Basic Shoulder Rehabilitation

       The stabilizers of the shoulder are the mid-level executives of the strength training world. With reasonable oversight and training they do their job well, but they are utterly hopeless when the boss (the larger shoulder structures and ultimately, you) does something stupid that renders their efforts useless or, at the very least, diminished. Just as with the mid-level executives in the corporate world, when the boss wants someone to demean for failure, the shoulder stabilizers bear an inordinately large share of the blame. It is common to see an athlete assuming every single issue with the shoulders stems from the much-discussed  but little-understood rotator cuff, or some specific muscular imbalance which must be corrected painstakingly with some ghetto-ized version of a physical therapy modality they saw on YouTube. This is even more prevalent in the well-educated, who often overthink any ache or pain they experience and skip the simple interventions to go right to band distracted PNF with pressure-augmented reflex modulation, or some such tool that sounds equally fancy but likely isn't warranted.

       In this post, I want to discuss simple interventions for misbehaving shoulders. If you are spending 30 minutes on rehab work and special warm-ups you are either too hurt to train or, more likely, you are just using the splatter approach - throwing everything you can think of at it in hopes something will work. But it need not be that complicated and with a little attention to detail you can prevent issues while fixing the ones you have.

       The first thing we need to get out of the way here is proper mechanics while lifting. If your form is atrocious you don't need rehab. You need to learn how to move. This must be the first step when dealing with shoulder problems: ensure you are moving correctly, with proper posture. Fixing your bullshit form will fix 90% (just a guesstimate to represent how staggering the number is) of the problems you face with the shoulder.

       Secondly, once proficiency is established, consideration needs to be made for muscular balance. All of your time spent pressing with no pulling will inevitably lead you to pain and problems. This again is not a rehab issue. You simply need to train correctly. Of the minority of issues not related to mechanics during movement, the majority are due to simple imbalances. Complicated variations of movements and dedicated rehab work is a waste of time here. Fix your structure by allocating training efforts.

       If neither of these is the issue, you are one out of a hundred, or maybe less.Once we have extablished a true stabilizing issue in the shoulder girdle we need to set out to find what the problem is. And here it gets tricky. Most likely, you cannot do this on your own, even if you are trained to do so. You need an outside view from a qualified diagnostician. The 18 year old PT at the gym is not one of these, and neither is the guy who slings test in the locker room or that really hot Zumba instructor. Seek out a physiologist or coach who specializes in rehab, an athletic trainer, a sports medicine physician, or a manual therapist of some sort (NMT, DPT, DC, ART). Once the problem is identified a specific rehabilitative approach will be recommended to address the specific issues you have.

       Many athletes of a more advanced sort, who have their training nailed down and their movements perfected, are looking for a basic set of movements to do as an adjunct to ensure weakness or movement restriction does not develop in the stabilizers. These include the rotator cuff (supraspinatus, infraspinatus, subscapularis, and teres minor) as well as other muscles acting on the shoulder girdle, depending on the movement in question. This article, while being a little on the academic side and thus boring as hell, provides a good synopsis of the basic movements we use to affect stability in the absence of special situations. These should be done when instability has been noted and the issue is not being solved by regular training, but may not be appropriate if you are injured.

       http://www.pitt.edu/~neurolab/publications/1992-1996/BorsaPA_1994_JSportRehab_Functional%20assessment%20and%20rehabilitation%20of%20shoulder%20proprioception%20for%20glenohumeral%20instability.pdf

       It's worth noting though, that in most cases, going as far as all that is simply time taken away from more important aspects of training. The following is the basic preventive toolbox I use to manage and prevent shoulder issues. It addresses joint position and mechanics, imbalances, and stability deficits while taking literally minutes.

       1. Muscle Snatches: These force stabilization of the shoulder girdle in myriad ways, in both dynamic and static positions; recruit the rotators, traps, and thoracic muscles involved in shoulder mechanics; and force activation of high threshold motor units that are often missed in traditional rehab movements.
     
       2. Face pulls. Superior to pull-aparts in my opinion, face pulls involve horizontal abduction of the shoulder, depression and rotation of the scapula, and external rotation of the humerus. EMG data even indicates it is a sufficient stimulus to cause a training effect in the medial deltoid.

       3. Pushups: These can be added as a warm-up drill or used as a stand-alone. The light load allows focus on shoulder position and mechanics and testing multiple positions can help identify issues. This link includes some more detail and offers examples of modifications. http://articles.elitefts.com/training-articles/what-you-don%E2%80%99t-know-about-the-push-up/

       That's it. I use these drills regularly, sometimes as a separate session and sometimes added into existing programming, as a basic way to ensure proper function, stability, and mechanics. If you are looking for a preventive strategy, this is simple and quick, and if you are looking to start rehabbing, this will allow you to make some corrections to the issues on your own. As always, evaluate the need, match the training stress to the need, and modify as needed based on result. Don't over-complicate, don't over-work, and don't look so intently at the details you forget the big picture. With proper training, you will not need real rehab in your training. Now that you aren't wasting time with a  bunch of irrelevant corrective work picked arbitrarily, you have more time to put weight over head, so do it.

      
      

      

Think Inside the Box

       In the last post, I discussed hamstring training. You may recall mention of knee flexion and hip extension being superior to squatting for specific hamstring stimulus. This caused a bit of a stir, so I want to go into more detail on that and offer another movement useful for training the posterior chain that allows you to squat while focusing the effort more on the hamstrings. That would be the box squat. On the surface this variation may not seem much different from conventional squats, but the two movements should in fact be considered totally different exercises, and cannot be used completely interchangeably (unless you squat in equipment, but that's another topic).

       What is it?

       Simply put, in a box squat, there is a box or some other surface placed behind and under the lifter's hips. The lift is performed in two parts. The lifter squats back and then down, pushing purposely out of the squatting groove (this backward accentuation is important) until gently coming to rest on the box. The knees should be behind the feet slightly, and the athlete should be seated in a position not possible to achieve while squatting without the box, braced and tight as always. When contact is made, the hips are momentarily relaxed to completely stop the movement. 

       The concentric portion of the lift starts here. Louie Simmons, of  Westside Barbell fame, has always advocated initiating the lift with knee flexion and explosive drive from the hips. In his (recognized as the primary) style of box squat, the hips are driven forward very hard while this occurs, pushing the athlete forward and up off the box and thereby placing the vast majority of the stress of the lift onto the posterior chain, and activating the hamstrings much more thoroughly than conventional squats. For more information on the execution of the lift, see westside-barbell.com or any of the videos by Dave Tate on the subject.

What makes it special?

       In addition to matching the groove of equipped squats more closely than traditional raw squats, the box squat also develops starting strength very well. Instead of the braking and reversal occurring in the transition between the eccentric and concentric, the movement is broken in two, requiring an athlete to overcome the static load to stand back up. Without going into too much depth, we can summarize the action by saying that rate of force production and power must improve for one to become proficient at the box squat. This is helpful to both the squat and the deadlift, as well as translating well to field sports, where rate of force production is often more important than absolute strength. The nature of the movement requires care to execute it safely, and the increased effort required to maintain position can be helpful for athletes who rush through the lift and often miss because of it. Lastly, as I mentioned earlier, the added stress on the hip extensors and knee flexors makes this a valuable tool in your arsenal.

  Programming

       The answer to questions regarding programming is, more often than not, "it depends." Whether you should add this variation or emphasize it over other movements should be determined by analysis of the movements and demands of your sport, or for physique athletes, by analysis of physique needs and experimentation with how this variation affects development. In general, it makes for an excellent adjunct to squatting for more focused posterior chain development or as a tool for improving bar speed and position. It may be useful as a supplement to deadlift training as well if you struggle in the bottom of the lift.And for athletes needing to focus on starting strength, rate of force development, and hamstring development, the box squat may be a more appropriate tool than the traditional squat for the bulk of the training. As always, analyze your needs, match training to competition, and modify as needed. No general list can match your needs as well as careful observation can.

Hamstrings: A straightforward look at what they do and how to make them better at it.

     The posterior chain, and the hamstrings in particular, are hot topics lately. Powerlifters talk about sitting back in the squat and driving the knees out to activate this area more effectively for producing maximal force. Weightlifters debate various timing and positioning strategies to improve rate of force development in the region. Strongman competitors know they need to train this area both for strength and for preventing injury in the various events they face. And bodybuilders in big shows get slaughtered without a good pile of striated meat on the posterior thigh. Athletes are often confused about how to train the hamstrings and how they work, and as a result  they often end up taking advice from people who mean well but are misinformed. You see, while the hamstrings may appear at first to be a fairly simple muscle group with fairly simple functions, the truth is a bit messy. To figure out what we should do to train them adequately for whichever activities we are preparing for, we need to start by understanding the structure and function of the hamstrings.

Anatomy and Function of the Hamstrings

     Three muscles (or four depending on your brand of semantics) comprise the muscle group we call the hamstrings: the biceps femoris (with a long and short head), the semitendinosus, and the semimembranosus. The semitendinosus and semimembranosus are biarticular. This means that they cross more than one joint, in this case the hip and the knee. They typically act on both joints, and they can produce both hip extension and knee flexion. Additionally, they contribute strongly to stability of the trunk and legs during application of force to the ground or other external elements by anchoring a joint or holding an advantageous position. 

     The biceps femoris isn’t straightforward however. It is innervated by two branches of the same nerve which serve the short and long heads respectively. Motor patterns involving one typically result in at least some activation of the other due to overlapping structural elements but the two heads have some differences, so the short head (the most functionally limited of the group) is often separated for ease of discussion in study and in training. The long head is biarticular like the other aspects of the hamstring, and as such it contributes primarily to both extension of the hip and flexion of the knee just as they do. But the short head only crosses the knee, making in monoarticular. Its primary function is knee flexion, as it has no self-contained structural attachment to the hip. It can only directly influence the knee joint. But it is quite active as a knee stabilizer even during action where it isn't a prime mover, and its position and line of pull make it adept at this purpose in situations where force is applied dynamically.

     As an example, consider the actions of braking while running and changing direction. These motor patterns mainly involve the hamstrings as eccentric (muscle lengthening) work to absorb and redirect force acting on the hip. While this is not the domain of the short head of the biceps femoris, it acts as a stabilizer on the knee by anchoring the joint to allow stability and on the hip by increasing tension in the supportive connective tissue. Similarly, in a deadlift, primarily a hip extension movement, the muscle contracts to stabilize the knee while maintaining proper position and tension in the lower extremity. So, even when this monoarticular muscle is not performing its primary anatomical function, it is still often active in more complex movements. For more on that, and for a discussion of how the hip and knee are inextricably linked, see this article, http://jap.physiology.org/content/99/3/1093.full , which concluded that, “the variability of hip joint torque during isometric knee joint torque exertion virtually affects the activity of the knee joint muscles including monoarticular muscles that span only the knee joint.”

     Training the Hamstrings

      As you might know, hip extension and knee flexion are the main movements having a training effect on the hamstrings. Deadlifts of all types, goodmornings, bridges, reverse hyperextensions, glute-ham raises, and even the scoffed-at leg curl are all effective for developing the hamstrings. Much has been said about variations of the deadlift. This study examines the two primary versions, the sumo deadlift and conventional deadlift, and discusses differences in effect: http://www.setantacollege.com/wp-content/uploads/Journal_db/An%20electromyographic%20analysis%20of%20sumo%20and.pdf . Also consider this piece, which examined several other common lifts used to focus training on the hamstrings: http://iconperformancenetwork.com/wp-content/uploads/2012/02/EMG-Hamstring-Study.pdf . The study found, not surprisingly, that hip extension and knee flexion are superior to the back squat for hamstring training, and that both can be used to develop the muscle group.

       The primary exercises in popular use for focusing on the hamstrings are the stiff-legged deadlift (hip extension) and the leg curl (knee flexion). The sumo and conventional deadlift, as primarily a hip extension movement, also has a strong effect on the hamstrings and typically results in higher loading and greater similarity to actions performed in athletic situations. Squats involve the hamstrings heavily as well, but hip extension is not emphasized over other aspects of the lift and the resulting training effect is more general, involving many other muscles more strongly than the hamstrings.

      So how should you train to improve the hamstrings? Well, it depends. The study above suggests, "Since there was no significant difference between the LC (leg curl) and SLDL (stiff-legged deadlift) for either integrated EMG or peak EMG, it is concluded that both of these exercises similarly involve the hamstrings. The choice of exercise for training would be dependent on which exercise is most sport specific for the athlete." For most, this means selecting movements and training strategies that load the spine and require hip extension. 
 
     Hip extension is among the most common movements we make regularly, and in sports this movement is often undertaken under load or with the intent of producing a large amount of force. This makes it the ideal way to train the hamstrings in most cases. Loading and motor unit activation are to be emphasized, as this ensures greater total stimulus. Similarity to competition must be considered as well. Knee flexion in a prone or seated position as in the leg curl is dissimilar to most athletic actions. Thus, except in limited and specific situations, the greatest load and most sport specific motor recruitment possible comes from the heavy basics like deadlift variations. These focus on high loading on the hip extension motor pattern. There are cases where isolation movements may be of use, such as in correcting an imbalance or rehabilitating an injury, but for the most part and for most lifters, this isn’t the most effective way to train. Work for knee flexion should be added only when warranted by a specific circumstance, since performing the movement when there is no clear benefit over more sport specific exercises is a waste of effort. By tracking performance and physique development, it will be evident if there is greater need for isolation. Everything in your training should have a purpose and a measurable effect. If you are adding movements for their own sake or not pursuing progression, then the movement is likely not doing you any good. It is important to identify and eliminate wasted work to better focus on what has tangible benefit. This is the basic way I approach the training: analyze the demands, match training to demand as much as possible, and minimize unnecessary effort. It falls to the individual to determine what is appropriate, as situations will be fluid and varied. What’s important is that you identify a training strategy that is effective for your goals and make changes when the effect isn’t matching the goal. Work, analyze, modify. Three habits of highly successful athletes. Happy training!

The Forum Effect

"Being a good coach is mostly about analyzing the situation and telling the truth about it even when it makes you look like an asshole. The rest is just support." -Mike Kidd, Coach of the Georgia Irondawgs powerlifting team and my mentor

      
       Right from the start, I want to make clear that there are some very intelligent individuals working in and around the fitness industry at the moment. We have a populace interested in science and results, experienced coaches and researchers, and veteran competitors all brought together in the orgy of information that is the internet. But along with these people are some astounding examples of intellectual vacancy. Out of the vast number of people on the web discussing exercise, nutrition, and health, it is overwhelmingly likely that most will be on the underinformed end of the spectrum in any discussion you may find yourself in. That mates rather well with the human tendency toward group-think and together the two breed armies of non-thinking followers refusing flatly to examine either the views of others or their own in enough detail to actually understand. Good thorough information is distilled down to its most basic points and mangled beyond recognition into a simplistic black and white presentation. Anyone suggesting unpopular ideas is ostracized and ridiculed. As a result, people are often scared away before even getting involved. Those who aren't repelled at the outset  often end up drinking the proverbial Kool-Aid of some sect or another or even just keeping their opinions and ideas to themselves. It's the Forum Effect, and it's making you stupid.

       No doubt you are aware of the state of the fitness industry if you are reading this. And it stands to reason that despite this, if you are strong-minded and determined you have found some good information after all. And if so, then perhaps you realize the importance of bringing good information, backed by both science and application, to the attention of those hungry for knowledge but fed the typical junk of the industry's gurus. In this blog I will address popular topics relating to exercise physiology, nutrition, training, and yes, even performance enhancing drugs. The goal isn't to get you to buy my book or go to a seminar or call me a guru. I just want to provide quality information about the topics I deal with often in a professional setting.

       So my goal here is to, in essence, be a coach for performance related research. I will be analyzing the topics that I encounter and will endeavor to simply tell you the truth as completely as current scientific and professional understanding will allow. Do yourself a favor though and think critically. Don't absorb information passively. To quote my long-time coach again, "If you just want to go through the motions, don't bother. This isn't for you." Welcome to the BCSS blog! Not dogma, just information.