All Young Athletes are “Injured” – even if they don’t know it

Written on January 7, 2011 at 7:27 am, by Eric Cressey

I’ve written quite a bit in the past about how one should always interpret the results of diagnostic imaging (MRI, x-ray, etc.) very cautiously and alongside movement assessments and the symptoms one has.  In case you missed them, here are some quick reads along these lines:

Preventing Lower Back Pain: Assuming is Okay
Who Kneeds “Normal” Knees?
Healthy Shoulders with Terrible MRIs?

While some of these studies stratified subjects into athletes and non-athlete controls, not surprisingly, all these studies utilized adult subjects exclusively.  In other words, we’re left wondering if we see the same kind of imaging abnormalities in asymptomatic teenage athletes, which is without a doubt our most “at-risk” population nowadays.

That is, of course, until this study came out: MRI of the knee joint in asymptomatic adolescent soccer players: a controlled study.

Researchers found that 64% of 14-15 year-old athletes had one or more knee MRI “abnormalities”, whereas those in the control group (non-athletes), 32% had at least one “abnormality.”  Bone marrow edema presence was markedly higher in the soccer players (50%) than in the control group (3%).

Once again, we realize that just about everyone is “abnormal” – and that we really don’t even know what “healthy” really is.  So, we can’t hang our hat exclusively on what a MRI or x-ray says (especially since we don’t have the luxury of knowing with every client/athlete we train).  What to do, then?

Hang your hat on movement first and foremost in an asymptomatic population.  Do thorough assessments and nip inefficiencies in the bud before they become structural abnormalities that reach a painful threshold.

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ACL Grafts: Which is Best? A Strength Coach’s Perspective

Written on November 15, 2010 at 3:53 am, by Eric Cressey

A few weeks ago, I came across this recent study of different ACL grafts.  It found that there was no difference in follow-up success rates at two-year mark between hamstrings and patellar tendon grafts.  The patellar tendon group did, however, exhibit more anterior knee pain – which isn’t a surprise because it’s not uncommon to see longer term tendinosis in athletes with patellar tendon grafts even after their “rehabilitation period” is over.  That said, I would be interested to see what would happen if they:

a) evaluated those patellar tendon graft subjects who received soft tissue treatments as part of their rehabilitation versus those who didn’t (my experience says that the anterior knee pain goes away sooner when manual therapy is present) .

b) evaluated those who went to effective strength and conditioning programs immediately post-rehabilitation versus those who didn’t (my hunch would be that those who continued to activation/strengthen the posterior chain would have experienced less anterior knee pain).

c) looked at performance-based outcomes at ~12-18 months in the hamstrings group, as these folks have more “intereference” with a return to normal training because of the graft site (you want to strengthen the posterior chain, but can’t do that as soon if you are missing a chunk of the hamstrings).  My experience has been that patellar tendon patients can do a lot more with their strength and conditioning program sooner than those who have hamstrings grafts.

It’s not to necessarily say that one is better than the other, as they both have their pros and cons – but I think this study potentially casts patellar tendon grafts in a less favorable light when the truth is that hamstrings grafts can have just as many complications down the road.  Above all else, the best ACL grafts are the ones that the surgeon is the most comfortable using – so pick your surgeon and defer to his expertise.

As an interesting aside to this, I remember Kevin Wilk at an October 2008 seminar saying that 85% of ACL reconstructions in the U.S. are performed by doctors that do fewer than 10 ACL reconstructions per year.  So, don’t just find a surgeon; find a surgeon that does these all the time and has built up a sample size large enough to know which ACL graft site is right for you, should you (unfortunately) ever “kneed” one (terrible pun, I know).

Related Posts

Who “Kneeds” Normal Knees?

An Intelligent Answer to a Dumb Question: A Review of “The Single-leg Solution”

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Strength Training Programs: When Did “Just Rest” Become a Viable Recommendation?

Written on September 2, 2010 at 7:14 am, by Eric Cressey

I suppose this blog title is more of a rhetorical statement than an actual question, but I’m going to write it anyway.

Just about every week, I get someone who comes to Cressey Performance – either as a new client, or as a one-time consultation from out of town – and they have some issue that is bugging them to the point that they opted to see a doctor about it.  This doctor may have been a general practitioner or an actual sports orthopedist.  In many cases, the response from this medical professional is the same “Just rest.”

“It hurts when you lift? Then stop lifting.”

Huh?  When did COMPLETE rest because a viable recommendation?

In case folks haven’t noticed, 64% of Americans are overweight or obese.  Even if rest was the absolute key to getting healthy, telling them to not move is like not seeing the forest through the trees.  Your bum knee will feel better, but you’ll have a heart attack at age 43 because you’re 379 pounds.

Oh, and nevermind the fact that exercise generally improves sleep quality, mooed, and immune, endocrine, and digestive function.  I’m not going to lie: I would rather have an achy lower back than be fat, chronically ill, sleep-deprived, impotent, angry, and constipated.

But you know what?  The good news is that you can still exercise and avoid all these issues – regardless of symptoms.  I can honestly say that in my entire career, I’ve never come across a single case who couldn’t find some way to stay active.

I’ve trained clients in back braces.

I’ve trained clients on crutches.

I’ve trained clients with poison ivy.

I’ve trained clients less than a week post-surgery.

I’ve trained a client with a punctured lung.

And, when I  did an internship in clinical exercise physiology, we trained pulmonary rehab patients in spite of the fact that they often had interruptions during their sessions to cough up phlegm for 2-3 minutes at a time.

All over the world, people are using exercise to rehabilitate themselves from strokes, heart attacks, spinal cord injuries – you name it.

However, Joe Average who sleeps on his shoulder funny and wakes up with a little niggle needs complete rest and enough NSAIDs to make John Daly’s liver cringe.

Sorry, but you’re going to need to be on crutches, in a back brace, with poison ivy and a punctured lung to get my sympathy.  And, you’re sure as heck not going to get it if you’re just “really sore” from your workout routine.  Seriously, dude?

I don’t care what your issue is: “just rest” is almost never the answer (a concussion would be an exception, FYI).  When a health care practitioner says it, it’s because he/she either a) doesn’t have the time, intelligence, or network to be able to set you up for a situation where you can benefit from exercise or b) doesn’t think you have enough self control to approach exercise in a fashion that doesn’t make it more harm than good.

There is almost always something you can do to get better and maintain a training effect.  While adequate rest for injured tissues is certainly part of the equation, it is just one piece in a more complex puzzle that almost always still affords people the benefits of exercise.

A great resource along these lines with respect to shoulders is our Optimal Shoulder Performance DVD set.  If you haven’t checked it out already, I’d highly recommend it.

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Random Friday Thoughts: 8/27/10

Written on August 27, 2010 at 2:01 am, by Eric Cressey

I didn’t do a “random thoughts” feature last week, so I’ll have to be extra random this week to make up for it.

1.  Bam!

You weren’t expecting me to come out with such amazing humor, were you?  Let that be a lesson to you; nobody is more random than EC (and nobody pulls off referring to himself in the third person better, either).

2. We all know that warm-ups are importance for enhancing power output, grooving appropriate neural patterns, and avoiding injury.  Here is some cool research that demonstrates how much more effective an active warm-up is than a passive warm-up when it comes to metabolic responses to exercise.  Namely, those who undergo an active warm-up demonstrate increased oxygen uptake and lower heart rate at a given workload than those participating in a passive warm-up (or no warm-up at all).

Anecdotally, I can tell you that there have been some days where I have felt like there was lead in my shoes and that there was no way I could get any interval training in on a day I’d planned to do so.  However, after a good dynamic flexibility warm-up, things “miraculously” got a lot easier.

3. A big congratulations go out to CP baseball athletes Jordan Cote, who committed to Coastal Carolina, and Joe Napolitano, who committed to Wake Forest. Both made their decisions last week and were featured at ESPN Boston.  We’re proud of our boys!

4. Likewise, I’ve got to give a congratulations to CP athlete and Lincoln-Sudbury All-American soccer player Cole DeNormandie, who became the second CP athlete featured on the cover of ESPN Rise Magazine in just the past few months (he joins Vanderbilt-bound pitcher Tyler Beede):

5. Mike Robertson published a three part series on Knee Pain Basics this past week; it is absolutely fantastic and I’d strongly encourage you to check it out.  Here are the links:

Part 1 – Philosophy
Part 2 – Programming
Part 3 – Coaching

Along these same lines, if you haven’t checked out Mike’s Bulletproof Knees Manual yet, I’d strongly encourage you to do so; it’s an excellent resource.

6. Greg Robins recently came down to spend some time observing the madness at Cressey Performance, and wrote up a detailed review of his experience; check it out: Science and Attitude: My Trip to Cressey Performance.

7. Here is a link to a great blog from Bret Contreras; it’s definitely worth a read: Sprint Research, Biomechanics, and Practical Implications – An Interview with Matt Brughelli.

8. I need some advice from the dog lovers out there.  Both my fiancee and I grew up with dogs and are thinking about getting a puppy after our wedding (less than six weeks away right now).  We both agree that we want something small – but at the same time, I’d like something that doesn’t make me want to instantly turn in my man card, like the silky poo for which she is currently pushing:

I actually really like bulldogs, but that’s going to be a tough sell for her unless it’s a “hybrid” where you can’t see a whole lot of bulldog.  Plus, I know a lot of people have said that they have a higher propensity for health issues.  I like puggles, mini pincers, and a few others, but what do those of you in-the-know suggest?  Thanks for any help you can offer!

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Who “Kneeds” Normal Knees?

Written on June 24, 2010 at 7:00 am, by Eric Cressey

Okay, this subject line was undoubtedly the worst of all time, but I promise that the information that follows will be worth reading.

A lot of you were probably hoping that you were out of the woods after I told you how bad your lower backs and shoulders look on diagnostic imaging such as MRIs.  I’m sorry to say that these “normal” structural disasters also apply to the knees.

A 2010 review from Flanigan et al. looked at studies that collectively examined the (1,862) knees of 931 athletes (40% of whom were professional athletes) using MRI and arthroscopy.  They found that 36% of these knees had full-thickness chondral defects, but 14% of these subjects had no symptoms when diagnosed.  The researchers concluded that “Over one-half of asymptomatic athletes have a full-thickness defect.”

Years earlier, Cook et al. screened 134 elite junior basketball players (268 total knees) for patellar tendinopathy.  At the time, only 19 (7%) of the 268 tendons presented with symptoms (pain) of tendinopathy.  Interestingly, though, under diagnosis with ultrasound, researchers actually found that 26% of all the tendons could be labeled tendinopathy based on the degenerative changes observed.  In other words, for every one that actually presents clinically with symptoms, more than three more go undiagnosed because people either haven’t reached threshold, or they move well enough to keep symptoms at bay.  Or they are Kurt Rambis and can just look so awkward that nobody even pays attention to their knee sleeve.

On the “move well enough” side of things, check out this study from Edwards et al.  They showed that these athletes with asymptomatic patellar tendinopathy actually land differently – both in terms of muscle recruitment and sequencing – than asymptomatic athletes without tendinopathy.  Fix that movement pattern neurally and strengthen the right muscles, and those issues never reach threshold.  Leave it alone, and they’ll be presenting with knee pain sooner than later.  Mike Robertson does a great job of outlining ways to improve knee health via movement retraining in his Bulletproof Knees Manual.

This is just the tip of the iceberg.  You’ll see loads of chronic ACL and meniscus tears that folks never realize they have.  I could go on and on. The take-home messages?  Yet again, diagnostic imaging is just one piece of the puzzle, and how you move is far more important.

Related Posts

The Importance of Ankle Mobility
Healthy Knees, Steady Progress

The Single-Leg Solution: Detailed Product Review

Written on May 5, 2010 at 6:43 pm, by Eric Cressey

About a year ago, Mike Robertson came out with an outstanding product, The Single-Leg Solution – and it reminded me of an experience I once had at a seminar.  A guy posed the following question to a panel of speakers in which I was included:

“If you could only choose one exercise to do, what would it be?”

We all agreed that it was a pretty stupid and unrealistic question, but reluctantly, we each answered.  In spite of my distaste for the question, I responded without hesitation: “Lunges – or any single-leg exercise, for that matter.”

In my eyes, single-leg work really is that valuable – and for a lot of reasons.

(Gold star to none other than me for thinking of up the title for him.  Booyeah.)

So why is single-leg work the best thing since sliced bread?

First, there is obviously going to be some direct carryover to the functional demands of life and athletics, as we spend most of our life on one foot in one capacity or another.  Muscular recruitment patterns are different for bilateral and unilateral exercises, so in terms of specificity, single-leg work really can’t be beat.

Second, it’s much more lower-back friendly, as you can load single-leg exercises appreciably without axial loading.  And, to take it a step further, it is easier to maintain neutral spine (and avoid lumbar flexion with compressive loading) with a split-stance – regardless of whether you axially load or hold the weights in the hands at one’s sides.  Simply stated, while single-leg exercises will never (at least in my eyes) take the place of squatting and deadlifting, they are absolutely essential supplemental exercises for one’s training repertoire.

Third, in the case of back pain (or hip pain, with femoroacetebular impingement being an example), they’re hugely helpful in allowing one to maintain a training effect in spite of whatever pain is present.

Fourth, single-leg exercises are hard.  Let’s face it: most people exercise like pansies and pick the exercises they like the most, not the ones that they need the most – or the ones that are the hardest.  This is 225 pounds for eight pretty effortless reps, which makes girls want him and guys want to be him (or something like that).

Fifth, Robertson insists they are good, and this guy knows as much about knees as anyone I’ve ever met.  If you want to keep your wheels strong and healthy for the long-term, including them is a no-brainer.

This is just five reasons to include single-leg work in your programming, and frankly, Mike includes a heck of a lot more in the 96-page tag-along manual that accompanies the 60-minute DVD in The Single-Leg Solution Package.

Knowing that single-leg work is important isn’t enough, though, as I see exercise enthusiasts and fitness professionals alike absolutely butchering the technique on these exercises.  And, they have absolutely no rhyme or reason for the “who, what, when, where, why” they include them; it is just throwing a wad of turd on the wall to see what sticks.  Optimal progress is dependent on population-specific exercise selection, pristine technical execution, and pinpoint exercise progressions – and this is where Mike really shines with this product.

So, whether you’re a personal trainer, bodybuilder, powerlifter, runner with knee pain, desk jockey with a bad back, or just some random dude who wants to get stronger, move better, and be just a little more awesome, I’d highly encourage you to check out The Single-Leg Solution..

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Stuff You Should Read: 4/27/10

Written on April 27, 2010 at 9:42 am, by Eric Cressey

Here are some reading recommendations for the week:

Q&A: Partial Knee Meniscectomy – Here is a great blog from Mike Robertson about training modifications for those who have had a portion of the meniscus removed.  Mike’s a brilliant knee guy (definitely check out Bulletproof Knees if you haven’t already).  Stick around Mike’s site and read a bit; he’s been kicking out some great content lately.

Are You Inflamed? - This is a good one on the nutrition side of things from Mike Roussell.

What Makes Roy Run? – This was an awesome article about Roy Halladay from a few weeks ago in Sports Illustrated.  To be blunt, a ton of professional baseball pitchers are lazy, one-trick ponies who rely on natural talent and don’t work hard to fulfill their potential.  Halladay is an exception to that rule: a guy who has worked incredibly hard to become arguably the best pitcher in the game.  This is a tremendously well-written and entertaining piece about the path he took and how he deserves every bit of success that comes his way.  Phillies fans are lucky to have him.

Great Results for a One-Time Consultation Client

Written on April 23, 2010 at 8:31 am, by Eric Cressey

Back in 2008, Ray Bennett made the trip from the West Coast all the way out to see me here in Massachusetts to figure out how to train around some chronic knee issues and get his body right so that he could compete as a bodybuilder at the young age of 41.  After his initial consult and training sessions at Cressey Performance, Ray “endured” four months of online consulting programs with me before we threw him back out into the wild on his own.

Recently, the bodybuilding dream came to fruition for Ray, and when I saw the pictures, I was so impressed that I asked if he’d be willing to be somewhat of a “posterboy” for our one-time consultation program at Cressey Performance (and my online consulting set-up) with a testimonial and some pictures.  As the pictures below show, those knees are doing just fine! Check it out:

“After meeting Eric in person for an evaluation at Cressey Performance in Boston I travelled back home to Portland, Oregon where I embarked on a new method of training.  I was so impressed with the knowledge and work ethic Eric and his performance facility displayed that I entered into a remote, on line coaching agreement.  For four months Eric programmed all my training, instructed me on proper exercise mechanics and answered all of my detailed questions without fail.  As an aging amateur bodybuilder I found I had hit a plateau in my training and was racking up more injuries than personal bests.  Eric understood that my failure to advance was due to a lack of focus on the core compound lifts and functional movement patterns.  With Eric’s help I began making progress again and all of my old aches and pains resolved.  He gave me the tools I needed to rediscover the reasons I go to the gym which are to excel and be my best.  Along these lines he helped inspire me to set a goal of actually competing in my very first contest.  I am in the best shape of my life, able to run and jump with my son pain free and am continually breaking personal lifting records that have stood for 25 years.  I am excited about my newfound viability in the gym and I have Eric to thank for laying the foundation.”

Ray Bennett
41 year old Natural Bodybuilder (2010 Vancouver Natural Bodybuilding Championship Competitor – 40 and over class)

A big congratulations goes out to Ray Bennett for not only an awesome transformation, but also for being living proof that no matter how annoying an injury is, you can always find a way to train around it and get better.

For more information on my one-time consultation service, click HERE.  Or, for online consulting, check out my Services Page.

Got Bum Knees? Want to Prevent Them? Check out this Sale.

Written on February 10, 2010 at 2:54 am, by Eric Cressey

Just wanted to give you all a heads-up that Mike Robertson is running a customer appreciation sale on Bulletproof Knees this week.  If you enter the coupon code KNEES2010 at checkout, it’ll get you $15 off the cost of the product.  I’ve raved about this resource in the past, as I think it’s the single-best corrective exercise product on the market with respect to knee pain.

Check it out: Bulletproof Knees. This sale only goes through the end of the day on Thursday, February 11.

The Importance of Ankle Mobility

Written on December 20, 2009 at 3:38 pm, by Eric Cressey

One of the most common issues we see in both athletes and our general population clients is a lack of ankle mobility – and more specifically, dorsiflexion range-of-motion.

For just about everything in life – from sprinting, to lunging, to squatting – we need a certain amount of dorsiflexion (think of how far the knees can go over the toes, or the positive shin angle one can create without lifting the heel).  If we don’t have it, we have to compensate.

One of the most common things we see in people with a lack of dorsiflexion ROM is an “out-toeing,” as this opens up the ankle and allows for them to get to where they need to be – even if it isn’t the most biomechanically correct way to do so.

This out-toeing may also be caused by hip internal rotation deficit (HIRD), so it’s important to assess both.  Check out this previous video blog for more information on how to assess for HIRD.

In a more “uncompensated” scenario, an athlete with poor ankle mobility may push through the toe instead of the heel – creating a quad-dominant propulsion in a scenario that should have signification contribution from the posterior chain musculature.  In the pictures below, you’ll see that Josh Beckett requires a considerable amount of dorsiflexion range-of-motion to get the job done (push-off without the heel leaving the ground).

This lack of ankle mobility may also negatively affect knee function.  Research has shown that a lack of ankle mobility can increase rotational torque at the knee.  This falls right in line with the joint-by-joint school of thought with respect to training; if you lock up a joint that should be mobile, the body will look elsewhere to create that range-of-motion.

This definitely applies to what happens to the lumbar spine during squatting in a person with an ankle (or hip) mobility deficit.  If someone can’t get sufficient dorsiflexion (or hip flexion and internal rotation), he’ll look to the lumbar spine to get that range of motion by rounding (lumbar flexion).  We know that combining lumbar flexion with compressive loading is a big-time no-no, so it’s important to realize that folks with considerable ankle mobility restrictions may need to modify or eliminate squatting altogether.

Take, for example, Olympic lifters who wear traditional Olympic lifting shoes with big heel lifts.  This artificially created ankle mobility allows them to squat deeper.  While I’m not a huge fan of this footwear for regular folks for squatting, used sparingly, it’s not a big deal.

Other individuals may be better served with hip dominant squat variations (e.g., box squats) that allow them to sit back and not squat quite as deep while they work to improve that ankle mobility and get closer to squatting deeper (with more dorsiflexion).  With these individuals, we supplement the more hip dominant squatting with extra single-leg work and plenty of deadlift variations.

The take-home message is that ankle mobility has some far-reaching implications, and it’s important to be able to assess it to determine if it’s the factor that’s limiting someone’s safe and efficient movement.

For more information on how to evaluate and address ankle mobility, check out Assess and Correct.

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