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Written on October 30, 2014 at 7:46 am, by Eric Cressey
This time of year, I'm doing a lot of assessments on professional baseball players who are just wrapping up their seasons. One of the biggest issues that I note in just about every "new" athlete I see is a lack of anterior core control. In other words, these athletes sit in an exaggerated extension pattern that usually looks something like this:
And, when they take their arms overhead, they usually can't do so without the ribs "flaring" up like crazy.
This is really just one way an athlete will demonstrate an extension posture, though. Some athletes will stand in knee hyperextension. Others will live in a forward head posture. Others may have elbows that sit behind their body at rest because their lats are so "on" all the time.
This isn't just about resting posture, though; most of these athletes will have faulty compensatory movement patterns, too. Once we've educated them on what better posture actually is for them, we need to include drills to make these changes "stick." Anterior core drills - ranging from prone bridges, to positional breathing, to dead bugs, to reverse crunches, to rollouts/fallouts - are a great place to start. Here's why they're so important:
The muscles of your anterior core are incredibly important for getting air out. The folks at the Postural Restoration Institute often discuss how individuals are stuck in a state of inhalation, with each faulty breath creating problematic accessory tone in muscles like scalenes, lats, sternocleidomastoid, pec minor, etc. These muscles aren't really meant to do the bulk of the breathing work; we should be using our diaphragm. Unfortunately, when the rib cage flies up like we saw earlier, we lose our Zone of Apposition (ZOA), a term the PRI folks have coined to describe the region into which our diaphragm must expand to function.
Bill Hartman has a great video demonstrating good vs. bad breathing here:
Step 1 is to get the ribs down and pelvis into some posterior tilt to reestablish this good zone. Step 2 is to learn how to breathe in this position, emphasizing full exhalation.
Step 3, as you may have guessed, is to strengthen these "newly rediscovered" patterns with good anterior core training.
2. Resisting extension.
This one is the most obvious benefit, as the muscles of the anterior core directly combat too much arching of the lower back. If you aren't controlling excessive lumbar extension, it's only a matter of time until you wind up with lower back irritation - whether it's just annoying tightness, a stress fracture, a disc issue, or something else.
3. Better force transfer and lower back injury risk reduction.
The research on core function is pretty clear: its job is to transfer force between the lower and upper body. Spine expert Dr. Stuart McGill has spoken at length about how spine range of motion and power are positively correlated with injury risk. In other words, the more your spine moves (to create force, as opposed to simply transferring it), the more likely you are to get hurt. How do you prevent your spine from moving excessively? You stabilize your core.
4. Indirect effects on rotary stability.
For a long time, I looked at control of extension as "separate" from control of rotation at the spine. In other words, we did our anterior core drills to manage the front of the body, and our chops, lifts, side bridges, etc. to resist unwanted rotation. However, the truth is that these two approaches need to be treated as synergistic.
As an example, every time I've seen an athlete come our way with an oblique strain, he's sat in an extension posture and had poor anterior core control - even though an oblique strain is an injury that occurs during excessive rotation. All you need to do is take a quick glance at the anatomy, and you'll see that external obliques (like many, many other muscles) don't function only in one plane of motion; they have implications in all threes - including resisting excessive anterior pelvic tilt and extension of the lower back.
What this means is that you can't simply ignore coaching in one plane when you think you're training in another one. When you do your chops and lifts, you need to prevent lumbar hyperextension (arching) . And, when you do your rollouts, you can't allow twisting as the athlete descends. Finally, you can add full exhales (a predominantly anterior core challenge) to increase the difficulty on rotary stability exercises.
5. Improved lower extremity function and injury risk reduction.
Lack of anterior core control directly interferes with lower extremity function, too. If the pelvis "dumps" too far forward into anterior tilt, the front of the hip can get closed down. As I described at length here, this can lead to hip impingement.
With a squat variation, while some athletes will stop dead in their tracks with this hip "block," others will slam into posterior tilt to continue descending. This is the "butt wink" we've come to see over and over again in lifting populations. When neutral core positioning is introduced and athletes also learn to manage other extension-based compensations, the squat pattern often improves dramatically. This can "artificially" be created transiently elevating the heels, turning the toes out, or by having an athlete hold a weight in front as a counterbalance.
Additionally, athletes in heavy extension patterns often carry their weight too far forward, throwing more shear stress on the knees during lunging and squatting. The more we can keep their weight back to effectively recruit the posterior chain, the better.
6. Improved shoulder function and injury risk reduction.
The lats can be your best friend and worst enemy. On one hand, they have tremendous implications for athletic performance and aesthetics. On the other hand, if they're "on" all the time (as we often see in extension-based postures), you can't get to important positions with the right movement quality. Overactive lats will limit not only shoulder flexion (overhead reaching), but also upward rotation of the shoulder blades. I covered this in quite a bit of detail in Are Pull-ups THAT Essential?. Moreover, with respect to elbow function, overactive lats can be a big issue with allowing throwers to get true external rotation, as I discussed here:
If you're using your lats as an "all the time" core stabilizer, you aren't just at risk of extension-based low back pain, but also problems at the shoulder and elbow. If you can get your anterior core control under control and normalize the length and tone of the lats, your "healthy exercise pool" for the upper body expands dramatically. Getting overhead is easier, and you'll feel stronger in that position. The same goes for external rotation; not surprisingly, pitchers always say that their lay-back feels smoother after soft tissue work on the lats, as an example.
These are just six benefits of training the anterior core, but the truth is that they could have been broken down in much more detail as they relate to specific injuries and functional deficits. If you're looking to learn more on this front - and get a feel for how I like to train the anterior core - I'd encourage you to check out my presentation, Understanding and Coaching the Anterior Core.
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Written on April 12, 2012 at 8:27 am, by Eric Cressey
We are creatures of habit - not only psychologically and socially, but physiologically as well. If you need proof, all you have to do is read up on shift work disorder, which shows that simply changing one's sleep and work schedule can have some profound consequences for our health.
With that in mind, it should come as no surprise that changing the time of day when one's workout routine takes place is a huge deal for everything from mood to performance. Perhaps the most common adjustment that takes place is when someone decides to exercise in the morning. It may be because a long day at work is too exhausting to be 100% when you hit the gym after it's over, or you may just not want to wait for equipment access in a crowded gym at 6PM. Or, it could be because a parent is super busy with kids' after-school activities, so first thing in the morning before they wake up is the best bet for getting in a strength and conditioning program.
Whatever the reason, the adjustment to exercise in the morning is without a doubt the toughest "time change" one could make. With that in mind, here are five keys to making it a smooth transition:
1. Get to bed earlier.
This seems like a no-brainer, but you'd be surprised at how many people complain that they can't get results from exercise in the morning without realizing that they're still going to be far too late at night.
If you're someone who is accustomed to sleeping 12AM-8AM, then racing to be to work at 9AM, it's going to be an adjustment if you want to start training at 6AM before you head to work. You're only making it tougher if you decide that you're simply going to sleep 12AM-5AM. It's also going to crush your productivity for the rest of the day, as you'll be sleep walking rather than enjoying the post-exercise energy boost most people experience. If you want to be up at 5AM or 6AM to train, you've got to be in bed by 10PM. In fact, I always tell my athletes that an hour of sleep before midnight is worth two hours after midnight.
2. Stand up for a bit.
Dr. Stuart McGill has made some fantastic observations on spine stiffness first thing in the morning. In a nutshell, when we lay down to sleep at night, our spine is decompressed, so the intervertebral discs actually collect water. This increased hydration status builds annular tension within the discs, and makes the spine stiffer overall. This isn't a good kind of stiffness, though; more stress is placed on the ligaments and discs than the soft tissue structures that typically protect them.
Simply standing upright and moving around decreases the hydration status of the discs - and, in the process, actually makes us shorter as the day goes on! While I don't know of many people that want to get shorter, the good news is that this height reduction reduces the spine stiffness and allows us to move the spine more safely and effectively. While disc hydration diminishes over the course of the entire day, the majority of it occurs in the first hour that we're awake.
With this in mind, you're someone with a history of back pain, you're probably best off not incorporating exercise in the morning, especially if your workout routine includes a lot of bending and rotating. If you're going for a walk or light jog, though, it's probably not a big deal.
Conversely, if you're someone who plans to use some of these more challenging compound movements and have to exercise in the morning, I'd encourage you to get up 30 minutes early and just focus on standing up, whether it's to read the paper, pack your lunch, or take the dog for a walk.
3. Take a hot shower before exercise in the morning.
One of the biggest struggles a lot of folks encounter is getting warmed up in the morning. Folks usually turn the heat down at night while they're asleep, and it's obviously colder outside at nighttime. You might think I'm nuts, but hopping out of bed and into a hot shower is a great "body temperature transition" strategy that bridges the gap between bed and exercise. And, since you'll be standing in the shower, it also helps to accomplish tip #2 from above!
It only has to be 25-30 seconds to get your body temperature up a bit, and then you can take your "real" shower after you sweat up a storm. As an alternative to shower #1, you can always splash some hot water on your face and drink a cup of coffee. There's no way you're getting out of shower #2, though, Smelly.
4. Extend the warm-up.
In line with points #2 and #3, it's a good idea to add a few more dynamic warm-up drills to your pre-exercise routine. Typically, our athletes do between eight and ten drills, but those who exercise in the morning are better off with as many as 15. It might add five minutes to your dynamic warm-up, but that's far better than spending far more than five minutes in physical therapy for an injury you got from insufficiently warming up!
In line with tip #2 from above, you likely want to focus on more standing variations in your mobility exercise selections.
For some additional options on mobility drills, check out Assess and Correct: Breaking Barriers to Unlock Performance.
5. Tinker with various nutrition approaches.
I've heard thousands of different nutritional strategies outlined for those who want to exercise in the morning, but the truth is, everyone is different. I have known folks who will throw up anything solid that they consume prior to exercise, and others (myself included) who could eat a giant breakfast and keep it down just fine. For most, I think sipping on a shake as you start the training session is a good place to start. If you handle that fine, you can consider having some solid food before the training session, if you find that you're hungry in the middle of the training session.
6. Recruit a training partner.
A training partner is almost always a good idea, but this is especially true when you're up at the buttcrack of dawn and not necessarily in the mindset to really push yourself. Plus, when you're awake for exercise before the sun rises, you're far more likely to hit the snooze button if someone isn't waiting for you at the gym.
While training first thing in the morning isn't exactly ideal, it may be your only option for staying consistent with your workout routine - and consistency is the name of the game. Implement these strategies to get the most out of your early morning training sessions.
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Written on April 2, 2012 at 7:48 am, by Eric Cressey
I was introduced to the bowler squat originally by Dr. Stuart McGill at one of his seminars back around 2005. Beyond the endorsement from one of the world’s premier spine experts, the fact that it’s been a mainstay in our strength and conditioning programs for about seven years should prove just how valuable I think this combination mobility/activation exercise is.
Before describing it, though, I should mention that the name is a bit misleading. While it does look like a bowler’s motion, the truth is that it’s more of a “rotational deadlift” than it is a squat. There is some knee flexion involved, but the shin remains essentially vertical, and most of the motion occurs at the hips – and that’s what makes it such a fantastic exercise. Have a look:
We talk all the time about how important glute activation is, but most folks simply think that a few sets of supine bridges will get the job done. The problem is that this exercise occurs purely in the sagittal plane, while the glutes – as demonstrated by their line of pull – are also extremely active in the frontal and transverse planes. The gluteus maximums isn’t just a hip extensor; it is also a hip abductor and external rotator.
As such, the gluteus maximus is essential to properly eccentrically controlling hip flexion, adduction, and internal rotation that occurs with every step, landing, lunge, and change-of-direction. You can even think of it as an “anti-pronator.”
A bowler squat effectively challenges the glutes to both lengthen and activate in a weight-bearing position in all three planes. And, for the tennis and baseball players out there, check out how closely the bowler squat replicates the finish position from a serve and pitch (I noted this in a recent article, Increasing Pitching Velocity: What Stride Length is and How to Improve It).
To perform the exercise, push the hips back as if attempting a 1-leg RDL, but reach across the body with the arm on the side of the non-support leg. The “hips back” cue will get the sagittal plane, while the reach across will get the frontal and transverse plane. Make sure to keep the spine in neutral to ensure that the range of motion comes from the hips and not the lower back. Keep the knee soft (not locked out), but not significantly flexed, either. Be sure to get the hips all the way through at the top, finishing with a glute squeeze.
A few additional cues we may use are:
1. Tell the athlete to pretend like he/she is trying to pick up a basketball with the support foot; it can help those who keep tipping over.
2. Provide a target – a medicine ball or dumbbell – that the athlete should reach for in the bottom position (this keeps folks from cutting the movement short, or making it too sagittal plane dominant).
3. Encourage the athlete to keep the chin tucked (to keep the cervical spine in neutral).
4. Put your hand a few inches in front of the kneecap and tell the athlete not to touch your hand with the knee; this keeps an athlete from squatting too much when he/she should be hip-hinging.
Typically, we’ll perform this drill for one set of eight reps per side as part of the warm-up. However, in a less experienced population – or one with very poor balance – this may serve as a great unloaded challenge that can be included as part of the actual strength training program.
Give it a shot!
For more exercises like this, be sure to check out Assess and Correct: Breaking Barries to Unlock Performance.
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Written on March 21, 2012 at 4:00 am, by Eric Cressey
Here’s a list of recommended reading for the week:
Exercises You Should Be Doing: Half-Kneeling Band Overhead Shrug – Here, Tony Gentilcore highlights an exercise we use quite a bit at Cressey Performance with some of our athletes who are stuck in scapular downward rotation. It’s a big hit with those guys with low shoulders (especially right-handed pitchers). As an aside, I actually prefer the tall kneeling version over the half-kneeling variation, but that’s minutia.
An Interview with Dr. Stuart McGill: Part 1 and Part 2 – This two-part interview by Chad Waterbury with Dr. McGill was fantastic. All of McGill’s work is must-read material if you’re in the fields of health and human performance.
The Red Meat Scare: What Do We Make of It? – Jonny Bowden does a great job of discussing the flaws in the way some folks have interpreted some recent research on red meat consumption and its relationship to mortality.
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Written on January 14, 2011 at 7:17 am, by Eric Cressey
Q: I’m confused about when I should arch. I was re-reading some of your older articles, and noticed that in the Neanderthal No More series, you and Mike Robertson advocate posteriorly tilting the pelvis while performing some core exercises, yet when it comes to performing squat and deadlift technique, you encourage people to maintain the arch.
My back tightens up a lot when I arch strongly, but if I just bend over to touch my toes in flexion, it doesn’t bother me at all.
1. Could it be possible that I am arching too much during everyday movements and strength exercises?
2. What really constitutes a neutral spine? Is it different for each person?
3. When is it (if ever) appropriate to have a flat spine?
A: The main thing to consider – at least in my experience – is whether there is compressive loading on the spine. In compression, you want an arch – or at the very least, the natural curve of your lumbar spine. The discs simply don’t handle compression well when the spine is in flexion (or flat). We do more of the posterior pelvic tilt stuff when you are on your back (glute brides, as the glutes posteriorly tilt the pelvis) or on your stomach (if you arch, you’re slipping into hyperextension, which defeats the purpose of trying to resist gravity as it pushes you down to the floor).
Bending over is a LOT different than squatting and deadlifting (and comparable strength exercises). When you add load, the game changes. Cappozzo et al. found that squatting to parallel with 1.6 times body weight (what might be “average” for the typical weekend warrior) led to compressive loads of ten times body weight at L3-L4. That’s 7000N for a guy who weighs about about 150. Meanwhile, in a study of 57 Olympic lifters, Cholewicki et al. found that L4-L5 compressive loads were greater than 17,000N. It’s no wonder that retired weightlifters have reduced intervertebral disc heights under MRI! They get strong, but at a “structural price.”
According to Dr. Stuart McGill in his outstanding book, Ultimate Back Fitness and Performance, the spine doesn’t buckle until 12,000-15,000N of pressure is applied in compression (or 1,800-2,800N in shear) – so it goes without saying that we’re always playing with fire, to a degree – regardless of the strength training exercise in question, as there’s always going to be compressive loads on the spine. That’s a laboratory model, though; otherwise, the Olympic lifters above wouldn’t be able to handle much more than 12,000N without buckling. In the real world, we have active restraints – muscles and tendons – to protect our spine.
If those active restraints are going to do their job, we need to put them at a mechanical advantage – and flexion is not that advantage. The aforementioned Cappozzo et al. study demonstrated that as lumbar flexion increased under load, compressive load also increased. In other words, if you aren’t mobile enough to squat deep without hitting lumbar flexion (because the hips or ankles are stiffer than the spine), you either need need to squat a little higher or not squat at all. That said, I don’t think that you have to force a dramatic arch when you squat (or any strength exercise, for that matter); I think you need to brace your core tightly and create stability within the range of motion that you already have – and, indeed, “neutral spine” is different for everyone. For instance, females have an average of 5-7 degrees of anterior pelvic tilt, whereas males are more like 3-5 degrees – meaning that females will naturally be a bit more lordotic.
Having sufficient lumbar flexion to touch your toes with “uniform” movement through your lumbar spine is certainly important, and for most, it’ll be completely pain free (regardless of range of motion), but that doesn’t mean that a flat or flexed lumbar spine is a good position in which to exercise with compressive load.
So, to recap:
1. Neutral spine is different for everyone. What’s the same for everyone is the need to have stability within the range of motion that you’ve got.
2. Flexion is fine (and a normal functional task) when it isn’t accompanied by compressive loading. And, there is a different between subtle lumbar flexion and end-range lumbar flexion.
3. Arching (lumbar extension) doesn’t need to be excessive in order to be effective in improving tolerance to compressive loads. In most cases, that “arch” cue simply keeps a person in neutral spine as they go into hip flexion in the bottom of a squat or deadlift (or comparable strength exercise). “Arch” doesn’t mean “hyperextend;” it means to maintain the normal lordotic curve of your lumbar spine.
Looking to learn more? Check out Functional Stability Training, a comprehensive resource for assessment, programming, and coaching.
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Written on December 1, 2010 at 7:51 am, by Eric Cressey
Today, we move forward with more strategies for correcting bad posture. In case you missed it, be sure to check out Strategies for Correcting Bad Posture: Part 1. We pick up with tip #5…
5. Don’t overlook a lack of glenohumeral (shoulder) joint internal rotation. When it comes to bad posture, everyone thinks that the glenohumeral joint is only a “player” when it’s stuck in internal rotation; that is, the ball – or humeral head – is rotated too far forward on the socket – or glenoid fossa – meaning that the individual just doesn’t have adequate external rotation. And, this is often true – especially in non-athletic populations.
However, you’ll also very commonly see poor posture folks who present with big glenohumeral internal rotation deficits (GIRD), particularly on the right side (for very legitimate reasons that go well beyond the scope of this article). This is much more common in athletes, particularly overhead throwers (read more: Static Posture Assessment Mistakes). When the posterior rotator cuff is stiff/short and there is an internal rotation deficit, we have to substitute excessive scapular protraction (winging) or thoracic flexion/rotation each time we reach for something.
So, for many folks, posterior shoulder mobility and soft tissue work is an important inclusion in cleaning things up in terms of appearance, function, and shoulder health. If – and only if – you’ve been assessed and it’s been determined that you have an internal rotation deficit that compromises your total motion at the glenohumeral joint, you can integrate some gentle sleeper stretches (scapula stabilized!) to get a bit more ROM in the posterior cuff.
6. Don’t overlook a lack of glenohumeral (shoulder) joint flexion. The shoulder is a tremendously mobile joint, so we need to appreciate what goes on outside the transverse plane as well. In particular, I see shoulder flexion limitations as a big problem. These limitations may come from the lat, teres major, long head of the triceps, or inferior capsule. Another overlooked cause can be posterior cuff restrictions; it’s not uncommon to see both GIRD and major shoulder flexion limitations on the same side. As the picture below shows, the infraspinatus and teres minor run almost vertically when the arm is abducted a mere 90 degrees – which means that they’re struggling to lengthen fully to allow full shoulder flexion (and abduction, for that matter).
These restrictions that can contribute to both faulty compensation patterns in certain positions, as well as overall bad posture chronically. Let’s have a look at what these issues look like in the real world. First, in someone with a shoulder flexion limitation, you’d first want to check them in the supine position, with the knees flexed and back flat (to avoid substituting lumbar extension for shoulder flexion). Ideally, the arms should rest flat on the table – so this would be a “not-so-hot” result (especially since the arms “fall” to the sides a bit instead of staying in “attempted flexion”):
Next, let’s take this same shoulder flexion limitation, and look at what would happen actively. In the first three reps of the video below, take note of the position of our subject’s head at the start and finish of each rep; you’ll see that as he “runs out” of shoulder flexion, he substitutes forward head posture. On the next three reps, after I cue him to keep his cervical spine in a more neutral posture, he has to arch his back excessively (lumbar hyperextension) to complete the movement.
Now, imagine taking this walking disaster (only kidding; I had Dave fake it for the video, as he’s actually a finely tuned trained killing machine who can’t be stopped by conventional weapons – and he’s single, ladies) taking up overhead pressing, Olympic lifting, or just reaching for a glass on the top shelf. Then, imagine him doing those tasks over and over again. Obviously, the posture will get worse as he reinforces these compensation schemes – but something is going to surely break down along the way; it’s just a question of whether it’s his low back, shoulder, or neck!
Correcting these issues is easier said than done; as I noted, there are several structures that could be the limiting factor. However, for those looking for a relatively universal stretch they can use to get a bit of everything, I like the wall lat stretch with stabilization, one piece of a comprehensive (but not excessive and boring) static stretching program included in Show and Go.
7. Don’t ignore the thoracic spine. The previous two examples focused exclusively on the glenohumeral joint, but the truth is that it is tremendously dependent on thoracic spine positioning. Ask any physical therapist, and they’ll tell you that if they can get the thoracic spine moving, they can instantly improve glenohumeral joint range-of-motion without even touching the shoulder (this is incredibly valuable with folks who may have stiff glenohumeral joints that can’t be mobilized aggressively following shoulder surgery; they need ROM in any way possible). And, truthfully, you can substitute a lack of thoracic spine extension for the shoulder flexion problems and compensation schemes above, and a lack of thoracic spine rotation can work in much the same way as a GIRD (substitute excessive scapular protraction with reaching tasks).
If you ever want to quickly check to see what limiting thoracic extension does to someone’s upper body posture, just put them in supine position and push the sternum/rib cage down – which will bring the thoracic spine into flexion. Watch what happens to the position of his chin, and the size of the “gap” between his neck and the table:
Now, just consider what kind of “yank” this puts on the sternocleidomastoid chronically…
…and you’ll understand why a lack of thoracic spine mobility can give people enough neck pain and tension headaches to make Lindsay Lohan’s hangovers look like a walk in the park. And this doesn’t even consider what’s going on with scalenes, suboccipitals, levator scapulae, subclavius, and a host of other muscles that are royally pissed off! Also, think about all those folks in your gym doing hours and hours of crunches (especially while tugging on the neck). Ouch.
For that reason, we need to get our thoracic spine moving – and more specifically, we need to get it moving in both extension and rotation. I’ve mentioned in the past that the side-lying extension-rotation is one of my favorites (assuming no symptoms); remember that the overwhelming majority of the range-of-motion is coming from the upper back, not just the shoulder:
Here’s another we’re using quite a bit nowadays in our folks who have good internal rotation (which we want to keep!):
8. Watch your daily habits and get up more frequently. I’m at 1,140 words for this post right now – plus several pictures and videos. In other words, some of you might have been hunched over your computer screens trying to figure out what I’m saying for over 20 minutes now – and that’s when “creep” starts to set in an postural changes become more and more harmful (both aesthetically and functionally).
With that in mind, make a point of getting up more frequently throughout the day if you have to be sitting a ton. Likewise, “shuffle” or “fidget” in your chair; as Dr. Stuart McGill once said, “The best posture is the one that is constantly changing.” Now, shouldn’t you get up and walk around for a few minutes?
I’ll be back soon with Part 3 of this series, but in the meantime, I’d encourage you to check out Show and Go: High Performance Training to Look, Feel, and Move Better, a comprehensive program that includes many of the principles I have outlined in this series.
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Written on June 21, 2010 at 7:43 am, by Eric Cressey
It’s widely known that approximately 80% of the population will suffer from lower back pain at some point during their lives. What isn’t widely known, however, is that even those who are asymptomatic are usually walking around with a host of nasty stuff going on with their spines. Don’t believe me?
A 1994 study in the New England Journal of Medicine found that in a study of MRIs of 98 asymptomatic individuals, 82% of those MRIs came back as positive for a disc bulge, protrusion, or extrusion at one level. And, 38% actually had these issues at more than one level. You can read the free full text HERE.
As the others discovered, it doesn’t stop with disc issues, either – and that’s where a great study from Soler and Calderon comes in. They looked at the incidence of spondylolysis (vertebral fractures) in elite Spanish athletes, and found that 8% of those they examined had them. Only about half of those diagnosed via imaging actually had back pain, though. The incidence was highest in track and field throwers, rowers, gymnasts, and weightlifters – and I’d expect that this figure is actually higher in the U.S., where we have more sports (hockey, baseball, lacrosse) involving violent extension and rotation, more contact sports, and more participation in weight training.
What does this mean for us? Well, as Chou et al. reported in The Lancet, “Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.” That’s not the point of my article today, though; I’ll leave that stuff to the physicians to decide and rehabilitation specialists to interpret and treat.
As fitness professionals, strength coaches, and even just fitness enthusiasts and athletes, we need to assume that there is are probably a lot of structural abnormalities going on in the spines we encounter – including our own. The programs we write and follow need to be sound and take these issues into account, considering differences in age, gender, sport participation, and injury history. The technique we use needs to position us so that we can avoid causing them to reach threshold. And, we need to appreciate that there is a risk-reward balance to be “struck” with everything we do in training because nobody will ever be “perfectly prepared” for the demands to be placed on their bodies.
Rather than lay all my thoughts out here, I’m going to direct you to some previous writing of mine:
I’d also highly recommend Ultimate Back Fitness and Performance by Dr. Stuart McGill.
Written on June 7, 2010 at 5:25 am, by Eric Cressey
A few months ago, I gave a two-day seminar to just over 80 fitness professionals and strength and conditioning coaches. Even with a seminar this long, I can never cover everything I’d like to cover – and it’s generally because much of what I’d like to address relies on some prerequisite knowledge that the attendees may not possess.
With that in mind, at the attendees’ request, I sent a follow up email to all of them with a list of some of the best resources – books/manuals and DVDs – that I’ve encountered along my journey of self-education.
Please keep in mind that this is not an exhaustive list, by any means, but it does cover what I’d consider requisite reading to get a good foundation in a lot of the concepts I covered last weekend.
1. Any anatomy text will do, but I prefer texts that speak more to functional anatomy. Netter’s Atlas of Human Anatomy is very good, and I know of many physical therapists in the US who keep a copy of this book on hand for patient education. Kinetic Anatomy is also a solid text that speaks to functional anatomy, and I believe the newer version comes with a tag-along DVD. Lastly, our Building the Efficient Athlete DVD set was created in part to educate folks on the functional anatomy side of things that they may miss during a conventional college curriculum. I know of several facilities in the US that use it extensively for staff training.
2. Anything from Stuart McGill – While there are several schools of thought with respect to low back function and rehabilitation (and I’d encourage you to check out each of them), McGill is the one that resonates with me the most. You can find a lot of his research on Pubmed, but he also has several books (and a DVD) available that I’d highly recommend. For those of you who are interested in some science and some applied, go with Ultimate Back Fitness and Performance.
For those of you who are a bit geekier and want to learn a lot more about the clinical side of things, check out Low Back Disorders. If you are going to train clients or athletes, you need to understand back pain.
3. Diagnosis and Treatment of Movement Impairment Syndromes by Shirley Sahrmann is probably the book that has influenced me more than any other in my career. It’s worth every penny.
4. For shoulder stuff, I think that The Athlete’s Shoulder is a great resource. It is written by physical therapists and surgeons, though, so it can get very clinical at times. Those of you who are more interested in actual practical applications would be more interested in our new Optimal Shoulder Performance DVD set, which is the video of a seminar I did with Mike Reinold, who is actually one of the co-authors of The Athlete’s Shoulder. If you enter the coupon code “reinold200osp” today only at checkout HERE, you can get the DVD set with free shipping today as part of Mike’s “sale week” to celebrate his 200th post.
5. Muscles: Testing and Function with Posture and Pain – This is a newer version of Kendall’s classic text, and it’s an incredibly detailed resource that you’ll find yourself referring back to time and time again. Several of the screens we use in our everyday assessments with clients and athletes were influenced in part or entirely by Kendall’s text.
6. Gray Cook’s work is fantastic. If you want quick, practical tips, check out Secrets of the Hip and Knee and Secrets of the Shoulder. Both DVDs give you some tips that you can immediately put into practice.
7. Anatomy Trains by Thomas Myers is an excellent read to get you thinking more and more about the role of the fascial system. I saw Thomas speak this past weekend in Providence, and he was absolutely fantastic – so excellent, in fact, that I’ll probably write up a blog with some quick notes from his lecture. And, I’ll be reading this for the third time this week, too!
8. Bulletproof Knees – Mike Robertson wrote this manual and I can honestly say that I haven’t seen a better product on the market with respect to information that can be quickly applied to clients with knee pain – both in terms of understanding it and correcting it.
9. Mike Boyle has some excellent products – including all the Functional Strength Coach DVDs (#3 was the most recent). You can always find some good reading at StrengthCoach.com. I believe they still have the 14 days for $1 trial period, and as part of that, you get his Designing Resistance Training Programs and Facilities book for free.
10. Anatomy of Breathing – I think it’s valuable to appreciate the muscles involved in respiration and start to put them into your functional anatomy framework as soon as possible. This book is a very quick read, but you’ll get that foundational knowledge and start to think about how all this stuff lines up.
11. 2008 Indianapolis Performance Enhancement DVD set – This is a product that has largely flown under the radar because it was overshadowed by several other products that were launched around the same time. However, the short vs. stiff discussion that Bill Hartman presented as part of it is well worth the cost of the entire DVD set.
12. Clinical Applications of Neuromuscular Techniques (Part 1 and 2) – These books read like stereo instructions, but they are insanely thorough. I recommend them to anyone who is really dorky like I am. They will definitely help you to collaborate with manual therapists and physiotherapists a lot more effectively.
13. Assess and Correct – Shameless self-promotion here, but I’m extremely proud of this product. It’s a DVD set and four accompanying manuals that cover 27 assessments and 78 corrective exercises we use with our clients and athletes. If I had to recommend one of our products to a trainer, this would be it. Stuart McGill have us some extremely flattering reviews on Assess and Correct as part of his new DVD.
I should note that the countless journal articles I’ve read over the years are noticeably absent from this list, but you can easily access the abstracts of those pieces at www.pubmed.com if you search by whatever keyword relates to your area of interest. I find myself using it daily, and I’ll generally follow up on these abstracts by getting the full-text articles. Also, in addition to the few resources I note below, you can find a more extensive collection of recommended readings on my resources page. This includes a collection of links to free blogs that I read daily. Many of my blog readers don’t know that, in addition to this blog, I have a free newsletter where readers get exclusive content and early notice on things – so you’ll definitely want to sign up HERE if you haven’t already.
It’s also been a matter of interacting with as many smart folks as possible, just making (and documenting) observations with our clients/athletes, and going to seminars. This list should get you started, though!
Written on December 11, 2009 at 8:00 am, by Eric Cressey
1. Sorry for the slower week here on the blog. In addition to trying to catch up from my three days in Houston, I had a few projects that needed to get sorted out this week. For starters, we had to finalize the agenda for my seminar in Vancouver in March.
And, the bigger task of late has been finishing up a chapter (on baseball testing and training) that I’m contributing to Dr. Craig Liebenson’s newest book. Others contributing include Dr. Stuart McGill, Sue Falsone (Athletes Performance), Dr. Ben Kibler, Dr. Pavel Kolar, Ken Crenshaw (Arizona Diamondbacks), and Mike Boyle (among others). Needless to say, I’m lucky to be in such awesome company, and you’ll definitely want to check it out once it’s available. In the meantime, you might be interested in Liebenson’s most popular work, Rehabilitation of the Spine: A Practitioner’s Manual.
2. Mike Reinold and I are also working on getting our seminar, Testing, Treating, and Training the Shoulder: From Rehabilitation to High Performance, ready for production and sale. We’re hoping it’ll be ready by the first of the year, but only time will tell; editing takes time, and it’s out of our hands now! Speaking of Mike, he just posted a blog outlining the recently revised pitch count rules. If you coach young players or one of your kids plays ball, definitely check it out HERE.
3. On the topic of little league, the clinic with Matt Blake and I at Cressey Performance on Tuesday night was pretty popular with local coaches. One of the things that Matt and I tried to stress is that kids almost never get hurt for JUST one reason. Usually, injuries are multifactorial, so you have to look at a host of different causes – from overuse, to physical limitations (weakness or immobility), to mechanical flaws in the pitching delivery.
The questions we received gave me some ideas for future posts, so keep an eye out for those in the not-so-distant future. Along those same lines, if there are specific baseball development questions you’d like covered, feel free to post some suggestions here as a reply to this blog.
4. I got the following question the other day, and thought it might make for a quick Q&A here:
Q: I am planning on training Westside style but I do not have access to bands and chains (or any other special equipment for that matter). What should I do to change up my dynamic effort days? Should I just use variations of the lifts (i.e. close grip vs regular grip bench, sumo vs conventional deadlifts)?
A: The whole idea that you absolutely have to have bands, chains, and specialized bars to learn from the Westside school of thought (which is constantly evolving anyway) couldn’t be further from the truth. There are bits and pieces borrowed from Westside teachings in Maximum Strength, and you’ll see that there is plenty of rotation among movements in the four-month program – and the assumption is that you don’t have any of these goodies. Rotating among back squats and front squats (without a box, with a box, or from pins) and deadlifts will give you a great rotation of movements.
Regarding dynamic effort days, I don’t think it’s as important to rotate exercises on a regular basis, as this speed work is there to improve bar speed on that specific movement and help you groove the movement pattern itself. However, if you want to change it up, it’s not too difficult.
In the lower body, simply go to a different deadlift or squat variation, or change the percentage at which you’re working. In the upper body, you can change the grip width on the bench press, do some plyo push-ups, or even just throw the medicine ball around.
5. I’m going to see The Nutcracker tonight with my fiancee. In the words of Forrest Gump, “That’s all I have to say about that.”
6. I will, however, say that I’m a little bummed that Jim Breuer is in town tonight about ten minutes from where I live, and I’m not going to get to see him. Doh!
Written on July 29, 2009 at 12:25 pm, by Eric Cressey
This post marks the first of a new series where I’ll give credit to a lot of the people who in one way or another have made me better at what I do. In most cases, they’ll be quick tips that I’ve taken away and applied immediately into my existing methodology. Very few of them will require more than a few sentences to explain – and I’ll usually give you some recommended reading at the end of the entry.
Today’s tip was one I picked up from Bill Hartman on a recent trip to Indianapolis. Keep in mind that this is more along the lines of “knowledge for the sake of being smart,” not because many of these provocative tests are ones that should be used by those who aren’t trained as physical therapists.
Anyway, We were talking about the high frequency of lumbar spine disc herniations and bulges on MRI that are not accompanied with any symptoms.
Taking it a step further, though, you’ll also see people who have back pain plus these issues on diagnostic imaging, yet that doesn’t necessarily mean that the imaging finding is clinical significant (the pain might be coming from something else). One classic test that’s been used to test for neural tension in this regard is the slump test.
As is the case with most physical assessments, though, a good test should simulate the injury mechanism, and while the slump test gets things rolling in the right direction, Bill actually mentioned that he favors a McKenzie-influenced repeated flexion test (slump test only involves a single “bout” of flexion) – which essentially simulates how you’d herniate a disc in a laboratory setting. If someone has a one of these findings on the MRI, plus back pain, but this repeated flexion test doesn’t provoke their symptoms, chances are that the pain is coming from somewhere else (muscular, etc.). If symptoms are exacerbated, it’s probably related to the disc issue. Of course, repeated extension would apply to more posterior issue.
Of course, check with a qualified physical therapist for issues along these lines; you don’t want to be self-diagnosing or provoking something on your own. However, the trainers and strength and conditioning coaches in the crowd can use this information attained by physical therapists to classify folks as extension-based or flexion-based back pain and program exercise accordingly alongside rehabilitation initiatives. I covered this in some detail in Lower Back Savers: Part I.
Recommended Reading: Ultimate Back Fitness and Performance, by Stuart McGill