Baseball Strength and Conditioning Programs: How Much Rotator Cuff Work is Too Much? – Part 2

Written on January 10, 2012 at 9:34 pm, by Eric Cressey

In part 1 of this feature, I talked about how many throwers actually overuse the rotator cuff because they don’t appreciate that throwing in itself is a tremendously stressful challenge to the shoulder.  I also made the point that cuff timing is more often the problem than cuff strength, so many folks are really training the rotator cuff incorrectly with thousands of reps of band exercises.  Let’s examine that in a bit more depth.

First, I should preface this piece by saying that I think there are definitely places for utilizing bands to strengthen the rotator cuff in a baseball training context.  They obviously provide outstanding convenience for on-field work and travel circumstances, as well as scenarios where players may not have qualified professionals at hand to help with manual resistance work and rhythmic stabilizations. Some cuff work is better than no cuff work!  Additionally, many players swear by bands during the warm-up phase to help with getting blood flow to the shoulder complex with a bit of activation at the same time.

However, there are two primary issues with relying exclusively on bands:

1. In an external rotation variation, the resistance is actually greatest at the point (near maximal external rotation) where the athlete is weakest.  In other words, the band doesn’t ideally accommodate the strength curve.  This is a huge concern for me, as one of the biggest things I notice in athletes is that when training in a position of somewhat significant external rotation, they can’t “pick up” the resistance quickly enough. More on this later.

2. Most people simply overlook eccentric control.  This is something that is coachable, no doubt, but most people do band exercises for so many reps per set that the athlete can quickly lose focus and resort back to bad habits.

As you can imagine, these are shortcomings that also exist – albeit to a slightly lesser extent – with cable and dumbbell/plate external rotation rotator cuff strength exercises:

So, how do we overcome these shortcomings while helping to address rotator cuff timing?  You have two great options.

1. Rhythmic Stabilizations

The true role of the rotator cuff is to stabilize the humeral head (ball) in the glenoid fossa (socket).  And, during throwing, it does a ton of work, as the humerus goes through extreme ranges of motion in all three planes.  Rhythmic stabilization drills are a great way to train the cuff to fire quicker, and they’re particularly valuable because you can train them at various points in the range of motion, modifying the challenge depending on how stable an individual is in a given position.  Plus, this is an outstanding way of monitoring cuff function over the course of weeks and months with athletes you see regularly; regular improvements are easily perceived.

You’ll notice that I don’t crank him back to extreme external rotation in this video; rather, we stop short of it and just assume that we’ll get some carryover in stability a bit further (as per previous research on carryover of isometric exercise).

The sky is really the limit in terms of how you train this one; we have about a dozen variations that we use on a daily basis.  A few quick guidelines:

a. The more congenital or acquired laxity an athlete has, the less aggressive you’ll want to be with your perturbations. When someone is less proficient, gently destabilizer, and apply the perturbations closer to the shoulder.  When someone is more stable, perturbate a bit more firmly, and apply it further down the arm.

b. I generally start those with significant laxity with closed chain exercises so that they can draw some stability from the floor.  Here’s an example:

c. Make sure that the scapula is positioned appropriately; it certainly shouldn’t be protracted, but don’t crank it into excessive retraction, either.  Just keep it from winging off the rib cage.

d. I like 2x/week rhythmic stabilizations during off-season training.  We typically integrate it between sets on lower-body strength training days.

2. Manual Resistance External Rotations

These drills are “where it’s at.”  On one hand, they are the best strength-building exercise for the cuff because they train it in its most function context: eccentric control.  However, more specific to today’s point, they are great for improving cuff recruitment at the most vulnerable point in the throwing motion: lay-back.

When we do a drill like this, I encourage the athlete to “pick it up early.”  In other words, I won’t apply downward pressure (eccentric overload) until they apply some external rotation force into my hand).  This is another variation I like to use:

Some quick guidelines for manual resistance external rotations:

a. Emphasize eccentric overload, but make sure you aren’t pushing all the way down, as most people will go into scapular anterior tilt as they are more internally rotated.  Pushing someone all the way down puts the shoulder in a pretty vulnerable position, as scapular stability is lost and the subacromial space is closed down.

b. Given that you have to apply the force further down the arm, make sure that the athlete isn’t cheating by just utilizing the wrist extensors.

c. Use the other hand to ensure ideal scapular positioning on manual resistance side-lying external rotations at 30 degrees abduction.  In the manual resistance external rotations at 90 degrees in the scapular plane, your other hand should “cup” the elbow to make sure that the rotation is taking place at the shoulder (as opposed to horizontal adduction/abduction).

d. I like to utilize manual resistance external rotations twice a week during the off-season, usually toward the end of upper body strength training sessions.  We’ll use less manual resistance work in this regard, though, when guys start to ramp up their throwing, as it tends to create a bit more soreness.

This wraps up our look at a different perspective on how to attack rotator cuff exercises with timing – and not just strength – in consideration.  For more information, I’d encourage you to check out Optimal Shoulder Performance: From Rehabilitation to High Performance.

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Baseball Strength and Conditioning Programs: How Much Rotator Cuff Work is Too Much? – Part 1

Written on January 9, 2012 at 8:15 am, by Eric Cressey

I just got back from presenting in front of 3,500 coaches at the American Baseball Coaches Convention in Anaheim.  I had an absolute blast, and since I received some great feedback from many coaches in attendance after my talk, I thought I’d use the first few posts of this week to recap a few highlights of my presentation.  To start off, one statement I made that I know turned some heads was:

I think most people overtrain the rotator cuff nowadays, and they do so with the wrong exercises, anyway.

To illustrate my point, I’m going to ask a question:

Q: What is the most common complication you see in guys as they rehabilitate following a Tommy John Surgery?

A: Shoulder problems – generally right around the time they get up to 120 feet.

Huh?  Shoulder pain is a post-operative complication of an elbow surgery?  What gives?

First, I should make a very obvious point: many of these guys deal with shoulder stiffness as they get back to throwing simply because they’ve been shut down for months.  That I completely expect – but remember that it’s stiffness, and not pain.  They always throw their way out of it.

The more pressing issue is what is taking place in their rehabilitation – and more specifically, what’s taking place with the synergy between their rehabilitation and throwing program. Let me explain.

Rehabilitation following a UCL reconstruction is extensive.  While different physical therapists certainly have different approaches, it will always be incredibly heavy on rotator cuff strength and timing, as well as adequate function of the scapular stabilizers.  Guys always make huge strides on this front during rehab, but why do so many have shoulder pain when they get further out with their long tossing?  The answer is very simple:

Most people don’t appreciate that throwing a baseball IS rotator cuff training.

Your cuff is working tremendously hard to center the humeral head in the glenoid fossa.  It controls excessive external rotation and anterior instability during lay-back.

It’s fighting against distraction forces at ball release.

And, it’s controlling internal rotation and horizontal adduction during follow-through.

Simultaneously, the scapular stabilizers are working incredibly hard to appropriately position and stabilize the scapula on the rib cage in various positions so that it can provide an ideal anchor point for those rotator cuff muscles to do their job.

A post-op Tommy John thrower – and really every player going through a throwing program – has all the same demands on his arm (even if he isn’t on the mound, where stress is highest).  And, as I wrote previously in a blog about why pitchers shouldn’t throw year-round, every pitcher is always throwing with some degree of muscle damage at all times during the season (or a throwing program).

Keeping this in mind, think about the traditional Tommy John rehabilitation approach.  It is intensive work for the cuff and scapular stabilizers three times a week with the physical therapists – plus many of the same exercises in a home program for off-days.  They’re already training these areas almost every day – and then they add in 3-6 throwing sessions a week.  Wouldn’t you almost expect shoulder problems?  They are overusing it to the max!  This is a conversation I recently had with physical therapist Eric Schoenberg, and he made another great point:

Most guys – especially at higher levels – don’t have rotator cuff strength issues; they have rotator cuff timing issues.

In throwing – the single-fastest motion in all of sports – you’re better off having a cuff that fires at the right time than a cuff that fires strong, but late.  Very few rotator cuff exercise programs for healthy pitchers take that into account; rather, it’s left to those doing rehabilitation.  Likewise, most of the programs I see altogether ignore scapular stability and leave out other ways to train the cuff that are far more functional than just using bands.

Now, apply this example back to the everyday management of pitchers during the season. Pitchers are throwing much more aggressively: game appearances, bullpens, and long toss.  They need to do some rotator cuff work, but it certainly doesn’t need to be every day like so many people think.

I’ll cover how much and what kind in Part 2.  In the meantime, if you’d like to learn more about the evaluation and management of pitchers, check out Optimal Shoulder Performance.

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Strength Exercise of the Week: Prone External Rotation

Written on January 4, 2012 at 6:33 am, by Eric Cressey

The prone external rotation is a strength exercise for the posterior rotator cuff that we’ve added to our strength and conditioning programs over the past few months with good success.  And, while the primary goal is to increase shoulder stability via improved rotator cuff function, the truth is that this drill also served as a motor control exercise to reeducate folks on what should be moving and when.

We use this drill a lot with guys who are in a dramatic anterior pelvic tilt, and start everything with the “gluteus tight, core braced” cues.  Effectively, this means that you force the athlete to actually externally rotate the shoulder instead of simply arching through the lower back to get to the desired “finish” point.  You’ll be amazed to see how many athletes have significantly less “observable external rotation” when they are locked into neutral spine.

You also want to cue the athlete to keep the scapula (shoulder blade) on the rib cage, but he/she doesn’t need to be aggressively pulled into scapular retraction in order to get there.

Once the scapula is set, I tell athletes to think about getting the ball to rotate in the socket without allowing the head of the humerus to slide down toward the table.  This is a very important cue, as many athletes will allow excessive anterior migration of the humeral head during external rotation exercises; we want them to learn to keep the ball centered in the socket.  If an athlete is really struggling with this, we may place a rolled up towel or half-roller underneath the anterior shoulder as feedback on where things should be.

Very rarely will we load this up, and in the rare instances we do, it wouldn’t be for more than 2.5 -5 pounds.  The shoulder is a joint with a broad range of movements that mandate a lot of dynamic stability, so we want to make sure things are working perfectly.

I’ll generally include this movement in the warm-ups for sets of eight reps – or we may use it as a filler on a lower-body day between sets of more compound strength exercises.  It can also serve as a great follow-up to shoulder mobility drill geared toward improving external rotation, as this is an avenue through which you can add stability to the range-of-motion you’re creating.

Give it a shot in your strength and conditioning programs and then let me know how it goes in the comments section below!

For more exercises along these lines, I’d encourage you to check out our Optimal Shoulder Performance DVD set.

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7 Reasons Baseball Pitchers Shouldn’t Do Year-Round Throwing Programs – Part 2

Written on December 1, 2011 at 9:06 am, by Eric Cressey

In Part 1 of this series, I outlined the first three reasons that I’m opposed to baseball pitchers using year-round throwing programs.  Here are the next four:

4. They need to get their shoulder and elbow range of motion back.

As I noted in Part 1, throwing a baseball is the single-fastest motion in sports.  With the crazy arm speeds one encounters, you have to keep in mind not only the muscles trying to accelerate the arm, but also the ones trying to slow it down.  This “braking” challenge is called eccentric stress – and I’ll talk more about it in a second.

What you need to know now, though, is that when left unchecked, significant eccentric stress can lead to tissue shortening.  If you need further proof, Reinold et al. reported that immediately after a pitching outing, pitchers lose an average of 9.5° of shoulder internal rotation and 3.2° of elbow extension – and that these losses persisted at 24 hours post-throwing.

Now, imagine these acute range of motion losses being left unchecked for an entire season – or a season that simply never ends because pitchers are always throwing.  That’s how elbows wind up looking like this:

(For more information, I’d encourage you to check out my Everything Elbow In-Service Video.)

Fortunately, we can prevent losses in range of motion during the season with appropriate mobility exercises, manual therapy, and breathing exercises – but the truth is that not everyone has access to these initiatives in terms of expertise, finances, or convenience.  So, while we work to educate the masses on arm care, emphasizing time off from throwing programs is also a key component of an overall strategy to reduce injury risk.

One last thing on this topic: it is a nightmare to try to improve shoulder or elbow range of motion in a pitcher during a season, as the very nature of throwing works against everything you’re trying to achieve.  The off-season is “where it’s at” in terms of optimizing range of motion in throwers.

5. They need to “dissipate” eccentric stress.

Okay, here’s where I take #4 and geek out a bit.  I apologize in advance.

Sometimes, you have to get away from the baseball world in order to learn about the baseball world.  To that end, I need to think Mike Reinold for bringing this great 2004 study from Tomiya et al to my attention.

These researchers created eccentric stress in muscle tissue of mice using an electrical stimulation model, and monitored blood markers of muscle damage for a period of time thereafter.  What you’ll see in the graph below is that myofiber disruption really peaks at three-days post-exercise, then start to return down to baseline, yet they still aren’t even there at seven days post-intervention.

Source: Tomiya A, et al. Myofibers express IL-6 after eccentric exercise. Am J Sports Med. 2004 Mar;32(2):503-8.

Now, let’s apply this to the world of pitching.  Every single pitcher who throws more than once every 7-10 days is surely pitching with some degree of muscle damage.  And, I can tell you that the two toughest challenges pitchers have reported to me are:

a) moving from starting to relieving

b) going from a 7-day high school or college rotation to a 5-day professional rotation

I’m firmly believe that pitchers need to throw in-season to stay strong, but I also know that we can’t trump physiology.  Sure, we need to have optimal nutrition and regeneration strategies in place, as we can’t just baby guys and expect them to get better.  However, make no mistake about it: high-level pitchers simply have to get good at pitching at 90% capacity (at best) if they are going to succeed.

If I already have a guy whose arm is working at a deficit for 8-9 months of throwing, the last thing I want to do is beat him up for the other three months with the same kind of volume and stress.

6. They need to allow any undetected low-grade injuries to heal.

As I discussed in an old blog, Pitching Injuries: It’s Not Just What You’re Doing; It’s What You’ve Already Done, most injuries (especially ulnar collateral ligament tears) come from the accumulation of chronic, low-level stress.  Maybe you get some calcification on your ulnar collateral ligament or a low-level rotator cuff tendinosis, and it takes a few years and hundreds of innings before something finally “goes.”

Old, low-level injuries are less likely to reach threshold if you give them some downtime and work on redistributing training stress.  By strengthening the rest of your body in the off-season, you’re dramatically reducing the demands on your rotator cuff with throwing.

You can’t teach other joints to share the burden if the burden is never removed temporarily.

7.  They need a chance to prioritize other competing demands.

Throwing is a good 20-30 minute endeavor each time you do it – and possibly even more.  When I think about all the things that pitchers can be doing to get better in the off-season from a strength and conditioning standpoint, I have a really hard time justifying giving away that much time and recovery capability.  There are other things that need to be prioritized at this time – and year-round throwing is an especially tough pill to swallow when you know that throwing is working against many of the very qualities – rotator cuff strength, scapular stability, mobility, and tissue quality – that you’re trying to establish.

Closing Thoughts

The lack of downtime from throwing is especially problematic in younger populations, as they are skeletally immature and weaker.  I’d argue that a really weak 15-year-old kid throwing 74-76 mph does far more damage to his body on each throw than a moderately strong professional player throwing 90-92 mph, especially given that the pro pitcher’s mechanics are more optimized to protect the arm.  This underscores the importance of “syncing up” mechanics, throwing programs, and the overall baseball strength and conditioning program.

Last, but certainly not least, remember that two weeks doesn’t constitute “time off.”  Rather, I firmly believe that pitchers need the ball completely out of their hands for at least two month per year, preferably continuously.  In other words, eight one-week breaks throughout the year is far from ideal, as it doesn’t really allow for positive adaptations to occur.

If you’re interested in learning more about managing the throwing shoulder, I’d encourage you to check out our DVD set, Optimal Shoulder Performance.

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7 Reasons Baseball Pitchers Shouldn’t Do Year-Round Throwing Programs – Part 1

Written on November 29, 2011 at 7:30 am, by Eric Cressey

Many of our professional baseball players at Cressey Performance are starting up their winter throwing programs this week after a full three-month break from throwing.  They’re always a bit rusty in the first week of tossing after the layoff, but every single one of them always “figures it out” in a matter of a few weeks – and still has plenty of time to get in a solid throwing program prior to heading off to spring training.  And, because they’ve been working hard in the gym on their strength, mobility, and soft tissue quality, they’re always better off in the end.

Still, there are those who insist that baseball pitchers don’t need time off from throwing.

I couldn’t disagree more.

I’m sure this will rub some folks the wrong way, but I can’t say that I really care, as most of those individuals can’t rationalize their perspectives outside of “guys need to work on stuff.”  I, on the other hand, have seven reasons why baseball pitchers need time off from throwing:

1.  They need to lose external rotation to gain anterior stability.

Having external rotation – or “lay back” – when is important for throwing hard, and research has demonstrated that simply throwing will increase shoulder external rotation range-of-motion over the course of a season.  This does not mean, however, that it’s a good idea to just have someone stretch your shoulder into external rotation, as I wrote previously: Shoulder Mobility Drills: How to Improve External Rotation (if you even need it).

You see, when you externally rotate the humerus (ball) on the glenoid (socket), the humeral head has a tendency to also translate anteriorly (forward).  In a well-functioning shoulder girdle, the rotator cuff musculature should prevent anterior instability, and it’s assisted by adequate function of the scapular stabilizers, which offer the dynamic stability to reposition the scapula in the right place to “accommodate” the humeral head’s positioning.  For the athletic trainers and physical therapists out there, this is really what you’re testing with an apprehension/relocation test.

The apprehension comes about because of either anterior instability or actual structural pathology (SLAP tear, rotator cuff impingement, or biceps tendinosis).  The relocation component is just the clinician posteriorly directing the humeral head to create the stability that should otherwise be created by the rotator cuff and scapular stabilizers.

The take-home message is that while just going on year-round throwing programs in hopes of increasing external rotation seems like a good idea on paper, it’s actually a terrible idea in the context of injury prevention.  Pitchers should actually lose a few degrees of external rotation each off-season intentionally, as it affords them an opportunity to improve their stability.  This leads us to…

2. They need a chance to get their cuff strength and scapular stability up.

Baseball pitching is the single-fastest motion in all of sports, as the humerus internally rotates at velocities in excess of 7,000°/second.  So, it should come as no surprise that at the end of a season, the strength of the rotator cuff and scapular stabilizers is significantly reduced.  Having dealt with many of our players for up to five off-seasons now, I have a unique appreciation for how they each respond differently to not only the stress of the season, but also to arm care programs that we initiate at season’s end.

It’s important to remember that improving rotator cuff strength is no different in terms of adaptation than improving a bench press or squat.  Adding 10% to a guy’s bench press might take three months in an intermediate population, or 12 months in a high-level lifter!  Adaptation of the rotator cuff and scapular stabilizers is comparable.  I need every minutes of those three months without throwing to get guys back to at least baseline, and hopefully a bit above it.

Can you imagine if some clown trying to improve his bench press went out and benched an additional 4-5 times a week on top of his regular strength and conditioning program?

His progress would be minimal, at best, and he’d be at a dramatically increased risk of injury.  Throwing during a dedicated, appropriate structured early off-season arm care program is no different.

3. They need an opportunity to do dedicated manual resistance rotator cuff exercises.

Ask anyone who has worked with throwers for any length of time, and they’ll always tell you that manual resistance exercises are the single-best option for improving rotator cuff strength.  This rotator cuff exercise approach allows you to emphasis eccentric strength better than bands, cables, and dumbbells allow.  It also keeps athletes more strict, as the one providing the resistance can ensure that the athlete isn’t just powering through the exercise with scapular stabilizers or lower back.

 The only downside to manual resistance rotator cuff exercises, though, is that because they generally prioritize eccentric strength, they will create more soreness.  With that in mind, we use them much more in the off-season than in the in-season, as we don’t want a pitcher throwing with added soreness.  They’re a great initiative in a comprehensive off-season baseball strength and conditioning program, but guys just don’t seem to like them as much in-season, presumably because both throwing and manual resistance rotator cuff exercises can be too much eccentric stress when combined.  As such, we used them a lot during the September-November periods, and then hold back in this area the rest of the year.

Of course, if you throw year-round, then you can forget about getting these benefits, as the last thing you want is to be sore while you’re “working on stuff” in the off-season.  That was sarcasm, in case you weren’t picking up on it.

In Part 2, I’ll be back with four more reasons baseball pitchers shouldn’t throw year-round.

In the meantime, to learn more about the management of throwers, I’d encourage you to check out the Optimal Shoulder Performance DVD set.

Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches used by Cressey Performance Pitchers after they Throw!

Baseball Strength and Conditioning: Early Off-Season Priorities 6-10

Written on September 21, 2011 at 8:15 am, by Eric Cressey

In Part 1 of this off-season baseball strength and conditioning series, I outlined the first five of my top 10 priorities when dealing with baseball players at the start of their off-season.  Today, I round out the top 10 “general” things always seem to be addressing with players coming in after a season.

1. Regaining lost mobility – This is an incredibly loaded topic that goes far beyond the scope of any blog or article, as it’s an entire two-day seminar or book! You see, losses in mobility – the ability to reach a desired position or posture – can be caused by a number of issues – and usually a combination of several of them.  Tissues can actually lose sarcomeres and become short after immobilization or significant eccentric stress (as with the deceleration component of throwing).  They can become stiff because of inadequate stability at adjacent joints (learn more HERE), protective tension (e.g., “tight” hamstrings in someone with crazy anterior pelvic tilt), or neural tension from an injury (e.g., disc herniation causing “tight” hamstrings).

The “Short vs. Stiff” issue is why you need to have a variety of tools in your “mobility toolbox.”  You need focal modalities like Active Release, Graston, and ASTYM techniques to assist with dealing with short tissues, whereas you need more diffuse modalities like traditional massage and foam rolling for dealing with stiffness (although both modalities can certainly help in the other regards, this is how I prefer to use them).

You need to understand retraining breathing appropriately and how posture affects respiratory function.  If you live in extension, you’ll have a poor zone of apposition in which the diaphragm can function.  The average human takes over 20,000 breaths per day.  If you don’t use your diaphragm properly, more of the stress is placed on the supplemental respiratory muscles: sternocleidomastoid, scalenes, pec major and minor, upper trapezius, and latissimus dorsi (to only name a few).  What are some insanely common sites of trigger points in just about everyone – especially thrower? Sternocleidomastoid, scalenes, pec major and minor, upper trapezius, and latissimus dorsi.  Improving respiratory function can be a complete game changer when it comes to enhancing mobility.  If you see a baseball player with a low right shoulder, prominent anterior left ribs, adducted right hip, huge anterior pelvic tilt, and limited right shoulder internal rotation, it’s almost always a slam dunk.

(Check out www.PosturalRestoration.com for more details on this front)

You may need low-load, long-duration static stretches to improve length in tissues that have lost sarcomeres.  This research has been around in the post-surgery community for decades (1984 research example here), but it’s actually not used all that much in strength and conditioning programs – presumably because of time constraints or the fact that most coaches simply don’t know how well it can work in the right people.

Finally, as we noted in our Assess and Correct DVD set, you also need dynamic flexibility drills in your warm-ups to reduce tissue and joint stiffness, and subsequent strength exercises in your strength and conditioning program to create adequate stability at adjacent joints to “hold” that new range of motion in place.

Many physical therapist employ heat early in a session to decrease stiffness prior to strengthening exercises, too.  The point is that there may be many different ways to skin a cat – but there are also a lot different types and sizes of cat.  And, for the record, I don’t condone skinning cats; it’s just a really gruesome analogy that has somehow “stuck” in our normally very politically correct society. Weird…but let’s move on.

2.Improving dynamic stabilization of the scapula – I say “dynamic stabilization” because you don’t just want scapular stability; you want a scapula with appropriate tissue length, stiffness, and density to allow for the desired movement.  A scapula that doesn’t move might be “stable,” but that’s not actually a good thing!

Truth be told, the scapular stabilizers generally fatigue before the rotator cuff does.  And, when the scapula isn’t positioned appropriately, the rotator cuff is at a mechanical disadvantage, anyway.  Additionally, poor scapular control can present as an internal rotation deficit at the shoulder, as you’ll just protract the shoulder excessively in place of internally rotating.  In other words, you can do all the rotator cuff exercises you want, but you don’t increase strength of the periscapular muscles, you’ll be spinning your wheels.  There are loads of drills that we use, but forearm wall slide variations are among our favorites:

3. Enhancing global strength while minimizing reactive training – As I’ve already noted in this series, we’re certainly spending a lot of time addressing specific areas of weakness like the rotator cuff, scapular stabilizers, and anterior core. However, I should be very clear that we’re still using “money” strength exercises like variations of the deadlift, single-leg exercises, squatting (in some of our guys), pull-ups, rows, push-ups, and dumbbell bench presses to get strong.  That said, the volume and intensity come down a ton on the reactive training side of things.  We’ll give our guys a few weeks off altogether from sprinting, as they’ve usually done a lot of that all season.  Plus, nixing all the sprinting and jumping for a few weeks ensures that they won’t tweak anything, given the soreness they’ll be working with from the strength training program – and it allows us to increase strength faster.

4. Putting guys in the right footwear – One thing that many folks don’t appreciate about playing baseball every day from February to October is the sheer amount of time one spends standing around in cleats, which will never be as comfortable as sneakers or going barefoot.  As such, one of the first things we do with most of our guys is get them into a good pair of minimalist shoes for training, as it gets them away from the rigidity, separation from the ground, and ankle mobility deficits that come with wearing cleats.  As I wrote previously, I’m a big fan of the New Balance Minimus.

Keep in mind that we ease guys into these minimalist shoe options, rather than throwing them in the footwear 24/7 right away.  They’ll start out just wearing them during training, and increase from there, assuming all goes well.

5. Normalizing sleep schedules - Professional baseball players (and really all professional athletes) have terrible sleep schedules.  Because most games are night games, they generally go to bed around 1-2AM and wake up anywhere from 7AM to 11AM.  The early risers I know will usually take a nap before going to the park, whereas the guys who sleep in roll out of bed and go straight to the park.  Additionally, much of this sleeping comes on planes and buses, which aren’t exactly comfortable places to get quality sleep.  I’m a firm believer that one hour of sleep before midnight is worth two hours after midnight – but this simply isn’t an option for professional baseball players.

That said, we try to normalize things as much as possible in the off-season.  All our athletes are encouraged to try to go to bed and wake up at the same time – and to hit the hay before 11pm every night.  Any naps they can get during the day are a bonus, too!

Wrap-up

While I’ve outlined ten things we address in the early off-season, these are really just the tip of the iceberg, as every player is unique and needs an individual approach.  That said, the one general theme that applies to all of them is that we’re shifting paradigms – meaning that some things about our philosophy may differ from what they’ve experienced.  Some guys may be accustomed to just “football workouts.”  Others may have been coddled with foo-foo training programs where they didn’t work hard.  Some guys ran distances. Some guys crushed the rotator cuffs every day while ignoring the rest of the body.

The point is that it’s not just our job to find what we feel is the best fit for these athletes, but also to educate them on why the unique program we’ve designed for them is a better approach than they can get anywhere else.

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Hip Pain in Athletes: The Origin of Femoroacetabular Impingement?

Written on August 22, 2011 at 6:39 am, by Eric Cressey

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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Shoulder Mobility Drills: How to Improve External Rotation (if you even need it)

Written on May 31, 2011 at 8:12 am, by Eric Cressey

Last summer, a college pitcher came up to Cressey Performance from the South to train for a month before his summer league got underway. He was seven months post-op on a shoulder surgery (Type 2 SLAP) and had been working his way back. Unfortunately, his arm was still bothering him a bit when he got up to see us.

After the first few days at CP, though, he told me that his arm felt as good as it’s felt in as long as he could remember. He’d been doing a comprehensive strength and conditioning program, but the “impact” stuff for him had been soft tissue work, some Postural Restoration Institute drills, an emphasis on thoracic mobility, and manual stretching into internal rotation, horizontal adduction, and shoulder flexion. From all the rehab, his cuff was strong and scapular stabilizers were functioning reasonably well – which led me to believe that his issues were largely due to tissue shortness and/or stiffness.

This realization made me immediately wonder what he’d been doing in the previous months for mobility work for his arm – so I asked. He then demonstrated the manual stretching series that every pitcher on his team went through every day on the table with their athletic trainer. Each stretch was done for 2x20s – and two of those stretches took him into extreme external rotation and horizontal abduction. I was pretty shocked.

Me: “You’re probably not the only guy on your team rehabbing right now, huh?”

Him: “No; there are actually too many to count.”

Me: “Elbows, too, I’m sure.”

Him: “Yep.”

Want to irritate a labrum, biceps tendon, or the undersurface of the rotator cuff? Stretch a thrower into extreme external rotation and simulate the peel-back mechanism. This also increases anterior capsular laxity and likely exacerbates the internal impingement mechanism over the long-term. To reiterate, this is a bad stretch!

Want to make an acromioclavicular joint unhappy? Stretch a thrower into horizontal abduction like this (again, this is a BAD stretch that is pictured):

Want to irritate an ulnar nerve or contribute to the rupture of an ulnar collateral ligament? Make sure to apply direct pressure to the forearm during these dangerous stretches to create some valgus stress. This is a sure-fire way to make a bad stretch even worse:

These stretches are very rarely indicated in a healthy population – especially pitchers who already have a tendency toward increased external rotation. The shoulder is a delicate joint that can’t just be manhandled – and when you’re dealing with shoulders that are usually also pretty loose (both from congenital and acquired factors), you’re waiting for a problem when you include such stretches. In fact, I devoted an entire article to this: The Right Way to Stretch the Pecs.

Everyone thinks that shoulder external rotation and horizontal abduction alone account for the lay-back in the extreme cocking position.

In reality, though, this position is derived from a bunch of factors:

1. Shoulder External Rotation Range-of-Motion – and this is the kind of freaky external rotation you’ll commonly see thanks to retroversion and anterior laxity:

2. Scapular Retraction/Posterior Tilt

3. Thoracic Spine Extension/Rotation

4. Valgus Carrying Angle

So, how do you improve lay-back without risking damage to the shoulder and elbow?

1. Soft tissue work on Pec minor/major and subscapularis – Ideally, this would be performed by a qualified manual therapist – especially since you’re not going to be able to get to subscapularis yourself. However, you can use this technique to attack the pecs:

2. Exercises to improve scapular retraction/depression/posterior tilt – This could include any of a number of horizontal pulling exercises or specific lower trap/serratus anterior exercises like the forearm wall slide with band.

3. Incorporate specific thoracic spine mobility drills – In most pitchers, you want to be careful about including thoracic spine mobility drills that also encourage a lot of glenohumeral external rotation. However, when we assess a pitcher and find that he’s really lacking in this regard, there are two drills that we use with them. The first is the side-lying extension-rotation, which is a good entry level progression because the floor actually limits external rotation range-of-motion, and it’s easy to coach. I tell athletes that they should think of thoracic spine extension/rotation driving scapular retraction/depression, which in turn drives humeral external rotation (and flexion/horizontal abduction). Usually, simply putting your hands on the shoulder girdle and guiding them through the motion is the best teaching tool.

A progression on the side-lying extension-rotation is the side-lying windmill, which requires a bit more attention to detail to ensure that the range-of-motion comes from the right place. The goal is to think of moving exclusively from the thoracic spine with an appropriate scapular retraction/posterior tilt. In other words, the arm just comes along for the ride. The eyes (and head) should follow the hand wherever it goes.

Again, these are only exercises we use with certain players who we’ve deemed deficient in external rotation. If you’re a thrower, don’t simply add these to your routine without a valid assessment from someone who is qualified to make that estimation. You could actually make the argument that this would apply to some folks in the general population who have congenital laxity as well (especially females).

4. Throw!!!!! – Pitchers gain a considerable amount of glenohumeral external rotation over the course of a competitive season simply from throwing. Sometimes, the best solution is to simply be patient. I really like long toss above all else for these folks.

In closing, there are three important things I should note:

1. You don’t want to do anything to increase valgus laxity.

2. You’re much more likely to get hurt from being “too loose” than you are from being “too tight.” When it comes to stretching the throwing shoulder, “gentle” is the name of the game – and all mobility programs should be as individualized as possible.

3. Maintaining internal rotation is a lot more important than whatever is going on with external rotation. In fact, this piece could have just as easily been named “The Two Stretches Pitchers Shouldn’t Do, Plus a Few That Only Some of Them Need.”

To learn more about testing, training, and treating throwing shoulders, check out Optimal Shoulder Performance: From Rehab to High Performance.

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Shoulder Hurts? Start Here.

Written on May 16, 2011 at 7:45 am, by Eric Cressey

As you can probably imagine, given that I deal with a ton of baseball players – and the fact that I’ve written about shoulder pain a ton over the past decade – a lot of people initially come to Cressey Performance because their shoulder hurts.  It might be rotator cuff pain, AC joint irritation, or any of a host of other issues, but you’d be surprised at how many similarities there are among the ways that you address most of these issues.

The problem is that pain can throw a wrench in your plans and limit you in your ability to get to exactly where someone needs to improve movement-wise.  For instance, you might have someone who has a significant glenohumeral (ball-and-socket) internal rotation deficit, but it’s hard to manually stretch them into internal rotation without further irritating a cranky AC joint.  Or, someone with a partial thickness rotator cuff tear may be dramatically limited in shoulder flexion, but even shoulder flexion with assisted scapular posterior tilt and upward rotation exacerbates their symptoms.  Very simply, you can’t just pound round pegs into square holes when it comes to dealing with a delicate joint like the shoulder – and that applies to both asymptomatic and symptomatic shoulders.

To that end, there are three initiatives that I think are the absolute most important places to start in just about every case.

First, I’m a huge advocate of soft tissue work with a skilled manual therapist.  In our office, we have a massage therapist and chiropractor who performs both Active Release and Graston.  And, we make sure that any physical therapist to whom we refer clients uses manual therapy as an integral part of their treatment approach.  Whether you’re a regular exerciser or not, tissues can get dense, nasty, and fibrotic, and integrating some hands-on work on the pec minor, posterior rotator cuff, lats, scalenes, sternocleidomastoid, and several other areas can dramatically reduce an individual’s symptoms and improve range-of-motion instantly – and that allows us to do more with a corrective exercise program.

Understandably, not everyone has access to a qualified manual therapist all the time, so you can always utilize self-myofascial release in the interim.  Here, in a video from Show and Go: High Performance Training to Look, Feel, and Move Better, CP massage therapist Chris Howard goes over a quick and easy way to loosen up the pecs:

The second area where you really can’t go wrong is incorporating thoracic spine mobilizations.  The thoracic spine has direct interactions with the lumbar spine, rib cage, cervical spine, and scapulae; as a result, it has some very far-reaching effects. Unfortunately, most people are really stiff in this region – and that means they wind up with poor core and scapular stability, altered rib positioning (which impacts respiration), and cervical spine dysfunction.  Fortunately, mobilizing this area can have some quick and profound benefits; I’ve seen shoulder internal rotation improve by as much as 20 degrees in a matter of 30 seconds simply by incorporating a basic thoracic spine mobility drill.

That said, not all thoracic spine mobility drills are created equal.  Many of these drills require the glenohumeral joint to go into external rotation, abduction, and horizontal abduction in order to drive scapular posterior tilt/retraction and, in turn, thoracic spine extension and rotation. If you’ve got a cranky shoulder, this more extreme shoulder position usually isn’t going to go over well.  So, drills like the side-lying extension-rotation are likely out:

For most folks, a quadruped extension-rotation drill will be an appropriate regression:

And, if the hand position (behind the head) is still problematic for the shoulder, you can always simply put it on the opposite shoulder (in the above example, the right hand would be placed on the left shoulder) and keep the rest of the movement the same.

Last, but certainly not least, you can almost always work on forward head posture from the get-go with someone whose shoulder hurts.  We start with standing chin tucks, and then progress to quadruped chin tucks.

Additionally, working on cervical rotation is extremely valuable, although teaching that is a bit beyond the scope of this post.

Keep in mind that these three broad initiatives are really just the tip of the iceberg when it comes to a comprehensive corrective exercise plan that would also include a focus on scapular stabilization and rotator cuff exercises, plus additional mobility drills.  They are, however, safe entry-level strategies you can use with just about anyone to get the ball rolling without making a shoulder hurt worse in a strength and conditioning program.

For more information on what a comprehensive shoulder rehabilitation program and the concurrent strength and conditioning program should include, check out Optimal Shoulder Performance, a DVD set I co-created with Mike Reinold, the Head Athletic Trainer and Rehabilitation Coordinator of the Boston Red Sox.

The Optimal Shoulder Performance DVD is a phenomenal presentation of the variables surrounding shoulder health, function, and performance. It combines the most current research, real world application as well as the the instruction on how to implement its vast amount of material immediately. After just one viewing, I decided to employ some of the tactics and methods into our assessment and exercise protocols, and as a result, I feel that myself, my staff and my clients have benefited greatly.

Michael Ranfone BS, CSCS, LMT, ART
Owner, Ranfone Training Systems

5 Reasons Direct Rotator Cuff Exercises are Necessary in a Strength Training Program

Written on February 16, 2011 at 8:36 am, by Eric Cressey

If you’ve read much of my stuff, you’ve probably come to realize that I’m quite the shoulder geek.  With that title comes a lot of questions at seminars and via email, and one of the more common ones is whether I think direct rotator cuff strengthening exercises are necessary for everyone.  A lot of coaches say that they aren’t essential, but I beg to differ for five reasons.  Here’s why:

1. Bad Posture – Nowadays, pretty much everyone has rounded shoulders – which means that the scapulae are winged out.  When a shoulder blade isn’t sitting right, the rotator cuff muscles that attach to that scapula are at a mechanical disadvantage because they are outside of their ideal length-tension relationship for creating force; it’s analogous to trying to shoot a cannon from a canoe.

Incorporating some direct rotator cuff exercises not only strengthens muscles that you know will be operating at a mechanical disadvantage, but also educates a lifter about how the scapula should be positioned for ideal shoulder function.

2. Shoulder impingement is a physiological norm. – Research from Flatow et al. demonstrated that everyone – regardless of age, activity level, sport of choice, acromion type, gender, you name it – has direct impingement on their rotator cuff tendons.  If you know a region is going to get beaten up regardless of what you do in your life, why wouldn’t you opt to strengthen it proactively?

3. Rotator cuff tears are far more common than you think. – In consideration of the previous point, it should be no surprise that rotator cuff tears are actually far more common than one might realize – even if you look at asymptomatic subjects.  Connor et al. discovered that on MRI, 40% of asymptomatic tennis/baseball players had evidence of partial or full-thickness cuff tears.  The general population is no different; Sher et al. took MRIs of 96 asymptomatic subjects, finding rotator cuff tears in 34% of cases, and 54% of those older than 60.  And these studies don’t even include the ones who are actually in pain!  It makes sense to strengthen these areas proactively – even if your shoulder doesn’t hurt…yet.

4. Lots of people also have labral tears. – In the past, I’ve written quite a bit about Active vs. Passive Restraints.  In the shoulder, the rotator cuff would be considered an active restraint, as it’s something that can be strengthened to improve dynamic stability.  The labrum, on the other hand, doesn’t get stronger with exercise; it’s a passive restraint that provides stability.  So, if the labrum is torn or frayed (as it very commonly is in both lifters and overhead throwing athletes), then the active restraints – the rotator cuff tendons – need to pick up the slack.

5. The “Just do normal stuff and the rotator cuff will take care of itself” philosophy isn’t working. - That’s been tried for quite some time, and nowadays, as a society, we move like absolute crap and – as noted above – have a boatload of issues on MRI even if we’re asymptomatic.  With respect to the cuff, we’ve built the deltoids up to the point that they absolutely overwhelm the rotator cuff (particularly the supraspinatus), which is trying to prevent the humeral head from migrating upward into the acromion.

My article, Clearing up the Rotator Cuff Controversy demonstrates some of our favorite rotator cuff exercises and talks about how to include them in a weekly strength training program.

For more information, check out the Optimal Shoulder Performance DVD Set.

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