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The Truth About Shoulder Impingement: Part 2

Written on November 30, 2008 at 6:36 pm, by Eric Cressey

In Part I, I went into some detail on why I really didn’t like the catch-all term “shoulder impingement.” This week, I’m going to talk about the different kinds of shoulder impingement: external and internal.

External impingement, also known as outlet impingement, is the one we hear about the most. Here, we’re dealing with compression of the rotator cuff – usually the supraspinatus, and over time, the infraspinatus (and biceps tendon) – by the undersurface of the acromion. This impingement can lead to bursal-sided rotator cuff tears – and happens a lot more with ordinary weekend warriors and very common in lifters (not to mention much more prevalent in older populations.

External impingement can be further subdivided into primary and secondary classifications. In primary impingement, the cause is related to the acromion – either due to bone spurring or congenital shape. As you can see in the photo below, hook (II) and beak (III) are worst than flat (I), as there are marked difference in “clearance” under the acromion.

Secondary impingement, on the other hand, is usually related to poor scapular stability (related to both tightness and weakness, as described in last week’s newsletter), which alters the position of the scapula. In both cases, pain is at the front and/or side of the shoulder and is irritated with overhead activity, scapular protraction, and several other activities (depending on the severity of the tissue problems). You’ll also generally see a lack of external rotation range-of-motion, as these are folks who do too much bench pressing and computer work (both of which shorten the internal rotators).

Conversely, internal impingement, also known as posterosuperior impingement, really wasn’t proposed until the early 1990s. This form of impingement is more common in younger individuals who are involved in overhead sports, making it more of an “athletic impingement.” Adaptive shortening and scarring of the posterior rotator cuff in these athletes causes a loss of internal rotation and an upward translation of the humeral head during the late cocking phase of throwing (or swimming): external rotation and abduction.  These issues are magnified by poor scapular control, insufficient thoracic rotation, and weakness of the rotator cuff.

When the humeral head translates superiorly excessively in this position, it impinges on the posterior labrum and glenoid (socket), irritating the rotator cuff and biceps tendon along the way. So, pain usually starts in the back of the shoulder, as you are seeing irritation of the posterior fibers of the supraspinatus and anterior fibers of the infraspinatus tendons. Gradually, this pain may “shift” toward the front as the biceps tendon, and that implies labral involvement.  At least initially, the pain is purely mechanical in nature; it won’t bother an athlete unless the “apprehension” position (full external rotation at 90 degrees of abduction) is created.

We often hear about SLAP lesions in the news. This refers to a superior labrum, anterior-posterior injury. In reality, when we are talking about labral injuries in overhead athletes as they relate to internal impingement, it’s mostly just posterior (although serious cases can eventually affect the anterior labrum, too). There are different kinds of SLAP lesions (1-4). Every baseball pitcher you’ll meet has a SLAP 1, which is just fraying. SLAP 2 lesions are far more serious and often require surgical intervention. SLAP 1 issues become SLAP 2 lesions when poor mobility and dynamic stability aren’t established.

 

So, just to bring you up to speed, we’ve got two different kinds of impingement, one of which (external) has two subcategories that mandate different treatment strategies (primary = surgery, secondary = corrective exercise). We also have two separate areas where pain presents (external = front/side, internal = back). That’s just the tip of the iceberg, though, as we have two more considerations…

First, symptomatic internal impingement tends to be “mechanical pain.” Unless you’re dealing with a more advanced case, athletes with symptomatic internal impingement only have pain when they get into the late cocking phase (and sometimes follow-through). It usually isn’t present when they’re just sitting around – and for this reason, they can usually be more aggressive in the weight room with upper body training. Keep in mind that I use the term “symptomatic” because I think that internal impingement is a physiological norm, just like I observed last week with external impingement.  You’re essentially just going to go out of your way to avoid this “apprehension” position in the weight room by omitting exercises like back squats.  An apprehension test – illustrated in the most enthusiastic video in internet history – is a quick and easy assessment many doctors and rehabilitation specialists use to check for symptomatic internal impingement, as it reproduces the injury mechanism.

 

Second, and perhaps more importantly, you are dealing with two rotator cuff tears that are fundamentally different. It’s these differences that make me think doctors need to get rid of the term “impingement.” Here’s the scoop:

Let’s say that we have two guys with partial thickness tears of the supraspinatus – one from external impingement and one from internal impingement.

With external impingement, we’re usually dealing with a bursal-sided tear, as the rubbing comes from the top (acromion). These issues will generally heal more quickly because the bursa actually has a decent blood supply.

With internal impingement, on the other hand, we’ve got an articular-sided tear, meaning that the wear on the tendon comes from underneath (glenoid). The tear is more interstitial in nature. Blood supply isn’t quite as good in this area, so healing is slower (or non-existent).

Traditionally, articular has been an athletic injury, and bursal has been a general population issue. This is not always the case, though.

Factor in the activity demands of overhead throwers, and they have more challenging tears and greater functional demands. Fortunately, they also typically have age and tissue quality on their sides, so things tend to even out.

With all these factors in mind, if a doctor ever tells you that you have “shoulder impingement,” ask:

1. Internal or external?

2. If external, is it primary or secondary? (It’ll probably be both)

3. If internal, is there labral involvement? Biceps tendon?

4. If internal, what is the internal rotation deficit? (They should measure it, as this will begin to dictate the rehabilitation plan)

5. Given my age, activity level, and the nature of the tear, do you feel that surgical or conservative treatment is best?

shoulder-performance-dvdcover

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Random Friday Thoughts: 11/28/08

Written on November 28, 2008 at 7:00 am, by Eric Cressey

I’m writing this blog on Tuesday night, as I’m pretty sure that my mind will be a bit hazy after the insulin-induced coma that follows my Thanksgiving feast.

1. While I’ve had a week-long argument with my new website set-up, I have to say that one of the cool features I now have is a really detailed analytic panel to look at hits, referring sites, and the keywords people used in their searches to find my site.  Believe it or not, 6.8% of my readers can’t spell my last name correctly in a web search.  So, just to be clear, it’s “CRESSEY,” not “CRESSY.”  The extra “E” stands for excellence, in case anyone was wondering.  Stop laughing.

2. I work with two pro ballplayers who were drafted out of Harvard, and the other day, we got to talking about how I had finally gotten DVR on my TV (mostly for my girlfriend, to be honest).  They started talking about how it’d be nice to be able to fast-forward through the commercials, and I commented on how that parallels what I do with educational DVDs.  You see, I just push fast-forward and listen to things in about half the time it would take to hear the entire thing.  I still comprehend everything – kind of like this guy:

They were kind of floored that I could do that – although I’m really not sure why.  I’d be willing to bet that there were a lot of students at Harvard who are a lot more cyborg-ish than I am.

3. For the record, this strategy comes in handy when listening to presenters with Midwestern and Southern accents.  I employed it with great success when viewing the 2008 Indianapolis Performance Enhancement Seminar DVD Series, as that Robertson character is one……..sloooooooowwwww……talker.

Kidding aside, this was a fantastic seminar; I’d highly recommend you pick up a copy.  I actually reviewed it in detail in a previous blog entitled The Best Thing I’ve Seen All Year.

4. Eric Chessen has a new blog about Autism Fitness.  Definitely check it out at www.Autism-Health.com if that’s your cup of tea.  Eric’s at the head of his field in this regard.

5. I’m going to be writing a new article for T-Nation this weekend.  And, while I have some ideas on what I am going to write, I’m always open to suggestions.  If you have one, please post it as a comment on this blog and I’ll see what I can do.

6. HERE is an interesting new study I just read that talks about performance decrements with subtle sleep deprivation.  These results seem to suggest that if you’re going to miss hours of sleep, it is better to do so by going to bed later than it is to do so by rising earlier.  We always teach our athletes that one hour of sleep before midnight is worth two after midnight, so these results would seemingly fly in the face of our recommendations. However, these recommendations assume no sleep deprivation.  In other words, I’d rather have an athlete sleep 11pm-7am than I would have him sleep 2am-10am.

Just a quick one this week in light of the holiday. Have a great weekend!


Unstable Surface Training for Hockey

Written on November 26, 2008 at 8:00 am, by Eric Cressey

In a blog last week, I discussed how important it is to differentiate between unstable surfaces and destabilizing torques applied further up the kinetic chain, as they comprise different kinds of instability training.

I receive a great question in response to the blog:

“Eric, what do you think about unstable surface training for hockey? I’ve been using half-dome stability balls for a long time now in many settings (high school through college) with my trainers. I can’t tell if the effect wouldn’t be the same if I were doing something else but skates do wobble under weak players when pivoting and stopping quickly under loads up to 2-3 times body weight, and ankles do adjust to become more stable after training like this. What’s your experience? Thanks, Boris”

It’s an interesting case, as the blade of a hockey skate is certainly different than regular flat surface.

Even more interestingly, though, is that Boris – through his question and also his personal experience – has directly highlighted some important research that was done in this regard.

In 2005, Behm et al. (1) examined the correlation between hockey skating speed and performance on a 30-second wobble board test. Interestingly, they found a significant correlation in players under the age of 19. However, no such correlation existed with players age 19 and older. So, how does this occur?

Here’s an analogy: go to a little league park, and find the kids who have the best fastball velocity. Chances are that they are also the kids who run the fastest, jump the highest, do the most chin-ups – or any other physical test that you throw at them. Very simply, this difference can easily be attributed to different levels of motor development in young skaters.  Heck, with just a quick Google search for “youth hockey,” I came across this picture.

You’ll notice that the physical development is markedly different across the board.  In fact, the 6-4, 230-pound goalie drove all the other 11-year-olds to the game, taught them how to shave, and then hit on all the hockey moms after the game at the local bar.

Moving back to the aforementioned Behm et al. study, the researchers noted, “The complex skills associated with skating would necessitate a more refined balance that would improve with maturity and perhaps training. Since skating is performed on a very small surface area (blade) in contact with a low friction surface, younger individuals with greater stability may have an advantage in executing the specific skating skills” (1).

So, in reality, we’re comparing physical development and not necessarily performance on a specific test – until we level the playing field and physical maturity is roughly equal for everyone (after the age of 18). At that point, you don’t see a correlation, so I’d be very reluctant to endorse lower-body unstable surface training as a useful training implement for hockey outside of specific rehabilitation situations.

Also, to take this a step further, I need to make a clarification with respect to this statement from the original question: “ankles do adjust to become more stable after training like this.”  This should actually be rephrased as “previously injured ankles do adjust to become more stability after training like this.”  The truth is that nobody has really verified the incremental benefit of such training in healthy ankles (read: no previous history of injury) with a truly functional outcome measure.

The long-term studies examining the issue have been poorly controlled in the sense that they’ve looked at ankle sprains over the course of an extended period of time with an unstable surface training intervention, but haven’t taken into account previous history  of injury.  So, the athletes engaged in the unstable surface training group may simply have been rehabilitating previous ankle injuries with longstanding functional deficits rather than “fortifying” already healthy ankles to prevent injuries.  Interestingly, in one study of elite female soccer players, balance board training did not decrease the rate of traumatic lower extremity injuries.  The frequency of major injuries – including four of five anterior cruciate ligament tears – was actually higher in the intervention (unstable surface training) group than the control group (2).

For more information, check out my new e-book, The Truth About Unstable Surface Training.

References:

1. Behm, DG, Wahl, MJ, Button, DC, Power, KE, and Anderson, KG. Relationship between hockey skating speed and selected performance measures. J Strength Cond Res. 19(2):326-31. 2005.

2. Soderman, K, Werner, S, Pietila, K, Engstrong, B, and Andredson, H. Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players: a prospective randomized intervention study.  Knee Surg Sports Traumatol Arthrosc. 8(6):356-63. 2000.

New Blog Content

Random Friday Thoughts
Unstable Ground or Destabilizing Torques
Built for Show

That’ll do it for this newsletter.

All the Best,

EC


Built for Show

Written on November 26, 2008 at 6:00 am, by Eric Cressey

You’ve probably come across Nate Green’s name over the past few years – either in my newsletter/blog or at T-Nation.  He’s established himself as a guy who knows his stuff, but also has a great writing style that is both entertaining and informative.  And, most specific to the product in question, Nate looks a lot of issues that nobody else considers.

I was fortunate to get an advanced copy of his new book, Built for Show, and I really enjoyed it.  The program itself is fantastic.  Those of you who enjoyed my Maximum Strength book would like it as a follow-up program, particularly if you’re interesting a bit more interested in the physique side of things than pure performance benefits.  The program includes four unique training phases to keep your progress moving full-speed ahead.

And, for those of you who haven’t picked up a woman since the Reagan administration, you’d be wise to take Nate’s advice.  Nate discusses the psychology of attraction quite a bit, and it’s actually really interesting stuff.  I will be the first to admit that I never had much (if any) game with the ladies, so I’ll defer to the expert (Nate) to elaborate on this crucial point from the book:

Take a look at the current men’s magazines and notices what’s on the covers.  You’ll see a ton of references to biceps, ripped abs, and a bigger chest – but those are three body parts women don’t really care about as much as you’d think.  If you go back in time, you’ll find that women are biologically programmed to be attracted to men who show more status and dominance.  One way to show that dominance is to have an imposing, strong body.  Take a look at your training and ask yourself why you’re doing what you’re doing.  I know this might sound sacrilegious, but maybe your question for the ultimate six-pack, biggest guns, or becoming so big that you frighten small children aren’t the greatest goals for you after all.  If you want girls, and you want a capable, athletic, muscular body, then Built for Show was written for you.

Check it out, folks; at less than $14, you can’t go wrong – at the very least for a very entertaining read:

Built for Show


FFL Week 12: Greg Tops Gregg

Written on November 25, 2008 at 12:08 pm, by Eric Cressey

I knocked off Gregg T. this week in fantasy football, 84-56, to bring my winning streak to three and catapult (yes, it was that dramatic) myself into a three-way tie for second place in our league at 7-5.  It was pretty redeeming, as Gregg talked a lot of smack a few weeks ago when he heard that I was terrible at bowling.

You see, Gregg’s bowled a few 800+ games (he defies conventional bowling scoring systems) and has enjoyed all the fame and fortune that goes along with dominating in a sport with so much international acclaim.  In fact, each time he walked from the car to Cressey Performance to train, he was swarmed by adoring fans.  He’d usually walk in the door, gather up all the women’s underwear that had been thrown at him, sign a few autographs, and then get his lift on.

This week however, Gregg T. was outdone by Greg J – Jennings, that is.  If you didn’t see it, Jennings (a Green Bay WR who carried my team this week) put on a show last night in spite of his team getting beaten like a rented mule.  And, he held on to this pass, where his helmet strap was permanently implanted in his cerebellum.

Fortunately, Gregg redeemed himself when he sent along this article to me for blog material:

Obese Have Right to 2 Airline Seats

Apparently, if you’re “functionally disabled by obesity,” you can get two airline seats for the price of one.  Yes, you read that right: being heftier affords you extra luxuries (most notably, avoiding the possibility of ever having to sit next to another obese person, which is something that I think would convince anyone to lose weight).

It will be interesting to see if they go by Body Mass Index (BMI), which will probably rank every individuals who is actually dedicated to lifting weights as obese.  At 5-8. 190-195, I am literally on the border between “overweight” and “obese.”  Forget First Class; I’m flying Fat A**!

Kidding aside (okay, not really; I’m never serious), this opens us up to a lot of dangerous precedents that could be the fallout from this court ruling:

1. Smelly people get two deodorants for the price of one.
2. Folks who are seven feet tall get to go on the amusement park rides twice because they’re twice as tall as the minimum height.
3. People who are soft tissue nightmares get two massages for the price of one (as if massage therapists aren’t burning out too fast already)

This list could go on and on.  Dangerous precedent, indeed.

Thanks for the link, Gregg.  Sorry I had to inflict such violent fantasy football dominance on you.


Dr. William Brady: Integrated Diagnosis

Written on November 25, 2008 at 9:29 am, by Eric Cressey

This past weekend, I attended a great seminar here in Boston with Dr. William Brady.  In fact, it was among the best I’ve seen.  I was the only non-chiropractor/manual therapist in attendance, but walked away from the seminar with some tremendously valuable insights that’ll help me with each and every one of my clients moving forward.

The first lesson of the day is that those of you who have an opportunity to see Dr. Brady speak should absolutely, positively check him out: Integrated Diagnosis.  Diagnostically, he’s among the best I’ve ever seen – and that includes his ability to teach others.

The second lesson of the day revolves around an important concept Dr. Brady extended – and my take on how you can modify this message to accommodate your role as a coach, trainer, or fitness enthusiast/athlete.  There is a reason that almost any doctor or physical therapist gets results – and it resolves around understanding where symptom threshold occurs.  To illustrate this, let’s examine a shoulder problem purely from a soft tissue perspective.

Dr. Brady talked about how you have building blocks to threshold.  Let’s say that after an accurate physical examination, this particular shoulder problem (supraspinatus tendinosis, for example) presents with soft tissue restrictions at the infraspinatus, teres minor, subscapularis, inferior capsule, and pec minor.  So, symptom threshold (the dotted line) might look like this relative to baseline (straight line):

Pec Minor
– – – – – – – – – – –
Inferior Capsule
Subscapularis
Teres Minor
Infraspinatus
BASELINE – NO SYMPTOMS

So, imagine a therapist who just addresses pec minor.  He gets that patient below threshold, but doesn’t necessarily “fix” him; he might be back in with the same problem weeks later.  This is confounded by the fact that “overuse” is actually one of the building blocks, too.  So, even if you leave all the soft tissue restrictions alone, simply resting will get someone below threshold – even if the therapist has done ZERO to address the underlying problems.

This is one reason why a MRI might not tell you much at all about someone’s problem.  With this problem, the MRI would probably just say “supraspinatus tendinopathy” and recommend physical therapy and rest from painful activities.  So, in the “full picture” – where soft tissue work is one of several components (assume they are equal contributors, for the sake of our argument) – the building blocks to threshold might look something like this:

Overuse
Rotator Cuff Weakness
Scapular Stability
Poor Glenohumeral (Ball-and-Socket) Range of Motion
– – – – – – – – – – – – – – – –
Soft Tissue Restrictions
Poor Thoracic Spine Mobility
Type 3 Acromion (non-modifiable, without surgery)
Poor Exercise Technique
Poor Cervical Spine Function
Opposite Hip/Ankle Restrictions (baseball pitchers are great examples)
Inappropriate Structural Balance in Programming (e.g., pressing more than pulling)
Faulty Breathing Patterns
BASELINE – NO SYMPTOMS

So, we’ve got 12 factors, and it’s been my experience that conventional physical therapy only treats the first four – which would, in fact, bring a patient below symptom threshold.  Put that patient back in the real-world with the other eight factors still present (seven of which are modifiable), and as soon as he gets back to bench pressing with terrible technique Monday, Wednesday, and Friday, he’s going to be back in for more physical therapy sooner than later.

So, what do we do in an ideal scenario (not always possible with today’s insurance plans)?

1. More time with patient education (exercise technique, programming strategies – or just outsource it to a qualified professional or good book/article or DVD).
2. Address Thoracic Mobility (Assess and Correct is a great resource for this)

Layout 1


3. When present, address Hip and Ankle Mobility
4. Retrain some breathing patterns with initial instructions home exercises
5. Provide some take-home neck drills and get people out of chronic forward head posture

All told, I think this could be as simple as 4-5 extra drills in each shoulder rehab program plus a brief sit-down conversation with each patient on exercise program modifications; it really is that simple.  Unfortunately, it rarely happens – and that’s when things become chronic.

So, fitness professionals and coaches need to step up as advocates for their clients and athletes, respectively, and fitness enthusiasts need to be relatively informed “consumers” to look out for themselves.


New Blog Content

The Mainstream Media Lag
Why Wait to Repair an ACL?
(Abbreviated) Random Friday Thoughts

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Unstable Ground or Destabilizing Torques

Written on November 24, 2008 at 6:30 am, by Eric Cressey

I don’t watch a ton of TV, but when I do, it’s almost always sports – be it football, baseball, basketball, or just regular ol’ Sportscenter.  Likewise, when I’m at working, I’m constantly coaching athletes from a variety of sports on everything from weight-training, to flexibility, to sprint mechanics, to medicine ball throwing techniques.

Everywhere you look, you’ll see destabilizing torques.  Maybe it’s a running back trying to fend off a tackler; his feet are fixed while the destabilizing torque (the force applied to his body by that tackler) occurs further up the kinetic chain.

Or, maybe it’s an athlete doing a suitcase deadlift.  The load in his hand is a destabilizing torque that attempts to shift him into lateral flexion as contralateral core musculature fires to keep him erect.  Again, the feet are on stable ground.

You’re probably getting my point by now.  Our lower extremities operate in predominantly closed-chain motion on stable surfaces in the real world – and the destabilizing torques we encounter further up the kinetic chain are truly functional instability training.

Conversely, when was the last time you saw the ground move on a fixed athlete?  Perhaps the earthquake during the San Francisco-Oakland World Series in 1989?  It’s a long shot at best.

With that in mind, why are we universally accepting unstable surface training in the lower extremity?  We know it has merit in the rehabilitation of functional ankle instability, but to assume that benefits would also be conferred on a healthy population is a dangerous.  That’s where we came in with my research back in 2005 – and it’s why I’ve got a great frame of reference for writing a book that discusses true core stability training and the appropriate and inappropriate applications of unstable surface training.  At risk of sounding overconfident, if you coach or rehabilitation athletes or regular fitness enthusiasts, The Truth About Unstable Surface Training is an important read for you.


Maximum Strength F.A.Q.

Written on November 23, 2008 at 3:40 pm, by Eric Cressey

Frequently Asked Questions

Q: I’m unsure about pre-testing some of these lifts heavily when I haven’t been performing them for an extended period of time to learn the technique. What do you recommend?

A: I’m not married to the idea of having everyone pre-test.  In the grand scheme of things, this program is based on the premise that you have some resistance training experience – but are looking to take it to the next level. That said, I realize that a lot of beginners are going to be buying this book, too – so we need to take that into account, particularly with pre-testing. If you’re in this situation, you have four options:

1. Spend 3-4 weeks practicing technique – following the descriptions in Maximum Strength – and then pre-test with conservative weights.

2. Skip pre-testing altogether – and just go directly into the program with conservative weights.

3. Test as recommended in the text – but only do those exercises on which you know you’ll be okay (broad jump, bench press, and 3-rep max chin-up). Then, do your squat and deadlift with conservative weights – stopping if you feel any sort of technique breakdown (although you should always stop your attempts if technique breaks down).

If you are at all uncomfortable doing one of the pre-tests, skip it.

Q: Do you have any recommendations of good online sites where I can download videos of various exercises?

A: Absolutely!

Robertson Training Systems

Exrx.net

UW-LAX

UI Strength Lab

Weight Trainers United

Q: I noticed that you recommend wearing shoes on some lower-body exercises, but not others. Can you put some general guidelines in place?

Category 1: No Shoes, or shoe that has little heel-lift (e.g., Nike Frees, Reebok Travel Trainers, Chuck Taylors/Converse All-Stars):

Mobility/Activation warm-up drills, all box squat variations, all deadlift variations, 1-leg squat-to-box

Category 2: Any shoes (that said, I like Nike Frees as a shoe you can use for both categories)

All single-leg movements (excluding 1-leg squat to box), all non-box squats

Q: I lack the flexibility to deadlift from the floor; what do you recommend I do to a) modify the program and b) work on my flexibility?

A: First off, you can elevate the bar until you get to the point where you can pull in good form. In other words, instead of all the pulling from the floor, do rack pulls.

As far as flexibility goes, you’ll need to do more of the various ankle mobilizations, overhead lunge walks, and thoracic extensions on the foam roller. I’d also highly recommend that you check out my three-part series, Mastering the Deadlift (you can find links to all three in the T-Nation section HERE).

Q: I tend to round over when I front squat. Any suggestions?

A: It could be several things: poor ankle, hip, or thoracic spine mobility; poor core stability; poor bar position; or faulty breathing patterns.

For the mobility issues, you can follow the suggestions for the deadlift flexibility issue above.

For core stability, keep plugging away at the core stability progressions in the book – and keep practicing your squat technique. That will come in a matter of time.

For your bar position, make sure that you’ve got it up on your shoulder girdle – and not just on your upper arms. It should be touching your Adam’s apple (or equivalent spot, ladies).

For your breathing patterns, make sure that you’re getting your air into your belly, not your upper torso. “Chest breathers” lack core stability, in my experience. Your goal is to make yourself a bit fatter by activating the core musculature and increasing intra-abdominal pressure with air in the right place; this mechanically makes the support for the load on your shoulders even bigger. A good trick is to imagine that you’re wearing a loose belt around your belly, and you want to tighten it up.

Q: The Maximum Strength program is a 4x/week program and you recommended lifting on MoWeFrSa; is it okay to deviate from this?

A: Sure.  My favorite is to lift on Days 1, 2, 4, and 6 – with rest days on Days 3, 5, and 7 (these might be energy workouts for you instead of lifts).  As long as the days are held constant, it doesn’t really matter whether Day 1 is Monday or Friday.  Some people can’t train on the weekends, too, so it’s cool to go MoTuThFr, if you want.

Q: For my foam rolling, how long should I spend on each spot?

A: Generally, you should be at about 10-15s per spot – and make sure you spend a little extra time on any of the “hot spots” you find. That said, if a region isn’t at all uncomfortable, you can skip right over it eventually.  For a little more background, give this article a read.

Q: Also on the topic of foam rolling, I noticed that there are several different kinds of rollers. Which do you recommend?

A: At Cressey Performance, almost everyone is okay starting with the Foam Roller Plus.  Some people who are really balled up might need to start with a basic (soft) white roller.

Q: I lift weights with my upper body, but just run to take care of lower body strength.  Is this okay?

A: Not if you are hoping to build strength and an impressive physique!  How many marathoners do you know with impressive legs?  Not many.  And, to be honest, just because they run doesn’t mean that they don’t need lower-body weight-training.  I actually wrote an in-depth article on the subject HERE.  That said, do your lower body lifting sessions.

Q: You recommend board presses, but I don’t have boards – or someone to hold them. What should I do?

A: First off, I’m a big believer in always making sure that you have a spotter handy when you bench press.  Hopefully, that’s something that you can make happen.

A few options for board-substitutions include using a rolled-up magazine or a foam roller cut-in-half.  If you can’t do these – and don’t have someone to hold them in place, you can just do pin presses (as outlined in the text) instead.

Q: What should I do if I miss a day?

A: Call it water under the bridge and pick it up as soon as possible thereafter wherever you left off.  Often, you can make up a session within the week just by going back-to-back on days when you otherwise wouldn’t.  For instance, if you were planning to train MoWeFrSa and couldn’t make the Saturday session, you just push it back to Sunday.  I outlined some strategies for flexible training splits in my article, 4 Ways to Stay on Track.

Q: If I’m really pressed for time, can I skip the warm-up?

A: No.  I’d rather see you warm up thoroughly and knock a few sets off the end of your training session than I would have you skip a warm-up and get hurt lifting when your body wasn’t ready for loading.

Q: I’m used to lifting 6x/week; is it okay to add a few sessions to the Maximum Strength program?

A: It’s not a good idea.  You build muscle and develop strength while you’re resting, not while you’re training.  To that end, what you do aside from the sessions should be aimed at optimizing recovery, not pushing you further into “training debt.”  Try doing some of the low-intensity resistance training circuits and light cardiovascular work I recommend; you’ll be very pleased with how it helps to improve recovery – and makes gaining strength and muscle mass easier in the process.

Q: Can I substitute exercises I don’t like?

A: Well, then you wouldn’t be doing the Maximum Strength program, would you?

Kidding aside, if you have an injury or equipment limitation you have to work around, by all means, substitute.  However, if you’re just taking a movement out because you don’t like it, you’re shortchanging yourself.  99.99% of the time, the exercises we dislike are the ones we need to do the most to succeed.  Suck it up.

Q: Can I repeat the strength tests in the middle of the program to check my progress?

A: You’ll actually find that there are strength tests built in to the program.  They aren’t identical to your pre-tests, but will definitely give you regular indicators of whether you’re improving.  With that in mind, if you want to test a broad jump here and there, feel free.  And, if you’re feeling particularly “fast” with your speed deadlifts or squats, work up to a moderately heavy single to see how you progressed.  DO NOT do this every training session; “pushing it” once a month is okay, but nothing more frequent than that.

Q: I work with a personal trainer; can he help guide me through the Maximum Strength program?

A: I don’t see why not.  Then again, the personal training industry leaves a bit to be desired at this point – and you are paying them for their knowledge – so don’t be surprised if they aren’t amenable to supervising someone else’s program.

Q: How soon will I begin to see results?

A: Individual results vary, but they almost always come in this order: mobility, strength, physique changes.  You’ll notice that you’re moving better in a matter of days, and the strength gains will be readily apparent by the time you come back to repeat exercises in Week 2 of Phase 1.  Increases in muscle mass and decreases in body fat will be dependent on your diet, too, so if you’re diligent with your training and nutrition, you should see some noteworthy changes within the first 2-3 weeks.

Have a question for Eric to be featured in the FAQ or Maximum Strength Blog?  Email ec@ericcressey.com with the subject line “Maximum Strength Inquiry.”


Maximum Strength Bonus Page

Written on November 23, 2008 at 3:39 pm, by Eric Cressey

Maximum Strength Bonus Page

First off, thanks for your purchase of Maximum Strength, and congratulations on making the decision to take your training to an all-new level! The original “guinea pigs” for the program all experienced fantastic improvements in strength, overall athleticism, and body composition – and these trends have held true with everyone who has tried the program since the manuscript was complete.

What pleases me the most, though, is that everyone who has completed the Maximum Strength program has also changed their overall approach and attitude toward exercise. They’re not working out anymore; they’re training. And, they look forward to their trips to the gym because they can see quantifiable improvements and experience how this training carries over to their daily lives.

One of the ways in which this book is different than others you’ve read is its devotion to tech support – and continued education. Matt and I want to hear reader feedback, help you with your questions, and help you to continue to grow during and beyond your Maximum Strength experience. To that end, I’ve pulled together a list of related resources that will make it easier for you to carry out the Maximum Strength program:

Frequently Asked Questions – On this page, you review the Q&A for the questions we’re hearing the most.

The Official Maximum Strength Blog – This free resource is updated daily with Q&As, exercise demonstration videos, postings about various training-related topics, and product reviews.

Eric Cressey’s Free Newsletter – “EC” puts out a weekly newsletter that has grown exponentially in popularity since early 2006.

Magnificent Mobility – This DVD outlines many of the lower-body warm-up exercises outlined in the book. It’s like having a coach in the room with you – teaching you not only what to do, but what common mistakes to avoid.

Inside-Out – This DVD works much the same as the Magnificent Mobility DVD, but its focus is on the upper body warm-up exercises. It’s a fantastic resource for anyone with shoulder problems.

Precision Nutrition – This resource is far and away the single-best nutrition resource available in the world today. Dr. John Berardi is tremendous not only in his knowledge, but in the way he relates it understandably to his audience. I’ve seen countless people make excellent progress with Dr. Berardi’s methods – and it’s one reason why I was so honored to have him author the foreword to Maximum Strength.

Gourmet Nutrition Cookbook – Also a Berardi product, this resource outlines 120 healthy (and tasty) recipes for the fitness enthusiast who wants a good meal without ruining his/her diet.

PoweringMuscles.com – Founded by Matt Fitzgerald, Powering Muscles is a nutrition information resource for athletes and fitness enthusiasts, featuring in-depth articles, interactive tools, discussion forums, and more.

Perform Better – This equipment supplier has just about everything you could need in a gym. They are affordably priced and offer excellent customer service.

Maximum Strength for Life: Recommended Further Reading

Education is a huge part of continuing to progress. To that end, I’ve compiled a list of recommended resources for those of you who are interested in learning more; check out my Recommended Resources Page.


Unstable Surface Training

Written on November 23, 2008 at 3:38 pm, by Eric Cressey

Finally, the truth is revealed and you can fully grasp one of the most misunderstood and controversial aspects of the fitness industry…


Unstable surface training has taken the world of fitness and strength and conditioning by storm.   Everywhere you go, you’ll find wobble boards, foam pads, full and half-dome stability balls, and inflatable rubber discs dictating the way people exercise.

However, there has been very little research done to validate or refute the use of these implements in healthy, trained populations. Trainers, coaches, therapists, and ordinary weekend warriors have essentially been flying blind when they use these implements. That is, until now!

Do you want to know the truth?


The Truth About Unstable Surface Training is the culmination of more than three years of intensive study, research, experimentation, and analysis on my part – combined with my “in the trenches” observations as a competitive athlete myself. Effectively, with this e-book, I’ve outlined and then translated the research to the real-world so that fitness professionals and exercisers can understand how to effectively integrate (or omit) unstable surface training in their programs.

Here’s what a few industry leaders had to say about the product:

“I used to advise trainers and other strength professionals that they must always continue to develop themselves and continue their education by reading every book and article and attending every seminar – but I was wrong. My advice now is to be very selective with the resources you seek out and the research and products you obtain. There is so much misinformation in the fitness industry and so much junk on the internet that it’s easy to be misguided.

“So what is the right information? Without hesitation, I can say anything from Eric Cressey. His new e-book, The Truth About Unstable Surface Training, is no exception. Learn how unstable surface training originated in a rehabilitative setting and led to one of the biggest controversies in the fitness industry today. I was honored to get a first look at this resources. It was not just the literature review, studies, exercise demonstrations and progressions that were eye-opening; it was the practical applications. As always, Eric provides a thorough explanation of complex ideas.

“If you’ve ever found yourself – or come across someone – using the term “functional training,” you absolutely must buy The Truth About Unstable Surface Training right now!

Jim Smith, CSCS
Author, Combat Core: Advanced Torso Training

“In The Truth About Unstable Surface Training, Eric Cressey has created tremendous resource - and, in fact, the ONLY resource one should consult on the topic of unstable surface training. Eric’s writing sheds light on the correct and incorrect times to incorporate these training initiatives in one’s programming.

The best part of this manual? It covers both the scientific background AND the practical application of unstable surface training. If you’re a personal trainer, strength coach, or fitness enthusiastic who has used or contemplated using these mediums in your programming, you owe it to yourself to pick up this e-book.”

Mike Robertson, MS, CSCS, USAW
Author, Bulletproof Knees

What You’ll Learn in The Truth About Unstable Surface Training:

  • The origins of unstable surface training

  • The problems with research-to-date on unstable surface training, and why you’ve been mislead

  • The difference between balance and stability

  • The five factors affecting one’s stability, and how you can modify them to become a more stable athlete

  • How unstable surfaces alter muscular recruitment patterns – and how you can use those alterations to your advantage or disadvantage

  • The actual science – and research data – that quantifiably justifies or refutes specific uses of unstable surface training

  • Guidelines for when and how to implement unstable surface training to maximize training efficiency and help you avoid wasting time and effort

  • How unstable surface training can help or hinder performance in different athletes

  • How unstable surfaces can increase the risk of injury in some populations, while actually rehabilitating others

  • Guidelines for alternative, more sport-specific instability approaches when unstable surface training is not the best avenue to pursue

  • 21 different stability progression models encompassing over 50 exercises with photos and descriptions

  • How to train balance for maximum functional carryover and superior athletic performance

All in all, you get the WHO, WHAT, WHEN, WHY, and HOW: everything you could possibly want to know about unstable surface training.





If you are a personal trainer, just think of what $39.99 is: far less than the cost of a single session with one of your clients!  When you think about what you’re getting – a lifetime of instability training exercise progressions for your clients – this e-book is an investment in your professional success, not an expense.  Just ask Matt McGorry:

“This e-book is the first real objective look at unstable surface training for non-injured populations that I have ever seen. When someone comes along who doesn’t accept anecdotal evidence and industry hype as dogma, it makes a lot of people angry. This manual is going to do just that.

“Cressey uses hard facts and research to disprove what many of the so-called fitness and performance experts have been touting as gospel ever since unstable surface training first hit the market. At the same time, though, he’s objective in pointing out the merits of such training in certain circumstances, outlining dozens of extremely effective, results-based exercise variations that can be scaled to challenge anyone from the novice trainee to the elite athlete.

“If you are a fitness or sports performance professional who is interested in learning about the real world of ‘core’ and ‘functional’ training, then you absolutely must buy this manual.”

Matt McGorry

Fitness and Performance Coach – New York, NY


All the Best,

Eric Cressey, MA, CSCS

PS – Don’t delay; your clients and athletes are counting on you to have the most up-to-date, safe, and effective programming ideas available!


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