentially increasing the likelihood that they want to have a total shoulder arthroplasty surgery to allow them to remain active.

Over the years, the surgical technique for a total shoulder replacement has improved, though I’m not sure our rehabilitation approach has also improved.  If our patients are younger and want to be more active after total shoulder replacement, then perhaps our rehabilitation programs should adjust based on their goals.

Rehabilitation Following Total Shoulder Replacement

Historically, a conservative approach was appropriate for many patients, as their needs and activity goals were less aggressive than many patients today.  It was acceptable to have a moderate loss of range of motion in exchange for less pain in their shoulder.

Many surgeons continue to recommend a conservative approach to the restoration of range of motion following surgery.

It is true that one of the primary goals of the postoperative rehabilitation following total shoulder replacement is to protect the subscapularis.  The subscapularis muscle is taken down to some extent during the surgical procedure and the integrity of this muscle has been correlated to the overall outcome of the procedure.

Other motions, such as behind the back and shoulder extension behind their body, also place the arthroplasty in a disadvantageous position and can lead to dislocation of the joint.

But even with these precautions, I am still an advocate of early range of motion, especially if you respect these restrictions.

Passive ROM and Active ROM are Not the Same

A recent report was recently published in Journal of Shoulder and Elbow Surgery that may actually be causing some confusion on when to start range of motion.

In the study, the authors compared a group of patients that began range of motion immediately versus a group that delayed 4 weeks.  The authors reported that the immediate range of motion group gained more motion, restored it earlier, and also showed an earlier increase in functional outcome scores.

However, 96% of the patients that delayed range of motion showed healing of the lesser tuberosity osteotomy, while only 82% of the immediate range of motion group showed healing.  Furthermore, functional outcomes scores 3 months and 1 year after surgery were similar between the groups.

This has led to many recommending a delay in range of motion.  But…

When looking deeper at the methods, the authors chose to use the rope and pulley and stick elevation range of motion exercises.  As we all know, these are not passive range of motion exercises, they are active assisted range of motion exercises.

There’s a big difference between passive and active range of motion exercises!

Previous EMG studies have shown the rotator cuff to be between 18-25% active and the deltoid to be between 21-43% active during these exercises.  Not very passive.  Conversely, passive range of motion exercises have been shown to be between 3-10% active.

This is a big difference.  I believe passive range of motion is appropriate, as long as you respect the restrictions on restoring external rotation to protect the subscapularis and avoid behind the body and behind the back motions to protect the replacement.
Immediate Range of Motion Restores Function Faster

Since we all work with these patients after surgery, we know that they are always happier when they restore their motion sooner.  And this increase in range of motion is likely related to the earlier improvement in functional outcome scores.

I think there is a middle ground of immediate, yet cautious, passive range of motion.  Again, I want to reiterate, “passive” range of motion.  Not active.

By focusing on this, I believe our patients will have much better outcomes.

Learn More About How I Evaluate and Treat the Shoulder

I’m pretty excited to announce I have revised my acclaimed online program teaching you exactly how I evaluate and treat the shoulder to now include a lesson on the arthritic shoulder!  If you want to learn more about how I work with the arthritic shoulder, patients following total and reverse shoulder replacements, and everything else related to the shoulder, you’re going to want to take my online course.

 

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.

 

The Kettlebell March Drill for Functional Core Stability

We’re big fans of farmer carries and suitcase carries at Champion.

Carries do a great job of developing functional core stability by adding an offset weight to the center of rotation of the body. But carries also offer so many other benefits – from grip strength, to upper body development, to overall athleticism.

Often times, clients with poor core strength or control will compensate during the carry.

If the core can not stabilize the trunk with the added load of the carry, it will compensate by relying on the static stabilizers of the body and rocking back into hyperextension of the back or leaning to the side.

In the below video, Kiefer Lammi, our Director of Fitness at Champion, shows how we have started to modify the carry in these individuals by adding a march. Not only does this promote better core control, it also facilitates training the trunk to remain stable while the distal extremities move functionally. This is one of the fundamental principles to enhance how well people move and perform.

Follow Champion For More

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