Home Posts tagged "Femoroacetabular Impingement"

Random Thoughts on Sports Performance Training – Installment 24

With only a few days to spare, here is the November 2016 edition of randomness!

1. Don’t let bad movement become cemented joints.

As I presented in Functional Stability Training of the Upper Body, mobility can be restricted for a lot of reasons.

One thing I didn't note in this video is that if you have muscular, capsular, or alignment issues that persist for an extended period of time, you'll eventually develop changes to the joint (bony overgrowth). In a 2013 study, world-renowned hip specialist Marc Phillipon examined how the incidence of femoroacetabular impingment (FAI) - bony overgrowth at the hip - changed across various stages of youth hockey. At the PeeWee (10-12 years old) level, 37% had FAI and 48% had labral tears. These numbers went to 63% and 63% at the Bantam level (ages 13-15), and 93% and 93% at the Midget (ages 16-19) levels, respectively. The longer one played hockey, the messier the hip – and the greater the likelihood that the FAI would “chew up” the labrum.

fai
Source: Lavigne et al. 2004

It's imperative for strength and conditioning coaches to understand these issues. On evaluation, if an athlete already has changes to the joint, we need to create training programs to deliver a training effect while working around these issues. If you squat an entire team of football players even though you know 4-5 of them already have significant FAI and associated pathologies in their hips, you're probably going to be funding some hip surgeon's retirement. Work on deadlifting and single-leg work instead, though, and you'll probably kick the can down the road for those athletes.

Conversely, if your assessment reveals that an athlete is out of alignment and has some tissue density and core control issues that are preventing quality hip flexion and internal rotation, you need to design a program to get to work on those problems before they can develop bony blocks at the hip. As my buddy Mike Reinold often says, "Assess, don't guess." 

2. We might be seeing the end of the versatile strength and conditioning coach.

One thing I've noticed in the strength and conditioning field over the past decade is an increased tendency toward specialization among coaches. Over the years, there have some been really bright coaches - Al Vermeil, Mike Boyle, and Bob Alejo come to mind - who've had success across multiple sports at the highest levels. They were few and far between, but it was still something that was feasible if someone was educated and motivated enough. I think that's changing and this versatility will be obsolete very soon.

We're seeing a much bigger focus on analytics in all professional sports; the focus on minute details has never been greater. In college sports, we are seeing more "baseball only" and "hockey only" guys to build on the years of the football strength and conditioning coach typically not working with other teams. At every level, specialization among strength coaches (and rehabilitation specialists, for that matter) is increasing. As a result, if a coach tries to venture out into another sport at a high level, it takes longer to get up to speed. 

If a guy leaves basketball to go to baseball, he's got to learn about thoracic outlet syndrome, ulnar collateral ligament injuries, and lat strains; these just don't happen very often in hoops. He won't have to worry much about humeral retroversion in his programming for shooting guards, either - but it has a huge influence on how he manages functional mobility in pitchers.

 

Today is Day 12 of #30DaysOfArmCare. Thanks to #Tigers pitcher @adamrav12 for the assist! Key takeaways: 1. Retroversion is a common finding and throwing shoulders. It gives rise to greater lay-back at max external rotation. 2. The more passive range of motion you have, the more consistently you must work to maintain active stability of that ROM. ROM without stability is injury risk. 3. Perform your cuff work in the positions that matter - and keep in mind that individual differences in passive ROM may be present. 4. Don't stretch throwers into external rotation, especially if they already have this much lay-back! Follow #30DaysOfArmCare and @cresseysportsperformance for more tips to keep throwing arms healthy. #cspfamily #armcare #baseball #mlb

A video posted by Eric Cressey (@ericcressey) on

Likewise, just because I have a solid handle on managing shoulders in overhead athletes doesn't mean that I'm equipped to handle the metabolic demands that swimmers encounter.

Versatility is still important; a well-rounded professional will never go hungry. However, at the higher levels, I just see fewer and fewer professional teams and colleges valuing it highly when the quickest option is to seek out specialists in specific realms.

3. Create context not only to improve coaching, but also to improve adherence.

Recently, I saw a professional pitcher who noted that his team had commented on how limited his extension on each pitch was. For those who aren't familiar, in recent years, teams have started tracking the actual release point of various pitchers. Basically, if two pitchers both throw 95mph, but one releases the ball closer to the plate, the one with more extension is actually releasing the ball closer to the plate, so it "gets on" the hitter faster. All things considered, a higher extension is generally better. You can view it as part of the Statcast panel on each MLB pitchers' page; here's CSP athlete Steve Cishek's, as a frame of reference. Steve's extension is well above MLB average, so the perceived velocity of his pitches are over one mph higher than their actual velocity.

cishekextension2

Returning to the pitcher I evaluated recently, he commented that although his fastball velocity is among the best in the minor leagues and he has quite a bit of movement, he doesn't strike a lot of guys out. While there are a lot of reasons for this, one consideration has to be physical limitations that don't allow him to get extension out in front. In his case, on evaluation, we saw a pseudo military posture; his shoulder blades were tugged back into adduction, and he lacked the upward rotation to effectively "get out front."

adductedscap

Additionally, in the lower extremity, he had significant bilateral muscular/alignment limitations to hip internal rotation. If you don't have sufficient hip internal rotation on your back leg, you aren't going to ride your hip down the mound very far. If you don't have internal rotation on the front hip, you won't be able to accept force on the front leg, so you'll effectively cut off your deceleration arc, also shortening your extension out front. These are usually the guys who "miss" up-and-armside, or cut balls off in an attempt to correct the issue.

If I had just told him he needed to fix these for the sake of fixing them - or even just to prevent injury - it probably wouldn't hold much water. However, by relating these movement inefficiencies back to aspects of his delivery with which he struggles, the buy-in is a lot higher. Striking guys out is a lot "sexier" than avoiding injury or conforming to some range-of-motion norm. 

4. This is a great weekend to be an up-and-coming fitness professional or rehabilitation specialist on a limited budget.

Black Friday/Cyber Monday might be annoying if you're in stores and dealing with a bunch of crazy Moms who are fighting over the last Tickle-Me-Elmo, but in an online context, it's pretty darn awesome - especially if you're an aspiring coach looking to get your hands on some quality educational material.

I did my undergraduate education at a smaller Division 3 school in Southern Maine. We didn't have a varsity weight room where I could observe or volunteer, and there weren't tip top internship opportunities right down the road where I could've found opportunities like that. Looking back, I realize that one of the main reasons I got on the right path was that I was willing to search high and low for those learning opportunities. I spent hours reading T-Nation and hard copy books I'd bought, not to mention driving to whatever seminars I could find.

Nowadays, education is much, more more accessible. Instead of driving nine hours to Buffalo or dropping $1,000 on a plane right, hotel, rental car, and seminar registration, you can spend 10% of that amount and get an awesome education - and you can pick and choose what you want to learn. This weekend, you can do it super affordably, too.

Want a crash course in relative stiffness? Check out my presentations in Functional Stability Training: Optimizing Movement (on sale for 20% off with coupon code BF2016). 

Looking to patch up the holes in your college anatomy course by learning about functional anatomy instead? Pick up Building the Efficient Athlete from Mike Robertson and me (20% off this weekend; no coupon code needed).

Need some cutting-edge hip mobility strategies? Watch Dean Somerset's presentations in The Complete Shoulder and Hip Blueprint (on sale for $30 off through Monday).

Interested in taking a peek into the mind of a successful NFL strength and conditioning coach? Soak up Joe Kenn's knowledge in Elite Athletic Development (20% off this weekend; no coupon code needed).

It's an amazing age in strength and conditioning; short of actual hands-on coaching experience, all the information you need to be successful is at your fingertips in a digital medium - and this is the weekend to get it at the best price.

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Random Thoughts on Sports Performance Training – Installment 19

It's time for the June installment of "Random Thoughts on Sports Performance Training."  With the introductory sale on Functional Stability Training: Optimizing Movement ending on Sunday at midnight, I'm going to use this post as an opportunity to highlight one of the key concepts that resounds throughout the product: relative stiffness.

FST-DVD-COVER-OPTIMOVE

1. All successful coaching hinges on relative stiffness - whether you're aware of it or not.

I first came across the concept of relative stiffness in reading Shirley Sahrmann's work. This principle holds that the stiffness in one region (muscles/tendons, ligaments, or joint) has can have a functional impact on the compensatory motion at an adjacent joint that may have more or less stiffness. You'll also hear it referred to as "regional interdependence" and the "joint-by-joint" approach by the FMS/SFMA and Mike Boyle, respectively.

For those who do best with examples, think of lower back pain in someone who has an immobile thoracic spine and hips. They don't move through these regions (excessive stiffness), so the lumbar spine (insufficient stiffness) just compensate with excessive motion. Likewise, a female soccer player with insufficient "good stiffness" in the hip external rotators and hamstrings might be more likely to suffer an ACL injury, as this deficit allows excessive motion into knee valgus and hyperextension.

This is why a knowledge of functional anatomy is so key for strength and conditioning coaches. Every cue you use is an attempt to either increase or decrease stiffness. When you hear Dr. Stuart McGill say, "lock the ribs to the pelvis," he's encouraging more (anterior) core stiffness. When you hear "double chin," it's to increase stiffness of the deep neck flexors. When you ask an athlete to take the arms overhead during a mobility drill, you're looking to decrease stiffness through the lats, thoracic spine, pec minor, etc. - and increase stiffness through the scapular upward rotators, anterior core, deep neck flexors, etc. 

laterallunge

In short, absolutely everything we do in training and in life is impacted by this relative stiffness.

2. Remember that elbow hyperextension doesn't only occur because of joint hypermobility.

I've written frequently about how elbow hyperextension at the top of push-ups is a big problem, especially in hypermobile athletes who may be more predisposed to the issue. Typically, this is simply a technique issue; you tell athletes to stop doing it, and they do.

elbowhyperextension

However, this doesn't mean that they'll automatically correct the tendency on other movements - like catching a snatch overhead, or throwing a baseball. It's when we look at the problem through a larger lens that we realize there is a big relationship to a lack of scapular motion. If you don't have enough good stiffness in serratus anterior to get the scapula to "wrap" around the rib cage and upwardly rotate, you'll have to go elsewhere to find this motion (elbow hypermobility). This is why I'm a huge stickler for getting good scapular movement on the rib cage - and the yoga push-up is a great way to train it. Think "more scap, less elbow."

3. If you want job security, become a hip surgeon.

The other day, I was speaking with a good friend who works with a lot of strength competitors - powerlifting, Olympic lifting, and Crossfit - and he made a comment that really stood out to me: "I'm seeing uglier hips than ever - even with females."

This has some pretty crazy clinical implications. Most females of "strength sport competitor age" have quite a bit of natural joint hypermobility, so they typically present with excellent hip range-of-motion prior to the age of 40. Even females who sit at computers all day rarely present with brutal hip ROM before they're middle-aged. What does this tell us? We have a lot of females who are developing reactive changes (bony overgrowth = bad stiffness) in their hips well too early, and when they later add increased ligamentous stiffness and a greater tendency toward degenerative changes (both normal with aging), we are going to see some really bad clinical hip presentations.

As an aside, it’s widely debated whether those with femoracetabular impingement (FAI) are born with it, or whether it becomes part of “normal” development in some individuals. World-renowned hip specialist Marc Phillipon put that debate to rest with a 2013 study that examined how the incidence of FAI changed across various stages of youth hockey. At the PeeWee (10-12 years old) level, 37% had FAI and 48% had labral tears. These numbers went to 63% and 63% at the Bantam level (ages 13-15), and 93% and 93% at the Midget (ages 16-19) levels, respectively. The longer one played hockey, the messier the hip – and the greater the likelihood that the FAI would “chew up” the labrum.

fai

Source: Lavigne et al.: http://www.ncbi.nlm.nih.gov/pubmed/15043094

So, whether it's strength sport athletes, hockey players, or some other kind of athlete, if you want job security, become a hip surgeon - and expect to do a lot of hip replacements in 2040 and beyond. There's a good chance these folks will need multiple replacements over the course of their life, too, if the longevity of the hardware doesn't improve before then. The same can probably be said for shoulders, too.

How does it relate to relative stiffness? Once you've used up all the "bad" stiffness you can acquire - muscles, tendons, ligaments, and joint - there's a good chance that you'll have beaten at least some structure up enough to warrant a surgery.

Wrap-up

I could go on and on with other examples of relative stiffness in action, but the truth is that they are countless - and that's why it's so important to appreciate this concept. To that end, I'd highly recommend you check out Mike Reinold and my new resource, Functional Stability Training: Optimizing Movement. It's on sale at an introductory $30 off discount through this Sunday at midnight.

eric and mike squat

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Quick and Easy Ways to Feel and Move Better: Installment 28

Here's this week's list of tips to get your nutrition and strength and conditioning programs on track.  Greg Robins took a break this week, so I'm stepping up my game and covering this installment.

1. If you always squat, try a month without squatting.

There's an old saying in the strength and conditioning field that "the best program is the one you're not on." In other words, everything works, but nothing works forever.  Squats have come under a fair amount of scrutiny over the past few years as diagnoses of femoracetabular impingement have gone sky-high and we've encountered more and more people in the general population who simply don't move well enough to squat in good form.  So, it makes sense to not shove a round peg in a square hole; at the very least, try to remove them from your strength training programs for a month here and there.

In these instances, I like to start the training session with an axially-loaded single leg exercise for 3-6 reps/side.  If you're not good in single-leg stance, start on the higher side with a lighter weight. If you're a long-time single-leg believer, though, you can really load these up:

After that, you can move on to deadlifts, barbell supine bridges/hip thrusts, or any of a number of other exercises.  The point to take away from this is that eliminated loaded squatting variations for a month here and there won't set you back.

2. Work on the squat pattern, not just the squat.

A lot of folks struggle to squat deep because they lack the ability to posteriorly shift their center of mass sufficiently.  This is particularly common in athletes with big anterior pelvic tilts and an exaggerated lordotic curve.

If you give these athletes a counterbalance out in front of their body, though, their squat patterns "clean up" very quickly.  As such, in combination with other mobility/stability drills, I like to include drills to work on the actual squat technique both during their warm-ups and as one of the last exercises in a day's strength training program.  Goblet squats and TRX overhead squats are two of my favorites:

3. Make muffins healthier.

My favorite meal is breakfast, and I know I'm not alone on this!  Unfortunately, once you get outside some of the traditional eggs and fruit choices, things can get unhealthy very quickly.  That's one reason why I'm a fan of Dave Ruel's recipe for the much healthier high protein banana and peanut butter muffins from Anabolic Cooking.  Dave has kindly agreed to let me share the recipe with you here:

Ingredients (for three muffins)
• ¾ cup oatmeal
• ¼ cup oat bran
• 1 tbsp whole wheat flour
• 6 egg whites
• ½ scoop vanilla protein powder
• ¼ tsp baking soda
• ½ tsp stevia
• 1 tbsp natural peanut butter
• 1 big banana
• ½ tsp vanilla extract
• ½ tsp banana extract

Directions
1. In a blender, mix all the ingredients (except for the banana). Blend until the mix gets thick.
2. Cut the banana in thin slices or cubes. Add the banana to the mix and stir (with a spoon or a spatula)
3. Pour the mix in a muffin cooking pan, and cook at 350°F. Until cooked (about 30 minutes).

Nutrition Facts (per muffin)
Calories: 190
Protein: 17g
Carbs: 18g
Fat: 4.5g

Quick tip: you can cook a big batch and freeze the muffins, then just microwave them when needed down the road.

Anabolic Cooking is on sale for $40 off until tonight (Friday) at midnight, so I'd encourage you to check it out and enjoy the other 200+ healthy recipes Dave includes.  My wife and I cook from this e-book all the time.

4. Dominate the back-to-wall shoulder flexion drill before you overhead press.

Whether your shoulders are perfectly structurally sound or not, overhead pressing can be a stressful activity for the shoulder girdle.  To that end, you want to make sure that you're moving well before you move overhead under load.  I like to use the back-to-wall shoulder flexion "test" as a means of determining whether someone is ready to overhead press or snatch (vertical pulling is a bit different).  Set up with your back against the wall, and your heels four inches away from the wall.  Make sure your lower back is flat against the wall, and make a double chin while keeping the back of your head against the wall.  Then, go through shoulder flexion.

If you can't get your hands to touch the wall overhead without bending the elbows, going into forward head posture, arching the back, or moving the feet away from the wall, you fail.  Also, pain during the test is a "fail," too.  Folks will fail for all different reasons - but a big chunk of the population does fail.  Fortunately, a bit of cueing and some corrective drills - and just practicing the test - will go a long way in improving this movement quality.  Hold off on the snatches and military presses in the meantime, though.

5. Drink with a straw to get better about water intake.

I always give my wife, Anna, a hard time about how little water she drinks.  She'll get busy at work and will simply forget to have a sip of water for 5-6 hours.  Other times, though, she just doesn't want to drink cold water - because it's winter in New England and she is always trying to get warm!  One quick and easy solution to the later problem is to simply drink with a straw, as water won't contact your teeth, which are obviously very cold-sensitive.  My mother gave Anna a water bottle with a straw for Christmas, and she's been much better about water consumption ever since.  Try it for yourself.

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4 Reasons the Game is Always Changing in the Fitness Industry

Yesterday, a reporter for MLB.com came by Cressey Performance to interview a few of our major leaguers.  While there, he asked me my take on whether or not I thought players' off-season preparation changes dramatically from year to year. My answer was something to the effect of:

The fitness and strength and conditioning industries as a whole change significantly each year, so that would certainly be the case in baseball, which features throwing - the single fastest motion in all of sports - and alarmingly high injury rates at all levels.  Guys certainly have mainstays that they stick with regardless of the points in their career, but with innovation as prominent as it is in our field, I change quite a few things each year with how we prepare our guys.

With that in mind, I thought I'd highlight four things that have forced innovation in the way that we train athletes and general fitness folks alike.

1. New Research

There are more scholarly journals - and research review services summarizing these publications - than ever before.  Even if you aren't trained in research methods, you can easily get access to interpretations of these research studies via those who are.  And, just by looking around online and attending seminars, you can see how other coaches and trainers in the field are integrating this new research in their programs.

2. Better diagnostic procedures, physical therapy treatments, and surgical interventions.

Nobody had ever heard of a sports hernia or femoroacetabular impingement before the last 10-15 years, yet nowadays, they're incredibly common diagnoses in athletes involved in violent extension and rotation.  And, taking it a step further, when you can diagnose something, you have to be able to treat it - whether it's conservatively or surgically.  Diagnostics, surgeries, and PT all give rise to the need for more trainers to understand new conditions - both from prevention and post-rehabilitation standpoints.

3. More competition.

When you're King Crap on Turd Mountain, there really isn't much incentive to try to better yourself.  Nowadays, though, while the fitness industry at times is perfectly described as "Turd Mountain," there is no definitive "King Crap."  This is especially powerful when you consider that the industry is moving toward more and more specialization.  People are focusing on specific athlete/client populations and still not differentiating themselves as the absolute best.  As a result, everyone who wants to be near the top really has to bust their butts.

As an interesting parallel to this, try to name a major professional sport where one athlete is so far superior to all the rest.  I'll give you Usain Bolt, but in every other major discipline, there is a far more even playing field.  I think innovations in strength and conditioning have played a big part in that.  Outstanding fitness can make up for a lot of what high level athletes may lack in raw talent/skill.

4. An aging clientele.

Anyone who has outstanding client retention can attest to this: people change over the course of the many years that you train them.  I've trained 13 year-olds who have gone on to be taken in the MLB draft.  I've written letters of recommendation for former high school athletes to get into medical school.  I've watched how career and financial success can change exercise adherence both for the good and bad.  And, I've learned that training single athletes is much different than training those athletes when they're married and have children. Heck, pretty soon, I'll be training their kids, too!

Aside from these social factors, people's bodies change.  There may be fluctuations in life stresses that may impact what they can do in the gym. There may be aches and pains over the years around which you have to work. An offensive lineman might decide he wants to lose 100 pounds after his playing career is over. A client may even finally have a hip replacement they've been putting off for a decade. 

The point is that you have to be educated in order to adjust to clients as they evolve as people.  And, in order to do that, you have to be educated - and stay educated.

This is one reason why I'm so proud to be a part of the Elite Training Mentorship team.  Twice each month, this site updates with in-services, exercise demonstrations, case studies, sample programs, and webinars to keep you up-to-date on what's going on with the fitness industry.

I'm excited to announce that through tonight at midnight, you can get 30 days of Elite Training Mentorship for just $1 - and to sweeten the deal, we're offering the entire Fitness Business Weekend seminar (twelve 45-60 minute presentations) as a bonus to those who sign up.  This is an absurdly good value, so don't miss out.  Click here for more information.

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Strength and Conditioning Stuff You Should Read: 2/27/12

Here's a list of recommended strength and conditioning reading to kick off you week.

The Prevalence of Radiographic Hip Abnormalities in Elite Soccer Players - This recently published study in the AJSM shows us just how common hip issues are in soccer players - even if they're asymptomatic.  You can apply this to hockey players as well - and possibly on an even more pronounced level.  This goes hand-in-hand with some of my writings in the past about knees, shoulders, and lower backs.  Just because someone is asymptomatic does not mean that they are "healthy" - and this is why assessment and an understanding of population-specific norms are so important!

Band-Assisted 1-arm Push-ups: A Better Alternative - My buddy Shon Grosse outlines a good progression for those looking to build up to a one-arm push-up.

Causes International - This isn't so much fitness-related, but I think it's a great organization worth checking out. The folks at Causes International provide an opportunity for you to help raise money for your favorite charities by donating your used electronics (a process known as upcycling).  Most people have old gadgets kicking around the house, and these can easily be upcycled to benefit others and protect the environment.

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The Best of 2011: Stuff that was Fun to Write/Video

Today, I'll wrap up my "Best of 2011" series by highlighting the pieces that I enjoyed creating.  Check them out: 1. 11 Years, 11 Lessons, 100 Pounds - This T-Nation article recapped my long journey in the strength and conditioning world to get to where I am.  It was definitely one of my most popular articles of all time at T-Nation. 2. The Fitness Business Blueprint - This product was a blast to create because I think it filled a gaping hole in the market.  Until we launched it, nobody had created a fitness business product that didn't just discuss how to grow a business, but also how to improve as a trainer/coach.  I had a blast collaborating with Pat Rigsby and Mike Robertson on it.

3. What I Learned in 2010 - I enjoy writing these articles every year, because they serve as a great opportunity to revisit some of the most valuable lessons from the previous year.  And, as the saying goes, the best way to master something is to teach it to others. 4. Strength and Conditioning Program Success: The Little Things Matter - This was a fun blog to write, as I did so right around the time when several of our athletes were recognized for some awesome achievements.  It gave me a chance to reflect on why they were successful - and why many other folks aren't.  There will be some valuable takeaways for you, regardless of your athletic or fitness goals. 5. Oblique Strains in Baseball: 2011 Update - I'd written about oblique strains in the past, but they continue to be the big fat white elephant in the corner that is being ignored in the context of baseball development.  Hopefully this article got some people to start paying attention to the fact that it's just the fallout of a lot of things that are wrong with the current approaches being employed with respect to baseball strength and conditioning. 6. The IYCA High School Strength and Conditioning Coach Certification - I was fortunate to be a contributor on this awesome resource that will hopefully change the tide of how high school athletes are trained.  Based on the feedback we've received thus far, it's already helped tremendously in this regard.

7. Strength Training Program Success: How Dr. P did at 47 What He Couldn't Do at 20 or 30 - This blog (and accompanying video) were awesome because our entire gym got involved on this goal - and were there to see our good friend accomplish it. 8. The Everything Elbow In-Service - This was an in-service I filmed for our staff this summer to prepare them for all the elbow issues that may come through our doors.  It lasted 32 minutes, and sold far better than I would have imagined - and led to a lot of requests for us to continue filming staff in-services and making them available for sale.

9. Strength and Conditioning Programs: Think the Opposite - This has a few tips about a counterintuitive way to achieve success in training and in business. 10. Hip Pain in Athletes: The Origin of Femoroacetabular Impingement - FAI is becoming more and more common (especially in young athletes), and in this blog, I talk about some of the reasons why. That wraps up our "Best of 2011" series.  Thank you very much for your support of EricCressey.com in 2011; I'm looking forward to making 2012 even more memorable! Sign-up Today for our FREE Newsletter and receive a four-part video series on how to deadlift!
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Down on Lumbar Flexion in Strength Training Programs? Enter the Reverse Crunch.

The other day, I got an email from another fitness professional saying that he really liked my Maximum Strength training program, but that he'd have left out the reverse crunches if it was his strength training program because he "doesn't use any lumbar flexion work" in his programming anymore.

Given that the book was published in 2008, I'd gather that he is under the assumption that I've jumped on board the anti-flexion bandwagon that's been piling up members in droves over the past 3-4 years.  That perception certainly has backing.  Afterall, if you want to herniate a disc, go through repeated flexion and extension at end range.  If you want to see a population of folks with disc herniations, just look at people who sit in flexion all day; it's a slam dunk.

And, you certainly don't want to go into lumbar flexion with compressive loading.  As far back as 1985, Cappozzo et al. demonstrated that compressive loading on the spine during squatting increased with lumbar flexion.

These points in mind, I'm a firm believer that you should avoid:

a) end-range lumbar flexion

b) lumbar flexion exercises in those who already spend their entire lives in flexion

c) lumbar flexion under load

It seems pretty cut and dry, right?  Don't move your lumbar spine and you'll be fine, right? Tell that to someone who lives in lumbar hyperextension and anterior pelvic tilt.  Let me make that clearer:

Flexion from an extended position to "neutral" is different than flexion from "neutral" to end-range lumbar flexion.

In the former example, we're just taking someone from 20 yards behind the starting line up to the actual starting line.  In the latter example, we're taking someone from the starting line, through the finish line, and then violently through the line of people at the snack shack 50 yards past the finish line as nachos and Italian ice fly everywhere and the spectators scurry for cover.  You get a gold star if you take out the band, too.

If you're someone who trains predominantly middle-aged to older adult clients, by all means, nix flexion exercises.  However, I deal with loads of athletes - most of whom live in lumbar extension and anterior pelvic tilt.

Now, I'll never be a guy who has guys doing sit-ups or crunches, as they can shorten the rectus abdominus, thereby pulling the rib cage down when we're working hard to improve thoracic extension and rotation.  Additionally, most athletes absolutely crank on the neck with these - and that leads to a host of other problems.

For reasons I outlined in a recent post, Hip Pain in Athletes: The Origin of Femoroacetabular Impingement, we need to work to address anterior pelvic tilt and excessive lumbar extension - which can lead to a "pot belly" look even in athletes who are quite lean.

Enter the reverse crunch, which selectively targets the external obliques over the rectus abdominus.  As Shirley Sahrmann wrote in Diagnosis and Treatment of Movement Impairment Syndromes, "The origin of this muscle from the rib cage and its insertion into the pelvis are consistent with the most effective action of this muscle, that is, the posterior tilt of the pelvis."

We utilize the reverse crunch as part of a comprehensive anterior core strengthening program that also includes progresses from prone bridging variations to rollout variations and TRX anterior core work (and, of course, anti-rotation exercises to improve rotary stability).  And, I can say without hesitate that this addition was of tremendous value to an approach that got cranky baseball hips and spine healthier faster than ever before at Cressey Performance.

In summary, remember that flexion isn't the devil in a population that lives in extension. Contraindicate the person, not the exercise.

To learn more about our comprehensive approach to core stabilization, be sure to check out Functional Stability Training of the Core.

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Hip Pain in Athletes: The Origin of Femoroacetabular Impingement?

Over the weekend, I attended my third Postural Restoration Institute seminar, Impingement and Instability.  I’ve written previously about how this school of thought has profoundly impacted the way that we handle many of our athletes – and this past weekend was certainly no exception.  This weekend was also my first chance to meet and learn directly from Ron Hruska, the man initially responsible for bringing many of these great ideas to light. While I am admittedly still processing all the awesome information from the weekend, I wanted to write today about one big “Ah-Ha” moment for me over the weekend.  At some point on Day 2, Ron said something to the effect of (paraphrased):

“A superior acetabulum isn’t much different than an acromion on a scapula.”

My jaw practically hit the floor.  I joked with the seminar organizer that I needed to go into the restroom to yell at myself for a few minutes for not thinking of this sooner.  Let me explain… Over the past few years, there has been a huge rise in hip injuries in athletes (I'd even written about it HERE in response to a New York Times article about number of hip injuries in baseball).  Sports hernias, labral tears, and femoroacetabular impingement (FAI) are commonplace findings on the health histories that I see every day on first-time evaluations. In terms of FAI, you can have bony overgrowth of the femoral head (cam), acetabulum (pincer), or both (mixed), as the graphic from Lavigne et al. below demonstrates:

  Many folks say that we’re getting better diagnostically and that’s why the prevalence has increased in recent years.  Let’s be real, though, folks: if we’d had hip pain and dysfunction on this level for decades, don’t you think anecdotal evidence would have at least tipped us off?  I find it hard that generations of athletes would have just rubbed some dirt on a painful hip, cowboyed up, and put up with it. Consider those over the age of 60, though.  Sher et al. reported that a whopping 54% of asymptomatic shoulders in this population have rotator cuff tears; that doesn’t even include those who actually have pain!  Why does this happen?  They impinge over and over again on the undersurfaced of the acromion process secondary to poor thoracic positioning, scapular stabilization, breathing patterns, and rotator cuff function.  The end result is reactive changes on the acromion process that lay down more and more bone as the years go on.  And, an anteriorly tilted scapula kicks that impingement up a notch.  The “early” cuff irritation likely comes in those with Type 3 (beak-shaped) acromions, whereas the Type 1 (flat) and Type 2 (hook) acromions need time to lay down more and more bone for their anterior tilt to bring them to threshold.

Conversely, consider femoroacetabular impingement of the hip.  You can get bony overgrowth of the acetabulum, femoral head, or both.  It’s widely debated whether those with FAI are born with it, or whether it becomes part of normal development in some kids.  Well, I guess it would depend on whether you consider playing one sport to excess year-round “normal.” You know what?  I’d estimate that over 90% of the femoroacetabular impingement cases I’ve seen have come in hockey, soccer, and baseball players.  What do these sports have in common?  They all live in anterior pelvic tilt – with hockey being the absolute worst.  Is it any surprise that the incidence of FAI and associated hip issues has increased dramatically since the AAU generation rolled in and kids played the same sport all 12 months of the year? Conversely, I’ve never seen a case of FAI in a field hockey player.  Additionally, when I just asked my wife (who rowed competitively in college) if she ever saw any hip issues in her teammates in years of rowing, she joked that there weren’t any until they added distance running to their training. Field hockey players and rowers live in flexion (probably one reason why they have far more disc issues).  And, taking it a step further, I’ve never seen an athlete with FAI whose symptoms didn’t improve by getting into a bit more posterior pelvic tilt.

Finally, a 2009 study by Allen et al. demonstrated that in 78% of cases of cam impingement symptoms in one hip, the cam-type femoroacetabular impingement was bilateral (they also found pincer-type FAI on the opposite side in 42% of cases).  If this was just some “chance” occurrence, I find it hard to believe that it would occur bilaterally in such a high percentage of cases.  Excessive anterior pelvic tilt (sagittal plane) would be, in my eyes, what seems to bring it about the most quickly, and problems in the frontal and transverse planes are likely to blame for why one side presents with symptoms before the other. People have tried to blame the increased incidence of hip injuries on resistance training.  My personal opinion is that you can’t blame resistance training for the incidence, but rather the rate at which these issues reach threshold.  Quality resistance training could certainly provide the variety necessary to prevent these reactive changes from occurring at a young age, or by creating a more ideal pelvic alignment to avoid a FAI hip from reaching threshold. Conversely, a “clean-squat-bench” program is a recipe for living in anterior tilt – and squatting someone with a FAI is like overhead pressing someone with a full-thickness cuff tear; things get ugly quickly.

Honestly, this probably isn’t revolutionary for folks out there – particularly in the medical field – who have watched the prevalence of femoroacetabular impingement rise exponentially in recent years, but Ron made a great point to reaffirm a thought I’d been having for years and strengthened the argument.  And, more important than the simple “Ah-Ha” that comes with this perspective is the realization that an entire generation of young athletes have been so mismanaged that we’ve actually created a new classification of developmental problems and pathologies: femoroacetabular impingement, labral tears, and sports hernias. Thanks, Ron, for getting me thinking! For more information on appropriately managing kids during these critical development time periods, check out the International Youth Conditioning Association’s High School Strength and Conditioning Certification, which I helped to write.

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Hip Injuries In Baseball

Q&A: Hip Injuries in Baseball Q: On Sunday, The New York Times published this article that discusses the dramatic increase in hip injuries in Major League Baseball in recent years.  I know you work with a ton of baseball players and was curious about your thoughts on the article.  Do you agree with their theories? A: As always, my answer is "kind of" or "maybe."  I think they make some great points in the article, but as is the case with mainstream media articles, they're written by reporters with word count limits, so a lot of the most important points get omitted.  For example, with respect to the hips, it isn't as simple as "weak or strong."  You can have guys with ridiculously strong adductors that are completely overused, balled up, and short - but terribly weak hip extensors and abductors.  So, part of the problem is that journalists don't even qualify as casual observers to exercise physiology, so the public only gets part of the story.

(Sorry, but that digression was totally worth it.) First, I agree that one of the reasons we are seeing more of these issues is because doctors have become better at diagnosing the problems.  The "corollary" to this would be that the issues are perceived as more severe because so few physical therapists, athletic trainers, and strength and conditioning coaches are comfortable treating and preventing the problems.  That's not to say that hip issues aren't serious in nature; it simply implies that there is a divide between diagnostic capabilities and treatment/prevention strategies. Second, I agree wholeheartedly that early specialization at the youth levels can lead to injuries down the road.  We're dealing with some significant rotational velocities at the hips.  In previous analyses of professional hitters, the hips rotated at a velocity of 714°/second.  This same velocity isn't the same with little leaguers, but with skeletally immature children, it doesn't take as much stress to impose the same kind of damage.  So, I don't see it as at all remarkable that some pro ballplayers have hip problems after they may have played baseball year-round from age 9 all the way to the time they got drafted.  They also have bad shoulders, elbows, knees, and lower backs that have taked years to reach threshold.  It just so happens that folks are getting better at diagnosing these problems, so we now have an "epidemic," in some folks' eyes. What I can tell you, though, is that it's borderline idiocy to think that strength training is responsible for these problems.  Injuries don't occur simply because you enhance strength. In fact, muscular strength reduces the time to threshold for tendinopathies, and takes stress off passive restraints such as ligaments, menisci, labrums, and discs. Making this assumption is like saying that strength training drills to bolster scapular stability may be the reason we see more shoulder and elbow injuries nowadays.  Um, no.  Shoulders and elbows crap out because of faulty mechanics, poor flexibility (e.g., shoulder internal rotation ROM), bad tissue quality, and muscular weakness.  Granted, the shoulder (non-weight-bearing) and hips (weight-bearing) have different demands, but nobody ever tried to pin the exorbitant amount of arm problems in pitchers on "the advent of strength training." That said, injuries occur when you ignore things that need to be addressed: pure and simple. To that end, I can tell you that a large percentage of the baseball players I see - including position players, pitchers, and catchers - have some signficant hip ROM and tissue quality problems.  In terms of range of motion, the most common culprints are hip internal rotation deficit (HIRD) and a lack of hip extension and knee flexion (rectus femoris shortness).  Pitchers are often asymmetrical in hip flexion, too, with the front leg having much more ROM. In terms of tissue quality, the hip external rotations, hip flexors, and adductors are usually very restricted. This is has proven true of guys who lift and guys who don't lift.  The latter group just so happens to be skinny and weak, too! Done appropriately, strength training isn't causing the problem - particularly when we are talking about huge contracts that restrict how aggressive programming can be.  Trust me; guys with $20 million/year contracts aren't squatting 500 pounds very often...or ever. The risk-reward is way out of whack, and no pro strength coach is going to put his job on the line with programming like that. However, strength training may be indirectly contributing to the problem by shifting an athlete's focus away from flexibility training and foam rolling/massage.  Pro athletes are like everyone else in this world in that they have a limited time to devote to training, but to take it a step further, they have a lot of competing demands for their attention: hitting, throwing, lifting, sprinting, stretching, and soft tissue work.  So, they have to pick the modalities that give them the biggest return on time investment and prioritize accordingly in terms of how much time they devote to these initiatives.  Some guys make bad choices in this regard, and hip flexibility and tissue quality get ignored.

mm1

Baseball is a sport that doesn't permit ignorance, unfortunately, and this is one of many reasons why it has one of the highest injury rates in all of professional sports.  We are talking about an extremely long competitive season with near daily games - a schedule that makes it challenging to maintain/build strength, flexibility, and tissue quality.  Throwing a baseball is also the fastest motion in all of sports.  Rotational sports have the pelvis and torso rotating in opposite directions at the same time.  And, as I noted in Oblique Strains and Rotational Power, most professional ballplayers have a stride length of about 380% of hip width during hitting.  It is really just a matter of which joint will break down first: hip, knee, or lower back.  Taking immobile hips with poor tissue quality out into a long season with these demands is like doing calf raises in the power rack when someone is around with a video camera: you are just asking for a world of hurt.

So, what to do?  Well, first, get cracking on tissue quality with regular foam rolling and massage (the more an athlete can afford, the better).  Here is the sequence all Cressey Performance athletes go through before training.

In many of our guys, we also add in extra adductor rolling on the stretching table.

Second, you've got to hammer on flexibility.  We spend a ton of time with both static stretching and dynamic flexibility.  Here are a few of the static stretching favorites (the first to gain hip internal rotation, and the second to gain hip extension and knee flexion ROM):

lyingknee-to-kneestretch

kneelingheeltobuttstretch

Third, as Dr. Eric Cobb has written, you use resistance training to "cement neural patterns."    This includes all sorts of lower-body lifting variations - from single-leg movements, to glute-ham raise, to deadlifting and squatting variations - and multi-directional core stability drills.  And, often overlooked is the valuable role of medicine ball training in teaching good hip (and scap) loading patterns:

For more information, check out my previous newsletter, Medicine Ball Madness, which describes our off-season medicine ball programs in considerable detail.

All taken together, my take is that the increase in hip injuries at the MLB level has everything to do with early baseball specialization and improved diagnostic capabilities.  However, when you examine hip dysfunction under a broader scope, you'll see that this joint breaks down for many of the same reasons that lower backs and knees reach threshold: inattention to tissue quality and targeted flexibility training.  Strength training works synergistically with these other components of an effective program just like it would at any other joint.

*A special thanks goes out to Tony "Explosive Calves" Gentilcore for being a good sport in the videos in this newsletter.

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