Weight Training Programs: Assess, Don’t Assume

Written on May 10, 2011 at 8:06 am, by Eric Cressey

Late last week, my buddy Nick Tumminello made the follow comment that some folks, unfortunately, took out of context:

“Everyone is talking about assessments (and that’s cool). But, no one seems to talking about simply not allowing poor form in training. If you can’t keep good form in a certain exercise (movement pattern), simply don’t do that exercise until you’ve improved the movement or decided that you’re simply not built for it to begin with. Not sure why things need be any more complicated than that!”

For the record, I agree 100% with Nick and understood what he meant, but it would have been easy to assume that he was referring to “trainers train, and therapists assess.”  In other words, many folks assume that as long as you aren’t symptomatic in some way, then you’re safe to start exercising because you can simply “feel” things out as you go and, if something hurts, you don’t do it.

While you obviously shouldn’t do something if it hurts, just because something doesn’t hurt doesn’t mean that it’s not harmful long-term – and to me, that’s the difference between “working someone out” and provided them with an optimal training experience.  As physical therapist Mike Reinold has said, “Assess; don’t assume.”

To illustrate my point, here are a few examples.

Let’s say you have someone with a chronically cranky acromioclavicular joint or osteolysis of the distal clavicle that might only be apparent upon reviewing a health history, palpating the area, or taking someone into full horizontal adduction at the shoulder.  While direct over-pressure on the area (as in a front squat) would surely elicit symptoms, my experience is that most folks won’t notice a significant amount of pain until the next day if the strength exercise selection is inappropriate (e.g., dips, full range-of-motion bench pressing).  You might have avoided what “hurt” during the session (presumably because the individual was warmed up), but you find out after the fact that you just set an individual back weeks in their recovery and fitness program.

How about right scapular winging?  It’s not easily observed if a client has a shirt on, and if you simply throw that individual into a bootcamp with hundreds of push-ups each week, you’re bound to run into trouble.  Here’s the thing, though: even if you observed that winging and wanted to address it in your training, you really have to consider that it can come from one or more of several factors: weak scapular stabilizers, a stiff posterior cuff, insufficient right thoracic rotation, faulty breathing patterns, or poor tissue quality of pec minor, rhomboids, levator scapulae (or any of a number of other muscles/tendons).  Just doing some rows and YTWL circuits will not work.

Also at the shoulder, a baseball pitcher with crazy congenital and acquired shoulder external rotation may have a ton of anterior instability in the “cocking” position of throwing (90 degrees of abduction and external rotation), but be completely asymptomatic.  Back squatting this athlete would exacerbate the problem over the long haul even if he didn’t notice any symptoms acutely.

Finally, in my recent article, Corrective Exercise: Why Stiffness Can Be a Good Thing, I spoke about how someone can have crazy short hip flexors and still manage a perfect squat pattern because his stiffness at adjacent joints is outstanding.  If I don’t assess him in the first place and just assume that he squats well, I’m just waiting for him to strain a rectus femoris during sprinting or any of a number of other activities.  Gross movement in a strength and conditioning program wouldn’t tell me anything about this individual, but targeted assessments would.

The point is that while Nick’s statement is absolutely true – demanding perfect form is corrective in itself – you’ve still got to assess to have a clear picture of where you’re starting.  Otherwise, many cases like this will slip through the cracks.

To that end, I’m happy to announce that my long-time friend and colleague, Mike Robertson, recently released his Bulletproof Knees and Back Seminar DVD Set.  This comprehensive product covers anatomy, assessments, program design, and coaching.  In fact, almost the entire second day is focused on coaching, and that’s an area in which most trainers really do need to improve.  All in all, this isn’t a collection of bits and pieces; it’s Mike’s entire philosophy on training someone who is suffering from knee or low back pain (and how to prevent it in the first place).  Effectively, Mike covers what both Nick and I are getting at in the paragraphs you just read.

Since Mike’s a great friend – and because he and his wife just had a new baby daughter that will surely shop a ton in her teenage years, go to college, and have an expensive wedding – I want to sweeten the deal and help him with sales, especially since this is tremendously valuable information that fitness professionals need to hear.

With that said, anyone who purchases the Bulletproof Knees and Back Seminar DVD Set by this Friday (5/13) at midnight will receive a free 37-minute upper extremity assessment video I recently filmed for my staff in-service and uploaded to the web.  In other words, Mike covers the back and lower extremity and I cover the upper extremity, meaning you’ve got a head-to-toe resource at your fingertips.  Just forward your receipt to me at ec@ericcressey.com and I’ll send it along this weekend.

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AC Joint Impingement vs. “Regular” Shoulder Impingement

Written on July 7, 2010 at 5:32 am, by Eric Cressey

I’ve seen a few acromioclavicular (AC) joint impingement cases at our facility in the last couple of weeks and thought it’d be good to do a quick blog to talk about how different they are from “regular” (external) shoulder impingement cases.  And, it is a very important differentiation to make.

I’ve already written at length about AC joint issues in Getting Geeky with AC Joint Injuries: Part 1 and Part 2.  And, I kicked out a two-part series called The Truth About Shoulder Impingement; here are Part 1 and Part 2.

While I talk a lot about the symptoms for both, several provocative tests for these issues, and training modifications to avoid exacerbating pain under these conditions, there was one important “differential assessment that I missed.”  Mike Reinold actually taught me it as we were planning the Optimal Shoulder Performance DVD set.

Just paying close attention to (and asking about) where folks have their pain during overhead motion can tell you quite a bit.  In an external impingement – where we’re talking about the rotator cuff tendons and bursa rubbing up against the undersurface of the acromion – you’ll usually get pain as folks approach 90 degrees of abduction (arm directly out to the side).  That pain will persist as they go further overhead, and in my experience, start to die off as they get to the top.

Conversely, for those with AC joint impingement – what is essentially bone rubbing up against bone – you see a “painful arc” only at the last portion of abduction:

You can usually confirm your suspicions on this front with direct palpation of the AC joint and checking to see if folks have pain when reaching across the chest.

Much of the training modifications will be the same for these two conditions, but there are also going to be several key things that should be managed completely differently.  For instance, front squatting someone with an AC joint issue would not be a good idea due to the direct pressure of the bar on the AC joint; it would, however, be just fine for most cases of external shoulder impingement.  In another example, some serious AC joint issues are exacerbated even by just doing the end-range of a rowing motion (to much shoulder extension/horizontal abduction) – whereas even folks with full-blown rotator cuff tears can generally do rows pain-free.

Assess, don’t assume!

For more information – including loads more assessments like these – check out the Optimal Shoulder Performance DVD set.

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Getting Geeky with AC Joints: Part 2

Written on September 9, 2009 at 6:29 am, by Eric Cressey

Getting Geeky with AC Joints: Part 2

In my last newsletter, I went into great detail on the types of acromioclavicular (AC) joint injuries we see, and some of the common inefficiencies that cause some folks to become symptomatic.  I also outlined some corrective exercise strategies to expedite recovery time.  This week, though, I discuss a very important – yet often-overlooked – piece of the puzzle: how to maintain a training effect in spite of these injuries.

Ask anyone who has ever had an AC joint injury, and they’ll tell you three things to avoid if you don’t want to irritate it:

1. Avoid direct pressure to the area (particularly because it has very little muscle mass to cushion it)

2. Avoid reaching across the body (horizontal adduction)

3. Avoid reaching behind the body (full extension)

We can use these three guidelines to get moving in the right direction with respect to maintaining a training effect in spite of the AC joint injury.

With respect to #1 from above, front squats are an absolute no-no.  The pressure on the bar across the shoulder girdle can really take an upset AC joint and make it markedly worse.  And, since this is in many cases an injury that we’re just “waiting out,” simply training through it will only makes things worse long-term.  So, deadlift variations, single-leg variations, and back squats (assuming no other related problems) are likely better bets.  That said, we generally use the safety squat bar and giant cambered bar exclusively with those who present with AC joint problems.

Another important consideration in this regard is overhead pressing.  Believe it or not, many individuals with AC joint problems will actually tolerate overhead pressing quite well, as direct trauma to the AC joint won’t really compromise scapulohumeral rhythm very much.  However, you have to consider two things.

First, as I mentioned in my previous newsletter, some folks might have developed the AC joint issue over time due to a scapular anterior tilt causing the acromion and clavicle to sit differently.  This dyskinesis would also make overhead work less safe – so the individual would actually be training through a faulty movement pattern, and potentially injuring the rotator cuff, biceps tendon, bursa, and labrum.

Second, if the individual is okay to overhead press from a movement standpoint, one needs to make sure that the bar, dumbbell, or kettlebell does not come down directly on the AC joint in the bottom position.

With respect to #2 from above, obviously, dumbbell flyes and cable crossovers are out (not sure why they’d be “in” in the first place, but that’s a whole different newsletter).  However, close-grip bench pressing variations will generally cause pain as well.  You also have to be careful with cable and medicine ball variations that may position the arm across the body.

Moving on to #3, full extension of the humerus will light up an AC joint pretty quickly.  So, dips are out – and, honestly, I generally tell folks they’re out for good after one has experienced any kind of AC joint issue.  Full range-of-motion (ROM) bench pressing and push-ups are generally issues as well, so I tend to start folks with more partial ROM work.  Examples would include dumbbell and barbell floor presses and board presses.  Here’s a 3-board press:

As the shoulder starts to feel better, one can move down to 2-board, 1-board, and eventually full ROM bench press.  Remember, a medium or wide grip will generally be tolerated better than a close grip.

I also really like push-up iso holds at a pain-free ROM for these individuals because closed-chain exercises are always going to be a bit more shoulder friendly than open-chain variations.  This is really quite simple: set up as if you are going to do a push-up, and go down as far as you can with no pain.  When you reach your pain-free end-range, hold there while bracing the core, locking the shoulder blades down and back, and tightening the glutes; do not let the elbows flare out or hips sag!  We’ll hold for anywhere from 10-60s, depending on fitness levels.  Over the course of time, increase the ROM as your symptoms reduce.

There you have it: acromioclavicular joints – from onset to corrective exercise – in a nutshell.  Obviously, make sure you seek out a qualified professional if you think you may have these issues, but keep this progression in mind as you return to (or just try to stay in) the iron game.

Feedback on Building the Efficient Athlete

“In my ten years in the fitness industry, I have been to many seminars and conferences – but the Building the Efficient Athlete Seminar was by far the most informative and comprehensive event I have attended in as long as I can remember.  The amount of knowledge you get when you combine Eric Cressey and Mike Robertson is unparalleled.  The seminar was filled with great classroom information, hands-on assessments, and on-site training tips.  I highly recommend this DVD set to any coach, trainer, or athlete who is looking to get a leg up on the competition.”

Mike Hanley, USAW, RKC
Morganville, NJ
www.HanleyStrength.com

Pick up your copy of Building the Efficient Athlete today!

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Have a great week!

EC

Click here to purchase the most comprehensive shoulder resource available today: Optimal Shoulder Performance – From Rehabilitation to High Performance.

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Getting Geeky with AC Joint Injuries

Written on September 2, 2009 at 6:39 am, by Eric Cressey

Getting Geeky with AC Joint Injuries

Lately, I’ve gotten quite a few in-person evaluations and emails relating to acromioclavicular (AC) joint issues.  As such, I figured I’d devote a newsletter to talking about why these injuries are such a pain in the butt, what to do to train around them, and how to prevent them in the first place (or address the issue once it’s in place).

First off, there is a little bit about the joint that you ought to know.  While the glenohumeral joint (ball-and-socket) is stabilized by a combination of ligamentous and muscular (rotator cuff) restraints, the AC joint doesn’t really have the benefit of muscles directly crossing the joint to stabilize it.  As such, it has to rely on ligaments almost exclusively to prevent against “shifting.”

As you can imagine, then, a traumatic injury or a significant dysfunction that affects clavicle positioning can easily make that joint chronically hypermobile.  This is why many significant traumatic injuries may require surgery.  While almost all Grade 4-6 separations are treated surgically, Grades 1-2 separations are generally left alone to heal – with Grade 3 surgeries going in either direction.

In many cases, you’ll actually see a “piano key sign,” which occurs when the separation allows the clavicle to ride up higher relative to the acromion.  Here’s one I saw last year that was completely asymptomatic after conservative treatment.  It won’t win him any beauty contests, and it may become arthritic way down the road, but for now, it’s no problem.

Now that I’ve grossed you out, let’s talk about how an AC joint gets injured.  First, we’ve got traumatic (contact) injuries, and we can also see it in people who bench like this:

Actually, that’s probably a fractured sternum, but you can probably get the takeaway point: don’t bounce the bar off your chest, you weenie.  But I digress…

Insidious (gradual) onset injuries occur just as frequently, and even moreso in a lifting population.  Most of the insidious onset AC joint problems I’ve encountered have been individuals with glaring scapular instability.  With lower trapezius and serratus anterior weakness in combination with shortness of pec minor, the scapula anteriorly tilts and abducts (wings out) – and you’ll see that this leads to a more inferior (lower) resting posture.

In the process, the interaction between the acromion (part of the scapula) and clavicle can go a little haywire.  The acromion and clavicle can get pulled apart slightly, or the entire complex can get pulled downward a bit.  In this latter situation, you can also see thoracic outlet syndrome (several important nerves track under the clavicle) and sternoclavicular joint issues in addition to the AC joint problems we’re discussing.

As such, regardless of whether we’re dealing with a chronic or insidious onset AC joint issue, it’s imperative to implement a good scapular stabilization program focusing on lower trapezius and serratus anterior to get the acromion “back in line” with the clavicle.  Likewise, soft tissue and flexibility work for the pec minor can also help the cause tremendously.

Anecdotally, a good chunk of the insidious onset AC joint problems I’ve seen have been individuals with significant glenohumeral internal rotation deficits (GIRD).  The images below demonstrate a 34-degree GIRD on the right side.

It isn’t hard to understand why, either; if you lack internal rotation, you’ll substitute scapular anterior tilt and abduction as a compensation pattern – whether you’re lifting heavy stuff or just reaching for something.  And, as I discussed in the paragraph above, a scapular dyskinesis can definitely have a negative effect on the AC joint.

Lastly, you can’t ever overlook the role of thoracic spine mobility.  If your thoracic spine doesn’t move, you’ll get hypermobile at the scapulae as a compensation – and we already know that’s not good.  And, as Bill Hartman discussed previously, simply mobilizing the thoracic spine can actually improve glenohumeral rotation range-of-motion, particularly in internal rotation.  Inside-Out is a fantastic resource in this regard – and is on sale this week, conveniently!

So, as you can see, everything is interconnected!  In part 2 of this series, I’ll discuss training modifications to work around acromioclavicular joint problems and progress back to more “normal” training programs.

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All the Best,

EC

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Pain with Horizontal or Vertical Pushing?

Written on July 14, 2009 at 6:25 am, by Eric Cressey

Last week, I published a post on shoulder issues with overhead pressing, and got two good comments as replies:

1. In HS I separated my AC joint during the first game of junior year. I played the rest of the year with out letting it heal, and to this day I have still have shoulder issues (college ball didn’t help the issue much either). It seems my shoulder allows me to overhead press/push press/jerk and incline press, but flat bench is out of the question unless I’m using DBs. Is this typical of this type of shoulder injury, or am I an outlier and most individuals show the same symptoms as yourself? Granted we each have different injuries but same local area.

2. I have pain doing flat bench presses with barbell and upright rows. Decline barbell press is also sometimes uncomfortable, but incline press and overhead press is working fine.

This is actually pretty typical of acromioclavicular (AC) joint problems.  Folks will have problems with exercises like full-ROM bench presses and dips, as they force full humeral extension. Decline bench pressing requires less humeral extension on the eccentric than regular bench pressing and dips, so that would explain the decrease in symptoms.

That said, overhead pressing will usually be okay because it doesn’t require so much humeral extension (nothing past neutral).  However, some folks will have other related problems (e.g., rotator cuff injury during the AC injury), so both horizontal and vertical pushing movements may become problems.

So, obviously, not all shoulder problems are created equal.  However, a lot of the time, they can be treated with similar means: good scapular stabilization movements, a focus on thoracic spine mobility, and dedication to strengthening the rotator cuff and improving soft tissue quality.

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