Home Posts tagged "ACL" (Page 2)

Repetition and The Art of the Deload

Last week, my girlfriend had a big decision to make.  As she finishes med school (optometry) this year, she had two offers on her plate: one for a job in a private practice, and one for a one-year residency.  If she took the job, it meant we'd move out of the city.  Instead, she took the residency - which means that we can stay in our current apartment for another year once our current lease is up on August 15. Now, this might seem mundane to a lot of you, but not for me.  I'm a guy who has moved eight times in the past ten years - including three separate states.  I was 100% supportive of any avenue that she opted to choose, but I had made it clear that if we went anywhere, we were getting a moving company to do it.  After ten years of moving, I was sick of putting my life on hold for 3-4 days at a time to relocate.  It made me think of a quote I read over at T-Nation a few years back: "Stagnancy is often confused with stability." In the strength and conditioning world, status quo is largely understood to be unacceptable.  We always have to be looking to get better.  Maybe a basketball player is looking to push work capacity by perpetually increasing training volume on the court.  Powerlifters rotate max effort exercises each week.  And, bodybuilders may constantly changing programs in hopes of keeping muscles "confused" and growing. However, in the world of "Eric Cressey hates moving more than he hates drunk Yankees fans in center field at Fenway Park," stagnancy is a beautiful thing. This stagnancy in living arrangements gives me stability with my schedule and productivity - so I guess the quote from above isn't always accurate.  And, it makes me think about a few examples from the world of exercise where stagnancy can be a good thing: 1. Activation Drills: I often get asked how to make a scap push-up, scapular wall slide, or other mobility/activation drill harder.  The truth is that you really shouldn't be trying to make them much harder; they're just low-intensity drills designed to be done with perfect technique to get certain muscles "turned on" before you get to the more complex stuff.  So, if you want to make these movements harder, do a bench press or loaded push-up after the scap push-up, or a chin-up after the scapular wall slide (just a few examples). 2. Learning New Movement Patterns: It actually takes a lot more repetitions to ingrain something in your "movement memory" than you might think.  In fact, research has shown that elite athletes have practiced their specific skills over 100,000 times to make them "subconsciously" learned. Let's be clear: I'm not saying that you have to do 100,000 body weight lunges before you can start to load the movement and derive benefit from that training in other tasks.  However, for untrained folks and those returning from injuries, motor (re-)education takes repetition and time.  You can't expect a 16-year old girl to have an ACL reconstruction, then do a session of body weight lunges and be ready to go out and play soccer or basketball safely the next day.  In fact, in this example, "stagnancy" - or consistency in training and gradual progressions - truly does enhance stability in more ways than one. 3. The Biggest Loser - When this TV show is on, it is best for you to leave your remote stagnant on the coffee table and your TV turned off.  This will ensure that ratings go down for NBC and this mind-numbing crap will eventually get yanked off the air. 4. In-Season Athletes - As I wrote in Four Ways to Stay on Track, you have to be very careful with modifying things too aggressively with athletes who are in the middle of their competitive season.  New exercises can bring about delayed onset muscle soreness, which may interfere with performance.  And, increasing training volume and/or loads in-season can inhibit recovery between practice sessions and competition, or lead to overuse injury. 5. Deload Phases - I devoted an entire e-book, The Art of the Deload, to this topic, in fact.  Make no mistake about it: the overwhelming majority of your time in the gym should be focused on getting better.  However, there should always be deloading periods in your training where it's okay to intentionally be "stagnant," as these periods give rise to adaptation that make you better in the long-term.

art-of-the-deload2

These five examples are really just the tip of the iceberg.  Feel free to post your thoughts in the comments section below to add to the discussion for everyone's benefit. New Articles The Seven Habits of Highly Defective Benchers was published at T-Nation last week. A Day in the Life of Eric Cressey was published at Precision Nutrition two weeks ago. Blog Updates Random Friday Thoughts Peak Power or Vertical Jump? The Most Detailed Maximum Strength Feedback To-Date Stuff You Should Read Have a great week! EC
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Stuff You Should Read: 2/26/09

This week, I encourage you to check out: 1. Why wait to repair an ACL? 2. 5 Keys to Bulletproofing Your Knees 3. The Agenda and Line-up for the 2009 MGH Sports Medicine Conference at which I'll be speaking alongside some really smart dudes.  While you're checking it out, read over Mike Reinold's stuff; Mike is the assistant athletic trainer for the Boston Red Sox and consistently puts out great material for the physical therapy community in his blog.
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Unstable Surface Training for Hockey

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
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Random Friday Thoughts: 8/29/08

1. As you probably know, I haven't been updating here quite as frequently of late, but fortunately, it's with good reason. The summer's winding down, so we've been getting our fall schedule all squared away with the high school guys - plus some local college guys at programs that don't have organized S&C programs. Additionally, all of our minor leaguers are in the final few days of their seasons right now, so coordinating with them and a few agents has been a priority right now. Fortunately, though, there are also some exciting things in store for this blog... 2. Basically, we're going to be combining EricCressey.com with EricCressey.Blogspot.com. So, my blog will be available directly from EricCressey.com. In the process, we have to transfer a ton of content - but the good news is that the finished product will look a lot more professional and organized when all is said and done. In the meantime, thanks for your patience as we make this switch. 3. I was chatting yesterday with Doug Carroll, a great hitting coach with whom we work. Doug played professional baseball to a very high level in both the Mariners and Devil Rays organizations. We both agreed that one thing you’ll notice in the majority of high level athletes is that they really don’t give a crap what anyone outside their family thinks of them. I think that if more people approached their lifting with this mindset, we’ve have a lot more people who were really big and strong. Interestingly, this closely parallels my approach to internet forums - and, thus far, ignoring what the haters say has been a great decision. 4. Never forget that you don’t have to leave the gym exhausted for the session to be considered productive. Take a 300-pound lineman and have him run five miles; he’ll be completely exhausted by the end of the session. He’ll also be slower, more likely to get injured, and definitely more likely to want to kick your teeth in. 5. Something you might not know: there are estrogen receptors on the anterior cruciate ligament (ACL) that – along with several other factors – make females more susceptible to ACL ruptures. The cyclical nature of estrogen and progesterone markedly influences ACL strength via fibroblast activity – so at certain times of the month, the ACL is more likely to tear. The ACL may also be predisposed to dramatic mood swings that make everything your fault, fellas. 6. I had a new article published yesterday, in case you missed it: 5 More Common Technique Mistakes. 7. I got two separate bills from Comcast in the past two days for a total of over $314. Do you think they read my blog, or is their billing system simply as hopelessly inadequate as their customer service? 8. Someone asked me yesterday, "Are single-leg leg press a good unilateral leg exercise? I hate lunges." Sorry, dude; single-leg leg presses don't count for anything. 9. I'm working on a detailed write-up on my views on running for pitchers right now. I think it'll open a lot of eyes - if I ever get time to finish it! I also have a new e-book in the works that I think will open a lot of eyes. 10. Have a great holiday weekend, everyone.
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5 Keys to Bulletproofing Your Knees

Mike Robertson flew up from Indianapolis to check out a seminar up here in Boston this past weekend. We really enjoyed watching Kevin Wilk, Bob Mangine, and Mark Comerford, three fantastic rehabilitation specialists. Additionally, I enjoyed catching up with Mike just as much, as he’s a wealth of information, particularly with respect to the knees. From just talking with Mike this weekend, I picked up some really good stuff – in addition to the entire day the presenters spent on the knee this weekend.

With that in mind, on Sunday, I wrote down five things that caught my attention this weekend. Then, I handed them to Mike and asked him to elaborate on them on his laptop on the plane ride home for a “guest spot” in my newsletter. Here’s what you’ve got:

5 Keys to Bulletproofing Your Knees

1. VMO specific work is currently poo-poo in the strength and conditioning industry. While I agree that we need to focus on strengthening the hip abductors/external rotators (especially glute max and posterior glute med), current literature leads us to believe that there’s more to the VMO than we might have expected.

Several studies in the past two years have indicated that there is a definite change in fiber pennation between the vastus medialis longus (VML) and the vastus medialis obliquus (VMO). Beyond that, while your other quad muscles like rectus femoris and vastus lateralis only have one motor point, the entire vastus medialis actually has THREE motor points! We may not totally understand the VMO yet, but I’m not willing to write off its importance with regards to knee health.

2. When looking at the body as a functional unit, we can’t overlook the core with regards to knee health. More specifically, we know the rectus abdominus and external obliques work to keep us in pelvic neutral and out of anterior pelvic tilt. Lack of strength in these core muscles increases anterior pelvic tilt, which drives internal rotation of the hip and valgus of the knee. Getting and keeping these muscles strong could go a long way to preventing knee injuries, especially in female athletes.

3. Are accelerated ACL rehab programs what we need? I’m not so sure, and I think making young athletes follow the accelerated programs the pros use may do more harm than good. Unlike the pros that are getting paid to play, we need to focus on the long-term outcomes of our young athletes, not simply getting them back on the field ASAP. Many have done an excellent job of rehabbing patients and getting them back on the field quickly, and quantifying strength and power production/absorption is critical.  Many of the leading PT’s and orthos, however, are moving back to a slightly more conservative approach to allow the graft itself more time to heal. The properties of a tendon graft slowly take on the properties of a ligament over time; this is called ligamentization. However, ligamentous changes can still be seen as late as 12-18 months post-surgery.

[Note from EC: so, if you have a patellar tendon graft for a new ACL, you might not really have what you want until 1-1.5 years post-surgery. Tendons and ligaments have different qualities.] 4. To piggy-back on the previous point, another factor that isn’t examined as often as it should is long-term outcomes of ACL rehabbed clients. Sure it’s great to get them back on the field in 6, 9 or 12 months, but what are the long-term ramifications? We know that females who have suffered ACL tears are much more likely to develop early osteoarthritis. If we can improve long-term outcomes by keeping them out a little longer, isn’t that worth it? As a PT or strength coach, it’s our job to help clients/athletes make the best decision for their long-term health, especially if they are too young to understand the long-term repercussions of their decision.

5. When an athlete tears their ACL, proprioceptive deficits are seen as quickly as 24 hours post-injury. What’s really intriguing, however, is that we often see this same deficit carried over to the healthy knee as well! Even after reconstruction this deficit can be seen for up to six years. To counteract this, don’t forget to include basic proprioceptive training (barefoot warm-ups, single-leg stance work, etc.), and train that “off” leg in the interim. For more tips, tricks, and programming recommendations on knees, check out Mike Robertson’s Bulletproof Knees manual. It’s by far the best resource I’ve seen on preventing and addressing knee pain.

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Training Around Elbow Issues in Overhead Athletes

Random Thursday Thoughts

Sturdy Shoulders: Big Bench

All the Best,

EC

PS - For those who missed it last week, be sure to check out my new e-book, The Truth About Unstable Surface Training, at www.UnstableSurfaceTraining.com.
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Calling Out Exercise Myths

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Just a quick heads-up: the EricCressey.com subscriber-only discount on Warp Speed Fat Loss expires TONIGHT at midnight. For those who missed it, check out last week’s newsletter for more details.
The Pendulum Comes Back to Center: Calling Out Exercise Myths
This past weekend, I was down in Stamford, CT to participate on a roundtable at Ryan Lee’s Bootcamp (and to check out the event myself). There was a ton of business information available specific to fitness professionals, and I had a good time catching up with a lot of old friends.
However, as my mind was packed with ideas on the business front, I got a wake-up call on Sunday morning that quickly reminded me that we still need to get better at the training and nutrition side of things as well to elevate our industry as a whole.
You see, my girlfriend and I had the TV on as we were getting ready to head down to breakfast at our hotel. They had a representative from some mainstream magazine on the show to offer four quick tips for folks to improve their exercise programs. Simply put, she gave out exercise advice that was not only ineffective; it was flat-out incorrect.
This “expert” claimed that we absolutely had to eat carbohydrates upon rising to fuel early morning workouts. And, she insisted that one can’t burn fat without consuming carbs. Huh? Has she ever heard of the catecholamines, growth hormone, or cortisol? We had specific hormones that allow us to do exactly this! And, it’s pretty well documented in the research that of the three macronutrients (carbs, proteins, and fats), carbs are the only one that is non-essential.
She took her nutrition advice to the next level by noting that protein was not a good pre-exercise choice because it is too hard to digest. Apparently, it should only be taken post-exercise. Riiiight. Apparently, all those years of peri-workout nutrition research at the U-Texas Medical Branch were for nothing. For those who don’t feel like reading the actual study: “These results indicate that the response of net muscle protein synthesis to consumption of an EAC solution immediately before resistance exercise is greater than that when the solution is consumed after exercise…” Would you rather listen to seven PhDs, or a lady in pink spandex? It actually gets better, though! This woman encouraged the audience (who, we can assume are for the most part completely untrained and predominantly female) to put a BOSU ball in the middle of their living room floor in front of the TV. Her justification was that you simply couldn’t walk by one without wanting to get on it (for the record, I could totally walk by it with no problems, but that’s a discussion for next week). She went on to recommend squats on the ball – and that’s even in light of the fact that most of the folks who would be following this information can’t even squat on stable surfaces in good form. And, we know that most women have issue with anterior weight bearing, so encouraging further pronation with unstable terrain is not a good idea. It took me all of three seconds with Google images to dig up this photo:
Looks like a great squat to me.  If you listen really carefully, you'll hear her ACL yelling "UNCLE!"  Again, I’ll get into a lot of detail on this soon; I promise…
The idiocy continued when she encouraged people to make exercise more complex, using the examples of doing biceps curls while doing lunges. You know what? Most untrained people can’t lunge to save their life! How about teaching them to lunge first – and then teaching them to lunge with something other than a plastic three-pound weight? If I can do walking lunges with well over 100 pound dumbbells, but can’t curl more than 55 pounds in each hand, which is the limiting factor?
So, she was 0-for-4 – but it gets even better.
I returned home to about 200 emails on Sunday night, one of which was a pitch from a guy with a “shoulder stretching apparatus” to promote. In his sales attempt, he actually confused internal with external rotation. And, when he stretched the external rotators and posterior capsule by going into internal rotation, he didn’t fix the scapula. This is a sure-fire way to jack up the anterior capsule, particularly in overhead throwing athletes.
I guess, in the end, my message is that you have to be a devil’s advocate at times in any field. There are bad doctors, lawyers, cab drivers, plumbers – you name it. And, the fitness industry is certainly no exception; in fact, it’s probably the majority that you have to watch out for as being sketchy due to the lack of strict licensure and certification requirements in this field.
Hopefully, people have come to recognize this newsletter as an exception to that rule. My goal is to make it a great information source that touches on a bit of everything, but still focuses on the topics I know best. I’ve recommended some products along the way, but rest assured that it wasn’t just because it was from a friend; it was because they were actually good. Believe me, I have a pile of crap products at home that have been sent to me by all sorts of folks (friends included); these products sit in a pile and you’ll never hear about them because I simply didn’t think they were any good.
To that end, if you are contemplating a purchase and want an honest perspective, drop us an email and ask for a review. If it’s something I’ve read/viewed and didn’t like, I’ll tell you. Or, I might even pick up a copy and check it out myself. I like to keep this newsletter positive, so I won’t rip on any products – but you’ll definitely hear about the best stuff I see.
Along those same lines, don’t hesitate to let us know if there are particular topics you’d like covered in newsletters, audio interviews, blogs, or articles.
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Newsletter #95

Inefficiency vs. Pathology

Q: I read with great interest your baseball interview at T-Nation, as I have two sons who play high school baseball. More interestingly to me, though, was this statement:

“Pathology (e.g., labral fraying) isn't as important as dysfunction; you can have a pathology, but not be symptomatic if you still move well and haven't hit "threshold" from a degenerative or traumatic standpoint.”

Is this something that can be applied to the rest of the body?

A: Great question – and the answer is a resounding “Absolutely!”

Many musculoskeletal issues are a function of cumulative trauma on a body with some degree of underlying inefficiency. People reach threshold when they do crazy stuff – or ignore inefficiencies – for long enough. Here are a few examples:

Lower Back Pain

As I touched on in a recent newsletter, we put a lot of compressive loading on our spines in the typical weight-training lifestyle – and you’d be surprised at how many people have spondylolysis (vertebral fractures) that aren’t symptomatic. But there’s more…

A 1994 study in the New England Journal of Medicine sent MRIs of 98 "healthy" backs to various doctors, and asked them to diagnose them. The doctors were not told that the patients felt fine and had no history of back pain.

80% of the MRI interpretations came back with disc herniations and bulges. In 38% of the patients, there was involvement of more than one disc.

It’s estimated that 85% of lower back pain patients don’t get a precise diagnosis.

Shoulders

You’d be amazed at how many people are walking around with labral fraying/SLAP lesions, partially torn rotator cuffs, and bone spurs. However, only a handful of people are in debilitating pain – and others just have a testy shoulder that acts up here and there. What’s the issue?

These individuals might have a fundamental defect in place, but they’ve likely improved scapular stability, rotator cuff strength/endurance, thoracic spine range-of-motion, soft tissue quality, cervical spine function, breathing patterns, mobility of the opposite hip/ankle, and a host of other contributing factors – to the point that their issues don’t become symptomatic.

Elbows

They do a lot of Tommy John surgeries and ulnar nerve transpositions for elbow issues that can often be resolved with improving internal rotation range-of-motion at the shoulder, or cleaning up soft tissue restrictions on flexor carpi ulnaris, flexor carpi radialis, pronator teres, etc.

According to Dr. Glenn Fleisig, during the throwing motion, at maximal external rotation during the cocking phase, there is roughly 64 Nm of varus torque at the elbow in elite pitchers. This is equivalent to having a 40-pound weight pulling the hand down.

The other day, I emailed back and forth with my good friend, physical therapist John Pallof about elbows in throwing athletes, and he said the following:

“Over the long term, bone changes just like any other connective tissue according to the stresses that are placed on it.  Most every pitcher I see has some structural and/or alignment abnormality – it’s just a question of whether it becomes symptomatic.  Many have significant valgus deformities.  Just disgusting forces put on a joint over and over and over again.”

Makes you wonder who is really "healthy," doesn't it? Carpal Tunnel

I can’t tell you how many carpal tunnel surgeries can be avoided when people get soft tissue work done on scalenes, pec minor, coracobrachialis, and several other upper extremity adhesion sites – or adjustments at the cervical spine – but I can tell you it’s a lot.

Knee Pain

Many ACL tears go completely undiagnosed; people never become symptomatic.

I know several people who have ruptured PCLs from car crashes or contact injuries – but they work around them.

Some athletes have big chunks of the menisci taken out, but they can function at 100% while other athletes are in worlds of pain with their entire menisci in place.

Many knee issues resolve when you clear up adhesions in glute medius, popliteus, rectus femoris, ITB/TFL, psoas, and the calves/peroneals; improve ankle and hip mobility; and get the glutes firing.

I’m of the belief that all stress on our systems is shared by the active restraints and passive restraints. Active restraints include muscles and tendons – the dynamic models of our bodies. Passive restraints include labrums, menisci, ligaments, and bone; some of them can get a bit stronger (particularly bone), but on the whole, they aren’t as dynamic as muscles and tendons.

Now, if the stress is shared between active and passive restraints, wouldn’t it make sense that strong and mobile active restraints would protect ligaments, menisci, and labrums? The conventional medical model – whether it’s because of watered-down physical therapy due to stingy insurance companies or just a desire to do more surgeries – fixes the passive restraints first. In some cases, this is good. In other cases, it does a disservice to the dynamic ability of the body to protect itself with adaptation.

I’m also of the belief that there are only a handful of exercises that are genuinely bad; upright rows, leg presses, and leg extensions are a few examples. The rest are just exercises that are bad for certain people – or exercises that are bad when performed with incorrect technique.

With these latter two issues in mind, find the inefficiency, fix it, and you'd be surprised at how well your body works when it moves efficiently.

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