Posts

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

If you enjoyed this video, the team at Champion and I have been producing a ton of great content on Champion’s social media profiles, including regular content for #MovementMonday and #TechniquesTuesday, plus a ton more:

 

2 New Self Myofascial Release Tools to Try

In my recent article on the best self myofascial release tools, I overviewed a variety of tools that people can use based on their goals and needs.

I mentioned a couple of newer self myofascial release tools that I have started using instead of a simple foam roller.  I still like foam rollers, but think that many people could benefit even more by upgrading to these newer tools.

A lot of people have been asking me about these newer tools, so I wanted to film a couple of videos showing you more.

 


Acumobility Eclipse Foam Roller and Mobility Ball

 


Mobilitas Mobility Sphere

 


Try these two new products and I think you’ll be impressed.  And be sure to check out my other recommendations of foam rollers, massage sticks, and other mobility tools.

 

 

 

5 Ways to Decrease the Risk for an ACL Injury

Injuries to the Anterior Cruciate Ligament (ACL) are some of the most common injuries in the active population. As incidence of other injuries have decreased, injuries involving the ACL have rose astronomically over the years.  There have been numerous studies done looking at what causes the ACL to tear. More specifically, female athletes are 4-5x more likely to tear their ACL as compared to their male counterparts.

Like with any injury, it cannot be blamed on one thing. Injuries are multi-factorial as well as non-preventable.  Injuries will always happen.  The only thing that we can do is to decrease the frequency or incidence of them. Luckily, as we continue to learn more about the mechanism of injury, we have developed some strategies to reduce your chance of ACL injuries.

 

5 Ways to Decrease the Risk for an ACL Injury

Here are 5 things to focus on when designing programs to reduce ACL injuries.

 

Optimize Mobility

If you look at the human body, there are many joints. Some of those joints require mobility and some of those joints require stability. Depending on which plane of motion you are in, mobility or stability is usually more imperative than the other.

When it comes to mobility, there are certain joints in the body that we need to have optimal mobility in order to decrease the risk for an injury to the ACL. The two joints that come to mind are the talocrural joint of the ankle, and the femoroacetabular joint of the hip.

For the ankle, specifically dorsiflexion range of motion is imperative to decrease strain at the knee. If the ankle doesn’t have the ability to dorsiflex and absorb force during a land from a jump or cutting maneuver, the mid foot or knee are the two joints that will have to have increased mobility to accommodate the athletic endeavor.

 

Ankle Mobility

To assess for adequate ankle mobility, use the Knee to Wall Ankle Mobility Test.

Key Points:

  • Place your foot 4 inches away.
  • Keeping your foot flat on the floor, attempt to touch your knee to the wall.
  • Don’t allow for valgus or varus collapse.

If you can reach the wall from 4 inches, then you have sufficient ankle mobility to run, squat, and perform without playing increased stress through the knee due to poor ankle mobility.

The other joint in the body that needs to have optimal mobility is the hip.  The motions at the hip that need adequate mobility are hip flexion, hip extension, hip abduction, hip internal and external rotation.

Now, you may be saying, “Wow, that’s a lot of areas that need mobility.”  Well, let’s break it down!

 

Hip Flexion

5 ways to reduce ACL injuriesAnecdotally, I like to see clients present with full hip flexion. If there is decreased mobility into hip flexion, this can send a signal to the brain to alter movement and muscle firing patterns and in turn, can affect how someone lands or moves.

A quick and easy test is to test passive hip flexion range of motion.  

This involves bringing your knee towards your chest. Ideally, your thigh should reach the inferior aspect of your rib cage. Now, everyone is made differently and depending upon what sport you play, hip structure can vary from person to person.

If you cannot reach your thigh to your rib cage, slightly abduct your thigh and see if you can go further. If you can, then your hips are structured a little differently.

 

Hip Extension

Key Points:

  • Thigh should be able to reach parallel to ground.
  • Knee should be at 90 degrees to thigh.
  • Thigh should drop straight down and not flare out towards side of body.

Hip extension mobility is necessary to be able to activate the gluteus maximus and hamstrings in order to decrease incidence of a valgus collapse. If adequate hip extension mobility is not present, then muscular compensation will occur and in turn, possible injury.

 

Hip Internal Rotation (IR)

Even though hip internal rotation is part of the combination of movements that contribute to an ACL injury, not having the requisite mobility is a risk factor. If the body doesn’t have certain available ranges of motion, then the brain and central nervous system are not able to prevent going into those said ranges of motion. Therefore, if someone doesn’t have adequate hip internal rotation, then the body has no way to prevent that motion from occurring.

VandenBerg et al. in Arthroscopy: The Journal of Arthroscopic & Related Surgery that “risk of ACL injury is associated with restricted hip IR, and as hip IR increases, the odds of having an ACL tear decreases.”

 

Hip External Rotation

Hip external rotation is important because avoidance of a knee valgus position is necessary to avoid injury to the ACL. Having adequate hip external range of motion will allow the athlete to be able to get into an athletic position to avoid that valgus position.

 

Learn How to Land

You watch any NFL or NBA game and guys are jumping to catch a ball to to tap in a rebound for 2 points. Most injuries to the ACL don’t occur on the jumping portion as it does on the landing portion.

When athletes have to land from a jump, the body has to absorb 7-10x their body-weight in forces from the ground.  If joints aren’t in an ideal position to absorb and adapt to stress, injuries can happen.

landing mechanics ACL injury

Photo credit

Therefore, we need to assess athletes in their landing patterns and mechanics to make sure their body is resilient and capable to land properly.

 

Step Down Test

 

The Step Down Test is a simple way to determine an athlete’s predisposition to absorbing eccentric stress. Ideally, we like to see the pelvis, hip, knee, and ankle remain in a line during descent.

 

If someone steps down and the femur internally rotates and the knee goes into valgus collapse,  this is something that needs to be rectified.

If you want to use a more quantitative analysis of landing mechanics and skill as compared to the contralateral limb, then here are 3 tests that can help with that.

 

Single Leg Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as then can and land on 1 leg.
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, take the average of the 2 trials, then repeat on the opposite leg.

 

Triple Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as they can, land on 1 leg, and continue for 2 more hops, sticking the 3rd landing
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, take the average, then repeat on the opposite leg.

 

Crossover Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as they can, land on 1 leg, and continue for 2 more hops, sticking the 3rd landing while crossing over a tape line on the floor with each jump.
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, find the average, then repeat on the opposite leg.

Now that you have the average for all 3 jumps, we need to determine if the difference between the two limbs is significant. According to Adams in the Journal of Orthopaedic and Sports Physical Therapy, limb symmetry indexes of 90% have previously been suggested as the milestone for determining normal limb symmetry in quadriceps strength and functional testing.

According to Phil Plisky, one of the developers of the Y-Balance Test, he advocates that the athlete’s reconstructed lower extremity be within 95% on the non-involved leg.

To determine if distances hopped are significant, the involved limb must be within 90-95% of the non-involved side. If it is less than 90%, then that athlete is at risk for future knee injury.

Using a regimen consisting of single leg plyometrics in the sagittal, frontal, and transverse planes as well as single leg exercises that focus on power development can help to improve any major deficits.

 

Achieve Symmetry

If an athlete presents with a gross asymmetry, their risk for injury can increase 3-17x. Besides using the Hop Tests, one way to assess gross asymmetry is also using the Y-Balance Test.

The Y-Balance Test consists of 3 lower and upper body movements. For the sake of this post, we will be focusing on the lower body. The movements consist of:

y balance test ACL injuries

Photo credit

If there is greater than a 4 cm difference right vs left on the anterior reach (1st picture), this is considered a risk factor for a lower extremity injury.

Smith, Chimera, and Warren found in Medicine and Science in Sports & Exercise that “ANT (anterior)  asymmetry >4 cm was associated with increased risk of noncontact injury.”

If there is greater than a 6 cm difference right vs left on the posteromedial or posterolateral reaches, pictures 2 and 3, then this is considered a risk factor for a lower extremity injury.

Asymmetry is a normal thing.  Everyone from elite level athletes to the average joe has natural asymmetries right vs left. Some asymmetries may not change and some asymmetries may make someone the elite level athlete that they are. Having a relative asymmetry right vs left is ok, but having a gross asymmetry is not.

 

Enhance Core Stability

The core musculature is responsible for providing a stable base for the pelvis, hips, knees, ankles, etc. to function off of in life and in sport. If a stable base is not provided, then it can create instability and injury further down or up the kinetic chain.

Decreased core stability can cause:

  • Pelvic Drop
  • Femoral Internal Rotation
  • Knee Valgus
  • Tibial External Rotation
  • Subtalar Excessive Pronation

All these movements are associated with injuries of the ACL. By stabilizing proximally and providing a stable base for all of the aforementioned areas to work off of, this can decrease the risk for injury.

In order to test for core stability, the Trunk Stability Push-Up (TSPU) by Functional Movement is a good test.

This is a great test to determine if someone can maintain a neutral spine while performing a push-up, but also to determine if they have a base level of core stability to maintain a certain trunk position during life/sport.

If someone cannot maintain a specific trunk position, this doesn’t mean that they have a “weak core.” or weak upper extremities. It means that the athlete doesn’t have the capability to stabilize their core proximally in order to exude force distally.

 

Learn How to Decelerate

Most athletes are fast or at least quick on their feet. The great athletes can speed up and slow down better than anyone. One common risk factor we see with ACL injuries is the inability or subpar ability to be able to decelerate.

What this means is that if someone is going to stop or change direction, they need to have the necessary skills to control their body in space when going from accelerating, to decelerating, and then back to accelerating again.

All fast cars are fast! All really fast cars have great brakes!

In order to assess an athlete’s ability to decelerate, observe how the do with change of direction drills.  For example, movements such as:

 

Sprint/Backpedal w/ Redirection

Lateral Shuffles w/ Redirection

Sprint with 45 Degree Cut

Sprint with 90 Degree Cut

Backpedal, Stop, to 90 Degree Sprint

Backpedal, Stop, to 45 Degree Sprint

All of these various movements test an athlete’s ability to accelerate, decelerate and change directions in all planes of movement. A coach, personal trainer, or physical therapist should be present to provide the athlete with the redirection component. This makes it more random and unpredictable to make sure the athlete can react and move appropriately.

While observing these various change of direction movements, observe the mechanics of the pelvis and lower extremity.

Does the pelvis and hip/knee stay in a relative stable and neutral position when decelerating and stopping?

Does the pelvis and hip/knee go into a valgus collapse during decelerating, stopping, and accelerating phases of movement? Compare these right versus left lower extremities.

If you are having trouble observing these things with the naked eye, film it!  There are apps such as DartFish or Hudl that you can download to film athletes and then you can watch it in slow motion to observe any differences side to side.

If differences are seen in right and left comparison, then work on change of direction drills. When first starting off, start the athlete at ½ or ¼ speed so that they can work on their deceleration, stopping, and accelerating mechanics.

We don’t necessarily want to bombard the athlete with too much information about biomechanics of the lower extremity, but having a basic discussion with them and showing them how they currently move and how you would want them to move safely and more efficiently is ideal.

Then once, then can master ¼ or ½ speed, then increase the speed of the drills until you are working at full speed on both sides. There are a multitude of drills out there to work on acceleration, deceleration, stopping, and change of direction. Make sure start with the sagittal plane, and then progress into the frontal and transverse planes.  

If you can’t master the sagittal plane, then the frontal and transverse planes will be much more challenging.

Assessing mobility, landing mechanics, relative lower extremity symmetry, core stability, and acceleration/deceleration can all help to improve an athlete’s performance as well as decrease their risk for an ACL injury.

 

About the Author

Andrew Millett is a Boston-based physical therapist in the field of orthopedic and sports medicine physical therapy.  He helps to bridge the gap between physical therapy and strength and conditioning.  Visit his website at AndrewMillettPT.com.

 

 

 

The Best Self Myofascial Release Tools

Self myofascial release tools, such as foam rollers, trigger point balls, and massage sticks, have become some of the most popular tools used for corrective exercises, fitness, and sports performance.  In fact, performing self myofascial release has become almost a uniform component in the majority of fitness and sports performance programs.

You can certainly argue the exact physiological benefit of performing self myofascial release.  Ironically we are likely not really “releasing” fascia.  

However, it’s hard to argue the benefits of self myofascial release.

Two recent studies in International Journal of Sports Physical Therapy and Journal of Bodywork and Movement Therapy have been published that analyzed the current state of research and conclude that self myofascial release:

  • Increases mobility and joint range of motion
  • Reduces post-workout soreness and DOMS (delayed onset muscle soreness)
  • Allows for greater workout performance in future workouts
  • May lead to improved vascular function and parasympathetic nervous system function

“Simply put, self myofascial release has been proven to help you feel and move better.” [click to tweet]

In order to get started, I wanted to share my years of experience with self myofascial release tools.  There are so many foam rollers, trigger point tools, and massage sticks out there these days.  
I’ve tried nearly all of them and these are what I consider the best self myofascial release tools.

Best Self Myofascial Release Tools

Over the years I have tried a ridiculous amount of different self myofascial release tools, some great, some awful, and some just a rip off.  Luckily, new products emerge all the time and continue to improve.

I’ve learned a couple of things that are important:

  • There are different types of self myofascial release tools for different needs, body parts, and intensities.  Building your own “kit” is probably going to be the most effective.  Trying to use just a foam roller on everything is going to not work well.
  • You tend to build up a tolerance to self myofascial release and want to upgrade to more advanced foam rollers, trigger point balls, and massage sticks.  Start with the basics and advance overtime.

Best Foam Rollers

Amazon Basics High-Density Round Foam Rollerself myofascial release - amazon foam roller

The first place to is a basic high density foam roller.  This could be the cheapest and most versatile tool you get.  Amazon has started to make their own version, which is a great price.  You’ll find various sizes.  I’ve never personally gotten much use of the large 36-inch versions and tend to favor the 18-inch version.

TriggerPoint GRID Foam Rollerself myofascial release - grid foam roller

The basic high density foam roller is a great place to start to get used to foam rolling, but quickly gets pretty easy.  You’ll want to upgrade to a more firm foam roller in increase the intensity.  My preferred choice is the GRID foam roller from TriggerPoint.  I’ve been using this foam roller for years with continued success.  It has a rigid hollow core that increases the intensity very well.  This is worth the extra investment as it will likely be your main foam roller for some time.

Mobilitas Mobility Sphere
self myofascial release - mobility sphere foam roller

Somewhere between a foam roller and a trigger point ball, I actually really like using 5” mobility balls.  Because of the round shape, the contact area is smaller so the amount of force to the area is larger.  Plus, you can use into in multiple planes of motion because it is a ball instead of a roller.  This is something I personally use.  You can get into smaller areas, like your chest, but I use this just as much as a standard foam roller.  There are a few but the one I use and recommend is the Mobilitas Mobility Sphere.

Acumobility Eclipse Foam Rollerself myofascial release - acumobility foam roller

I was recently turned onto the Eclipse Foam Roller from Acumobility and have been impressed.  I was intrigued by the design and wanted to try it myself.  I’m not a big fan of foam rollers with ridges, as I just feel they don’t do much and concept is more of a marketing gimmick.  But Acumobility has a made a great advanced foam roller that includes a firm middle section that can encompass a body part really well.  It’s a really unique design and a great tool for advanced foam rolling.

Best Massage Roller Stick

While foam rollers are the primary self myofascial release tool for most needs, there are body parts that simply don’t do as well and need a massage stick tool.  The next tool you should add to your self myofascial release tool kit is a massager stick roller.  There are a few popular massage sticks on the market, and as it is with most things, I actually don’t prefer the two most popular massage sticks.

TheraBand Roller Massager+self myofascial release - theraband massage stick roller

The original massage stick began with plastic pieces and did a fairly well job, but newer tools have used a more grippy surface that I feel is far more effective. A plastic roller is just placing pressure downward on the tissue, where the grip on the TheraBand Roller Massager+ seems to also create a tissue traction with the friction produced.  This is a great product for areas like the forearms and feet, but also areas where you want to apply more pressure than what you can with just body weight, like the quads, hamstrings, and calves.  Plus, this has been the massage roller featured in many of the research reports.

Best Trigger Point Release Tools

In addition to foam rollers and massage sticks.  Trigger point release tools are another must have addition to your self myofascial release tool kit.  Essentially, these just tend to be smaller self myofascial release tools that can get into tighter areas.

Lacrosse Ballself myofascial release - lacrosse ball trigger point tool

Yup, that’s it, just a lacrosse ball.  People have tried to make better versions of trigger point balls, but nothing beats the affordable lacrosse ball.  Great material, density, and durability.  This is a great place to start.  Get a couple so you can use two at once one places like your spine.

Acumobility Mobility Ballself myofascial release - acumobility ball trigger point tool

Acumobility, the maker of the Eclipse Roller above, has another great tool, their Mobility Ball.  This is made from a great dense material, but has a flat bottom that allows you to keep this in one spot on the floor or even against the wall.  This really helps to provide firm pressure while performing movements of the muscle group.  This is a great upgrade from the lacrosse ball.

Trigger Point Wandself myofascial release - trigger point wand

Sometimes an area is hard to reach, such as your neck or back.  That’s where sometimes a trigger point wand comes in handy.  I would definitely consider this a speciality tool, however a very popular choice.

Foot Rubz Massage Ballself myofascial release - foot rubz massage ball

Another speciality tool, but something that I wanted to include as I really love, is the hand and foot massage ball from Foot Rubz.  This is a smaller trigger point ball perfect for the hands and feet.  You can use a lacrosse ball or even the TheraBand Massage Roller above for these areas, but I feel this is slightly better and worth it for many.  (I’m literally using one as I type this haha…)

Create Your Own Self Myofascial Release Tool Kit

All of the above options are great choices.  I would recommend getting one of each of the foam rollers, massage sticks, and trigger point tools.  Together, these cover pretty much all of your self myofascial release needs.

If you are interested, I also have an Inner Circle webinar on how I perform self myofascial release.

 

 

Sorry, Sitting Isn’t Really Bad for You

Over the last several years, the health concerns surrounding sitting have really been highlighted by the health and fitness crowds, as well as the mainstream media.  In fact, there have been entire books published on this topic.  I’ve seen articles with titles such as “Sitting is Evil,” “Sitting is the New Smoking,” and even “Sitting will kill you.”

Wow, those seem pretty aggressive.  We’ve been sitting since the beginning of time!  I’m going to really shock the world with this comment…

Sorry, sitting isn’t really bad for you.

Yup.  There is nothing wrong with sitting.  I’m actually doing it right now as I write this article.  You probably are too.  Don’t get me wrong, sedentary lifestyles are not healthy, but let’s get one thing straight:

It’s not sitting that is evil, it’s NEVER moving that is evil. [Click to Tweet]

By putting all the blame on sitting, we lose focus on the real issue, which is lack of exercise.  So we see a shift in people switching to standing desks at work, still not exercising, but thinking that they are now making healthy choices.  

This is so backwards it boggles my mind.

The body adapts amazingly well to the forces and stress that we apply to it throughout the day.  If you sit all day, your body will adapt.  Your body will lose mobility to areas like your hips, hamstrings, and thoracic spine.  Your core is essentially not needed while sitting so thinks it’s not needed anymore during other activities.  And several muscles groups get used less frequently while sitting and weaken over time, like your glutes, scapular retractors, and posterior rotator cuff.

Unfortunately, when all you do is sit all day, and you never reverse this posture or exercise, your body adapts to this stress to make you the most efficient sitter.  That’s right, you get really good at sitting.

For example, think about what happens to the core when you sit all day.  One of the functions of your core is to maintain good posture and essentially to keep the bones of your skeleton from crashing to the floor.  The core is engaged at a low level of EMG activity throughout the day for postural needs.  

The problem with sitting is that the chair also serves this function, so your core isn’t needed to keep you upright, the chair serves this function. If sitting is all you do, then when you stand up, your core essentially isn’t used to providing this postural support so you rock back onto your static stabilizers by doing things like standing with a large anterior pelvic tilt and lumbar extension.  

sitting isnt bad for you

Unfortunately, this becomes the path of least resistance, and most energy efficient, for your body.  Your core gets used to relying on the chair to function, then when you need it, gets lazy.

It’s OK to sit all day, as long as you are reversing this posture at some point.  This can be as specific as exercises designed to combat sitting and as general as simply taking a walk in the evening.

 

3 Strategies to Combat Sitting All Day

I want to share the 3 things that I often discuss with my patients and clients.  You can apply these yourself or use them to discuss with your clients as well.  But if you sit all day, you really should:

  1. Move, Often
  2. Reverse your posture
  3. Exercise

But the real first step is to stop blaming sitting and calling a spade a spade.  It’s lack of movement and exercise that is the real concern, not sitting.

 

Move, Often

The first step to combatting sitting all day is to move around often.  The body needs movement variability or it will simply adapt to what it does all day.  

I get it, we all work long days, and sitting is often required in many of our jobs.  But the easiest way to minimize the effects of sitting all day is to figure out ways to get up and move throughout the day.

This doesn’t need to be 10 minutes of exercise, it could simply be things like getting up to fill up a water bottle or taking quick 2 minute walk around the office.  When I am not in the clinic or gym, I personally tend to work in hour long chunks, so I will get up and walk around in between chunks to get a glass of water, snack, or use the bathroom.  

This works well for me, but you need to find what works for you.  I know of others that use things like Pomodoro timers, or even some of the fitness tracking devices, which can remind you to stand up and move around at set times.

 

Reverse Your Posture

I’ve been talking about the concept of Reverse Posturing for years.  The concept is essentially that we need to reverse the posture that we do the most throughout the day to keep our body balanced and prevent overuse.

Sitting involves a predominantly flexed posture, so doing exercises that promote the posterior chain would be helpful.  These will depend on each person but a basic set of exercises may look like:

Chin Tucks

Shoulder W’s

Thoracic Extension Exercises

View one of my past articles for several more great thoracic mobility drills.

Bridging Exercises

True Hip Flexor Stretch

Perform each of these for 10 reps.  These should take 5 minutes to perform and will make a big impact on how you feel throughout the day.  

I also often tell people to perform the prone press up exercise, cobra yoga poses, or to simply lay on their stomach in the evening while reading or watching TV.  

fig 1 - sitting isnt bad for you

 

Exercise

Remember going back to some of the past concepts above, the body adapts to the stress applied.  To combat this perfectly, a detailed exercise program that is designed specifically for you and comprehensively includes a focus on total body and core control is ideal.  

This will assure that the muscle groups that are not being used while sitting all day get the strength and mobility they need, while the core gets trained to stabilize the trunk during functional movements.

If you want to get the most out of your body and stay optimized, you need to do things like work on your hip and thoracic spine mobility, strengthen your rotator cuff, groove your hinge pattern, and learn how to deadlift and work your glutes.

 

Sitting Isn’t Bad For You, Not Moving Is

As a profession, we need to get away from blaming sitting as the enemy and labeling it evil.  Our society is sitting more and more each generation.  We need to be honest with ourselves and realize that sitting isn’t the problem, it’s not moving enough that is the concern.  We need to stop pointing fingers and get to the root of the problem.  

Go ahead and sit, just move more often and use these 3 strategies to combat sitting all day.

 

 

 

How to Assess Thoracic Mobility

The latest Inner Circle webinar recording on How to Assess Thoracic Mobility is now available.

 

How to Assess Thoracic Mobility

how to assess thoracic mobilityThis month’s Inner Circle webinar is on How to Assess Thoracic Mobility.  In this presentation, I’m going to show you how I assess thoracic mobility from multiple perspectives.  Many people have thoracic mobility restrictions and just blindly throwing thoracic mobility drills at them is going to be suboptimal without an accurate assessment.  Some need to focus on extension, some rotation, and others can move well, they just don’t!

This webinar will cover:

  • The key things I look at to assess thoracic mobility
  • How to integrate posture, thoracic movements, and functional movements
  • How to assess for compensation elsewhere when the thoracic spine is limited

 

To access this webinar:

 

Shoulder Impingement – 3 Keys to Assessment and Treatment

Shoulder impingement really is a pretty broad term that most of us likely take for granted.  It has become such a junk term, such as “patellofemoral pain,” especially with physicians.  It seems as if any pain originated from around the shoulder could be labeled as “shoulder impingement” for some reason, as if that diagnosis is helpful to determine the treatment process.

Unfortunately, There is no magical “shoulder impingement protocol” that you can pull out of your notebook and apply to a specific person. [Click to Tweet]

I wish it were the simple.

A thorough examination is still needed.  Each person will likely present differently, which will require a variations on how you approach their rehabilitation.

But the real challenge when working with someone with shoulder impingement isn’t figuring out they have shoulder pain, that’s fairly obviously.  It’s figuring out why they have shoulder pain.

 

 

Shoulder Impingement: 3 Keys to Assessment and Treatment

To make the treatment process a little more simple, there are three things that I typically consider to classify and differentiate shoulder impingement.

  1. Location of impingement
  2. Structures involved
  3. Cause of impingement

Each of these can significantly vary the treatment approach and how successful you are helping each person.

 

Location of Impingement

The first thing to consider when evaluating someone with shoulder impingement is the location of impingement.  This is generally in reference to the side of the rotator cuff that the impingement is located, either the bursal side or articular side.

shoulder impingement assessment and treatment

See the photo of a shoulder MRI above.  The bursal side is the outside of the rotator cuff, shown with the red arrow.  This is probably your “standard” subacromial impingement that everyone refers to when simply stating “shoulder impingement.”  The green arrow shows the inside, or articular surface, of the rotator cuff.  Impingement on this side is termed “internal impingement.”

The two are different in terms of cause, evaluation, and treatment, so this first distinction is important.  More about these later when we get into the evaluation and treatment treatment.

 

Impinging Structures

To me, this is more for the bursal sided, or subacromial, impingement and refers to what structure the rotator cuff is impinging against.  As you can see in the pictures below (both side views), your subacromial space is pretty small without a lot if room for error.  In fact, there really isn’t a “space”, there are many structures running in this area including your rotator cuff and subacromial bursa.

Shoulder impingement

You actually “impinge” every time you move your arm.  Impingement itself is normal and happens in all of us, it is when it becomes excessive or abnormal that pathology occurs.

I try to differentiate between acromial and coracoacromial arch impingement, which can happen in combination or isolation.  There are fairly similar in regard to assessment and treatment, but I would make a couple of mild modifications for coracoacromial impingement, which we will discuss below.

 

Cause of Impingement

The next thing to look at is the actual reason why the person is experiencing shoulder impingement.  There are two main classifications of causes, that I refer to as “primary” or “secondary”shoulder  impingement.

Primary impingement means that the impingement is the main problem with the person.  A good example of this is someone that has impingement due to anatomical considerations, with a hooked tip of the acromion like this in the picture below.  Many acromions are flat or curved, but some have a hook or even a spur attached to the tip (drawn in red):

shoulder impingement

 

Secondary impingement means that something is causing impingement, perhaps their activities, posture, lack of dynamic stability, or muscle imbalances are causing the humeral head to shift in it’s center of rotation and cause impingement.  The most simply example of this is weakness of the rotator cuff.

The rotator cuff and larger muscle groups, like the deltoid, work together to move your arm in space.  The rotator cuff works to steer the ship by keeping the humeral head centered within the glenoid.  The deltoid and larger muscles power the ship and move the arm.

Both muscles groups need to work together.  If rotator cuff weakness is present, the cuff may lose it’s ability to keep the humeral head centered.  In this scenario, the deltoid will overpower the cuff and cause the humeral head to migrate superiorly, thus impinging the cuff between the humeral head and the acromion:

evaluation and treatment of shoulder impingement

 

Other common reasons for secondary impingement include mobility restrictions of the shoulder, scapula, and even thoracic spine.  We see this a lot at Champion.  In the person below, you can see that they do not have full overhead mobility, yet they are trying to overhead press and other activities in the gym, flaring up their shoulder.

shoulder impingement mobility

If all we did with this person was treat the location of the pain in his anterior shoulder, our success will be limited.  He’ll return to gym and start the process all over if we don’t restore this mobility restriction.

The funny thing about this is that people are almost never aware that they even have this limitation until you show them.

 

 

Differentiating Between the Types of Shoulder Impingement

In my online program on the Evidence Based Evaluation and Treatment of the Shoulder, I talk about different ways to assess shoulder impingement that may impact your rehab or training.  There are specific tests to assess each type of impingement we discussed above.

The two most popular tests for shoulder impingement are the Neer test and the Hawkins test.  In the Neer test (below left), the examiner stabilizes the scapula while passively elevating the shoulder, in effect jamming the humeral head into the acromion.  In the Hawkins test (below right) the examiner elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, grinding the cuff under the subacromial arch.

Shoulder impingement tests

You can alter these tests slightly to see if they elicit different symptoms that would be more indicative to the coracoacromial arch type of subacromial impingement.  This would involve the cuff impingement more anteriorly so the tests below attempt to simulate this area of vulnerability.

The Hawkins test (below left) can be modified and performed in a more horizontally adducted position.  Another shoulder impingement test (below right) can be performed by asking the patient to grasp their opposite shoulder and to actively elevate the shoulder.

how to assess shoulder impingement

There is a good chance that many patients with subacromial impingement may be symptomatic with all of the above tests, but you may be able to detect the location of subacromial impingement (acromial versus coracoacromial arch) by watching for subtle changes in symptoms with the above four tests.

Internal impingement is a different beast.

This type of impingement, which is most commonly seen in overhead athletes, is typically the result of some hyperlaxity in the anterior direction.  As the athlete comes into full external rotation, such as the position of baseball pitch, tennis serve, etc., the humeral head slides anterior slightly causing the undersurface of the cuff to impingement on the inside against the posterior-superior glenoid rim and labrum.  This is what you hear of when baseball players have “partial thickness rotator cuff tears” the majority of time.

shoulder internal impingement

 

 

The test for this is simple and is exactly the same as an anterior apprehension test.  The examiner externally rotates the arm at 90 degrees abduction and watches for symptoms.  Unlike the shoulder instability patient, someone with internal impingement will not feel apprehension or anterior symptoms.  Rather, they will have a very specific point of tenderness in the posterosuperior aspect of the shoulder (below left).  Ween the examiner relocates the shoulder by giving a slight posterior glide of the humeral head, the posterosuperior pain diminishes (below right).

how to assess shoulder internal impingement

 

3 Keys to Treating Shoulder Impingement – How Does Treatment Vary?

There are three main keys from the above information that you can use to alter your treatment and training programs based on the type of impingement exhibited:

Subacromial Impingement Treatment

To properly treat, you should differentiate between acromial and coracoacromial impingement.  Treatment is essentially the same between these two types of subacromial impingement, however, with coracoacromial arch impingement, you need to be cautious with horizontal adduction movements and stretching.  This is unfortunate as the posterior soft tissue typically needs to be stretched in these patients, but you can not work through a pinch with impingement!

A “pinch” is impingement of an inflamed structure!

Also, I would avoid elevation in the sagittal plane or horizontal adduction exercises.

 

Primary Versus Secondary Shoulder Impingement

This is an important one and often a source of frustration in young clinicians.  If you are dealing with secondary impingement, you can treat the persons symptoms all you want, but they will come back if you do not address the route of the pathology!

I do treat their symptoms, that is why they have come to see me.  I want to reduce inflammation.  However, this should not be the primary focus if you want longer term success.

This is where a more global look at the patient, their posture, muscle imbalances, and movement dysfunction all come into play.  Break through and see patients in this light and you will see much better outcomes.

A good discussion of the activities that are causing their symptoms may also shed some light on why they are having shoulder pain.  Again, using the example above, if you don’t have full mobility and try to force the shoulder through this tightness you are going to likely cause some issues.  This is especially true if you add speed, loading, and repetition to elevation, such as during many exercises.

 

Internal Impingement

One thing to realize with internal impingement is that this is pretty much a secondary issue.  It is going to occur with any cuff weakness, fatigue, or loss of the ability to dynamically stabilize.   The athlete will show some hyperlaxity in this athletic “lay back” shoulder position.  Treat the cuff weakness and it’s ability to dynamically stabilize to relieve the impingement.  How to treat internal impingement is a huge topic that I cover in a webinar for my Inner Circle members.

 

Learn Exactly How I Evaluate and Treat the Shoulder

If you are interested in mastering your understanding of the shoulder, I have my acclaiming online program teaching you exactly how I evaluate and treat the shoulder at ShoulderSeminar.com!

The online program at takes you through an online 8-week program with new content added every week.  You can learn at your own pace in the comfort of your own home.  You’ll learn exactly how I approach:

  • shoulder seminarThe evaluation of the shoulder
  • Selecting exercises for the shoulder
  • Manual resistance and dynamic stabilization drills for the shoulder
  • Nonoperative and postoperative rehabilitation
  • Rotator cuff injuries
  • Shoulder instability
  • SLAP lesions
  • The stiff shoulder
  • Manual therapy for the shoulder

The program offers 21 CEU hours for the NATA and APTA of MA and 20 CEU hours through the NSCA.

Click below to learn more!

large-learn-more

 

Working Core Training in 360 Degrees

The notion of core training has been around for years and years.  As far back as I can remember, people have been doing crunches, sit-ups, weighted side bends, and more.  You could walk into any gym in the world and probably see someone doing some sort of “core” exercise.

core training sit ups

Photo credit

Even today, there are still people performing sit-ups or some other variation in their training program.  But as we continue to learn more about the spine, these traditional core exercises may actually be disadvantageous.  According to Dr. Stuart McGill, a noted spine biomechanist from the University of Waterloo:

“The spine may be more prone to injury when they are in a fully flexed posture.”

Last time I checked, when someone is performing a sit-up, they are in a great deal of flexion.  

Many other studies by McGill and other researchers have been published on the increased risk of high repetition and/or loaded lumbar spine motion.  Since this research has been published, there has been a pendulum swing towards performing more neutral spine movements such as planks.

core training plank

In another study by Cholewicki and McGill in Clinical Biomechanics:

“One important mechanical function of the lumbar spine is to support the upper body by transmitting compressive and shearing forces to the lower body during the performance of everyday activities. To enable the successful transmission of these forces, mechanical stability of the spinal system must be assured.”

By performing some type of plank or neutral spine exercise, this can potentially train the core to transmit force from the upper body to the lower body or vice versa without compromising the spine.

Performing plank variations is great, but as humans, we move in multiple planes of motion.  Therefore, we need to train the core to function in all planes of motion.

 

Core Musculature

360 degree core trainingThere are many muscles that contribute to the functioning of a stable core position.  These muscles include:

 

  • Rectus Abdominis
  • Internal Obliques
  • External Obliques
  • Transverse Abdominis
  • Multifidi
  • Quadratus Lumborum
  • Diaphragm
  • Pelvic Floor
  • Latissimus Dorsi

There have been studies performed over the years saying that transverse abdominis or multifidi are the main stabilizers of the lumbar spine.  Study after study, many by McGill, have refuted that 1 or 2 muscles are the primary stabilizers of the spine.  McGill et al. in the Journal of Electromyography and Kinesiology found that:

“The collection of works synthesized here point to the notion that stability results from highly coordinated muscle activation patterns involving many muscles, and that the recruitment patterns must continually change, depending on the task.”

Therefore, when we are training or treating our clients, we should not be attempting to isolate one muscle we performing lifting tasks.  Some muscles may be more active than others in one task as compared to another.  Instead, we should be working to maintain a neutral spine position and to resist motion through the lumbar spine.

The McGill Big 3

McGill came up with a series of 3 exercises, entitled “The Big 3” to help teach and re-educate patients or clients returning from a low back injury on how to properly stabilize their spine.

They include:

McGill Curl-Up

Key Points:

  • Place finger tips under low back.
  • Maintain a neutral spine position at low back and neck.
  • Slightly lift shoulders off ground while maintaining spine position.

Bird Dog

Key Points:

  • Maintain a neutral spine.
  • Imagine you have a drink on your low back. Don’t let it spill

Side Plank

Key Points:

  • Start on your side in a hip hinged position (hips slightly flexed).
  • Bring hips forward, not up.

These exercises are great implements to add into the beginning of a strength and conditioning program or during a rehab program for someone returning from a low back injury.  But, these exercises are a foundation for movement.  If we are going to build core stability throughout, thence need to have a solid foundation as well as solid “walls and a roof.”

 

Core Training Progression

There are typically two functions of the core:

  1. Transmit force from the lower body to the upper body or vice versa.  
  2. Resist motion.  

For example, if you are a baseball player and are throwing or swinging a bat, you want to have some motion through your lumbar spine, but predominantly through the hips and thoracic spine.  If we try to stop motion at the lumbar spine, your effectiveness as an athlete will be subpar.

Don’t forget…  the spine needs to move.  This is something Mike has covered in his article Are We Missing the Boat on Core Training?

Regarding the other aspect of resisting motion, if you are going to pick something heavy up off the ground, you want to maintain a neutral spine posture so that your core can transmit force from your legs and into your arms as you lift to the implement.

We need to appreciate these two different situations as we program for our clients.

The three planes of movement that the core musculature works in is the:

  • Sagittal Plane
  • Frontal Plane
  • Transverse Plane

The sagittal plane is lumbar spine flexion and extension. The frontal plane is lateral flexion or sidebending.  The transverse plane is rotation to the right or left.

The following progressions are a big part of Mike Reinold and Eric Cressey’s Functional Stability Training For the Core program.

 

Anti-Extension Core Training

Anti-extension core training consists of the body’s ability to resist movement into lumbar spine extension or to slow down motion from a flexed position to neutral, or from neutral to extension.

Exercises that focus on anti-extension stability are:

RKC Plank

Key Points:

  • Pull your elbows toward your toes.
  • Squeeze your glutes as hard as you can.
  • Maintain a neutral spine.

TRX Fallouts

Key Points:

  • Maintain a neutral spine.
  • Tuck tailbone/bring belt towards chin.
  • Slide arms out while keeping neutral spine.

Farmer’s Carries

Key Points:

  • Hold relatively heavy weight in each hand.
  • Ribs down/neutral spine.
  • Walk.  Don’t lose neutral spine posture as you walk.

Dead Bugs

Key Points:

  • Flatten low back to ground so that spine is neutral.
  • Bring right arm overhead and left leg out away from body.
  • Do not lose neutral spine position.  Return to starting position.
  • Repeat on other arm/leg.

Tall Kneeling Anti-Extension Press

Key Points:

  • Setup cable at head height when in tall kneeling.
  • Maintain a neutral spine and press cable overhead.
  • Cable will try to pull you into extension.  Don’t let it.
  • The only thing moving should be your arms.

Anti-Lateral Flexion Core Training

Anti-lateral flexion core training consists of the body’s ability to resist movement into lumbar spine lateral flexion to the right or left or to slow down motion from a flexed position to neutral, or from neutral to the opposite laterally flexed position.

Exercises that focus on anti-lateral flexion core stability are:

Suitcase Carries

Key Points:

  • Hold weight in one hand.
  • Do not let weight pull you out of a tall, neutral posture.
  • Don’t overcompensate to and flex to the opposite side.
  • Walk.

Side Planks

Key Points:

  • Start on your side in a neutral spine, slightly hips flexed position.
  • Maintain neutral spine and bring hips forward.
  • Maintain a straight line from your head, shoulders, spine, hips, knees, and ankles.

Racked Carries

Key Points:

  • Maintain a tall posture similar to the suitcase carries.
  • Walk.

Anti-Rotation Core Training

Anti-rotation core training consists of the body’s ability to resist movement into lumbar spine rotation to the right or left or to slow down motion from a rotated position to neutral, or from neutral to a rotated position.

Exercises that focus on anti-rotation core stability are:

Anti-Rotation Press

Key Points:

  • Start behind cable arm.
  • When you press your hands away, don’t let the machine rotate you.  Maintain a neutral spine.
  • Perform facing both directions.

1/2 Kneeling Chops

Key Points:

  • Leg closest to the machine should be up.
  • Bring arms down and across your body to you far side hip.
  • Only move head and arms.
  • Perform on both sides.

1/2 Kneeling Lifts

Key Points:

  • Leg closest to machine should be down.
  • Same cues as chops, but bring cable to far side shoulder.

TRX Anti-Rotation Press

Key Points:

  • Feet should be in tandem.
  • Maintain a neutral spine position.
  • Don’t let your body rotate or sidebend during press.
  • Perform on both sides.

 

Multi-Planar Movements and Rotational Sport Athletes

Once the body has mastered the basic core progressions and anti-movement-based drills, it is important to incorporate multi-planar and rotational movements.  These movements work on incorporating movement through the hips and thoracic spine versus some of the movements before where basically no movement was occurring.

As mentioned before, these exercises will help the athlete and client to control themselves going from one position to another.  As a rotational sport athlete, we don’t want to completely limit any spine motion.  We want the body to be able to control and decelerate the body using the musculature versus passive restraints (ie. bone, ligament, etc.) at end range.  These can also be used by non-rotational sport athletes as well.

Sledgehammer Hits

Key Points:

  • Bring the sledgehammer up over one shoulder.  Don’t let it bring you into lumbar extension.
  • Hit the tire while maintaining a neutral spine.
  • Alternate per side.

Medicine Ball Overhead Slams

Key Points:

  • Raise the medicine ball overhead.
  • Avoid going into lumbar extension.
  • Slam the ball to the ground while maintaining a neutral spine.

Medicine Ball Overhead Rotational Slams

Key Points:

  • Bring the ball up overhead.  Don’t let it bring you into lumbar extension.
  • Throw while maintaining a neutral spine.

Medicine Ball Scoop Toss

Key Points:

  • Load your back leg with your weight.
  • Transfer weight quickly from back to front leg.
  • Majority of the motion should be coming from the thoracic spine and hips.
  • Perform on both sides.

Medicine Ball Shotput Toss

Key Points:

  • Load medicine ball at shoulder height.
  • Load back hip/leg.
  • Quickly drive off back leg and twist through hips/thoracic spine.
  • Perform on both sides.

 

Breathing and Core Training

Implementing breathing with core training is very important.  If we are constantly holding our breath while performing core exercises, then we are compensating using the valsalva maneuver versus training the musculature to have to stabilize throughout the exercise.

Related Articles:

*Disclaimer*: if you have heavy weight in your hands or on your back in the cases of a deadlift or squat, then I am a proponent of using the breath to brace the core and spine.  When it comes to core exercises as mentioned above, remember to breath.  

With the said, here are a couple of exercises where implementing the breath adds another component to the movement.

Anti-Rotation Press with Full Exhale

Key Points:

  • Same as before with Anti-rotation Press.
  • Complete full exhale when hands are out in front of your body.
  • Maintain proper form during exhale and inhale.

Prone Plank with Full Exhale

Key Points:

  • Same as before with Plank.
  • Complete full inhale and exhale without losing form.

 

Strength Training and Core Stability

Lastly, we can’t go through an entire article and not discuss the use of core stability and strength training.  I am a firm believer that just performing squats and deadlifts are not enough to improve core and trunk stability.  Adding some of the movements mentioned above can add another component to create a well-rounded training program.

When it comes to performing squats, deadlifts, etc., maintaining a neutral spine during the lifts is extremely important.  Yes, there are some elite level lifters out there who can sway away from a neutral position in one direction or the other.   For the vast majority of people performing strength movements such as these, a neutral spine should be maintained.

There you have it.  By incorporating core stability exercises throughout all planes of motion, it will allow your clients and/or athletes to reduce their risk for injuries as well as improve their performance.

 

Learn More About Core Training

If you want to learn even more about functional core training, check out Mike Reinold and Eric Cressey’s Functional Stability Training for the Core.  The program goes over many of these progressions and a whole lot more to help you completely understand the true role of the core and how to incorporate functional core training into your rehab and strength training programs:

 

About the Author

andrew_millettAndrew Millett is a Boston-based physical therapist in the field of orthopedic and sports medicine physical therapy.  He helps to bridge the gap between physical therapy and strength and conditioning.  Visit his website at AndrewMillettPT.com.