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How to Assess Shoulder Capsular Mobility

The latest Inner Circle webinar recording on Assessing Shoulder Capsular Mobility is now available.

 

Assessing Shoulder Capsular Mobility

Assessing Shoulder Capsular Mobility - Social MediaThis month’s Inner Circle webinar is on Assessing Shoulder Capsular Mobility.  This is a recording of an actual inservice we performed with the students and interns at Champion this week.  I’m super excited to be able to record and share things like this with my Inner Circle.  It’s like having a front row seat at our inservices!  I think this offers many benefits over the traditional webinar/lecture format, as you can watch the interaction and also see some of the clinical techniques better.

In this webinar, we discuss:

  • The anatomy of the shoulder capsule and glenohumeral ligaments
  • How different arm positions stress different aspects of the capsule
  • How to determine which ligament and aspect of the capsule is tight
  • How to assess range of motion at different positions to assess different portions of the capsule
  • How to perform range of motion and capsular mobility assessment of the shoulder
  • Clinical tips on the assessment technique

To access this webinar:

 

 

Anterior Pelvic Tilt Influence on Squat Mechanics

anterior pelvic tilt influences squat mechanicsI feel like we’ve been discussing anterior pelvic tilt lately in several articles and an Inner Circle webinar on my strategies for fixing anterior pelvic tilt.  I wanted to show a video of a great example of how a simple assessment really tells you a lot about how pelvic positioning should influence how we coach exercises such as squats and deadlifts.

If you haven’t had a chance to read my past article on how anterior pelvic tilt influences hip range of motion, you should definitely start there.

In this video, I have a great example of a client that has limited knee to chest mobility and with boney impingement.  However, if we abduct the leg a bit, it clears the rim of the hip and has full mobility with no impingement.

YouTube Preview Image

As you can see, because he is in anterior pelvic tilt, he is prepositioned to start the motion in hip flexion, so therefor looks like he has limited mobility.  I have a past article on how anterior pelvic tilt influence hip flexion mobility, which discusses this a little more.

While you are working on their anterior pelvic tilt, you can work around some of their limitations.  I hate when people say there is only one way to squat or deadlift.

Our anatomy is so different for each individual.

Some need a wider stance while others need more narrow.  Some need toes out while some need more neutral.  Do what works best for your body, not what the text book says you are supposed to look like.

 

 

The Effect of Ipsilateral and Contralateral Loading on Muscle Activity During the Lunge

One thing I talk about a lot when it comes to training and rehabilitation is the need to train the body in all three planes.  This often requires moving in one plane of motion and stabilizing in the other two.   We are often very good at moving in the sagittal plane, and poor at stabilizing in the transverse and frontal planes.  This is a big topic of discussion in my program Functional Stability Training of the Lower Body.

To enhance this triplanar stability, we often attempt to facilitate greater contraction of the gluteus medius muscle during sagittal plane exercises.  The lunge in particular is a great exercise for triplanar stability as the narrow stance challenges strength in the sagittal plane and stability in the transverse and frontal planes.

 

The Effect of Ipsilateral and Contralateral Loading on Muscle Activity During the Lunge

The Effect of Ipsilateral and Contralateral Loading on Muscle Activity During the LungeA recent study was published in the Journal of Strength and Conditioning Research that investigated the effect of holding a dumbbell in either the contralateral or ipsilateral hand during a split squat and forward lunge.  (Note: they called it a “walking lunge” but I am 99% certain it was a forward lunge, so I’m just going to say forward lunger in this article…  probably just semantics.)

The study found that:

  • Holding the dumbbell on the ipsilateral side had no effect on glute med activity.
  • Holding the dumbbell on the contralateral side resulted in a significant increase in glute med activity, but only during the forward lunge, not the split squat.

I was a bit surprised that glute med activity was not impacted during the split squat, but perhaps the static nature of the position inherently requires less transverse and frontal plane stability.

There was one other finding from this study that I thought was interesting.  Kinematic differences during the forward lunge were found between a group of trained individuals in comparison to a group without training experience.

This makes sense as the forward lunge is a complex movement pattern that requires an understanding of how to control the pattern.  It requires both mobility and stability, but also the ability to control the eccentric deceleration phase.

contralateral lungeHowever, there were no kinematic differences between training age during the split squat, meaning that both novice and experienced trainees performed the split squat in a similar fashion.  This make split squats a great exercise to incorporate in the early phases of training for those with limited training experience, eventually progressing to forward lunge as they get better at moving and stabilizing the pattern.

This helps solidify the use of split squats in our lunge regression system.

 

Implications

I like simple studies like this.  Having the rationale to make small tweaks to your program is what sets you apart.  It’s the small things that may not be obvious at first but will produce better results over time.

Based on these results, I would recommend using the split squat with bilateral dumbbells to maximize strength gains since a unilateral load did not alter glute med activity.  The split squat is more of a basic exercise, so why not just use it to work on strength gains in the novice trainee.  As the person progresses, you can add the forward lunge variation with a contralateral load to enhance triplanar stability.

 

 

 

How to Improve Overhead Shoulder Mobility

The latest Inner Circle webinar recording on my How to Improve Overhead Shoulder Mobility is now available.

 

How to Improve Overhead Shoulder Mobility

Improving Overhead Shoulder MobilityThis month’s Inner Circle webinar is on how to improve overhead shoulder mobility.  In this webinar I’ll discuss:

  • We we are losing overhead shoulder mobility
  • Why it matters
  • The 4 main reasons why we lose overhead mobility
  • How the body compensates when we lose overhead mobility
  • How to assess for a loss of overhead shoulder mobility
  • What you MUST stop doing immediately with people that have lost overhead mobility – you are making them worse!
  • Corrective exercises to enhance overhead position
  • Manual therapy techniques to improve mobility

 

To access this webinar:

4 Ways to Improve Overhead Shoulder Mobility

4 Ways to Improve Overhead Shoulder MobilityOne of the most common areas we attempt to improve in clients at Champion PT and Performance is overhead shoulder mobility.  If you really think about it, we don’t need full overhead shoulder mobility much during our daily lives.  So our bodies adapt and this seems to be an movement that is lost in many people over time if not nourished.

I’m often amazed at how many people have a significant loss of overhead mobility and really had no idea!

That’s not really the issue.  The problem occurs when we start to use overhead mobility again, especially when doing it during our workouts and training.  Exercises like a press, thruster, snatch, overhead squat, kipping pull up, toes to bar, handstand push up, wall ball, and many more all use the shoulder at end range of movement.  But here are the real issues:

  • Add using the shoulder to max end range of overhead mobility and we can run into trouble
  • Add loading during a resisted exercise and we can run into trouble
  • Add repetitions of this at end range and we can run into trouble
  • Add speed (and thus force) to the exercise and we can run into trouble

 

4 Ways to Improve Overhead Shoulder Mobility

In this video I explain the 4 most common reasons why you lose overhead shoulder mobility and can work on to improve this movement:

  1. The shoulder
  2. The scapula
  3. The thoracic spine
  4. The lumbopelvic area

The first three are commonly address, but not so for the lumbopelvic area, which is often neglected.  I’m going to expand on this even more in this month’s Inner Circle webinar.  More info is below the video:

 

Improving Overhead Shoulder Mobility

This month’s Inner Circle webinar is going to expand on this topic and discuss how and why you want to improve overhead shoulder mobility.  In this webinar I’ll discuss the importance of overhead mobility, how to assess the 4 most common causes of loss of mobility we discussed above, what corrective exercises to perform, and tips for manual therapy.  The live webinar will be on Monday April 20th at 8:00 PM EST, however will be recorded for those that can not attend live.

 

 

 

Scalene Hypertrophy

I recently evaluated yet another Major League baseball player with the “yips,” or what I like to call thoracic outlet syndrome.  I really don’t believe in the yips at all and feel that thoracic outlet syndrome is almost always to blame.  Telling a professional athlete it’s all in their head or some mysterious mechanical flaw is just insulting.

One of the major reasons that thoracic outlet syndrome occurs in baseball pitchers is from hypertrophy of the scalene muscles (and sternocleidomastoid).  Throwing a baseball causes many adaptations to the body, including this increase in scalene size.

Here is a video of the athlete inhaling with his head turned to each side.  Notice the significantly larger scalene and sternocleidomastoid on his right side.

scalene hypertrophy

I wish I had a magic trick to help in this situation.  I will perform manual therapy on the scalene muscles, surround musculature, 1st rib, and thoracic cage, however, it’s hard to combat the hypertrophy associated with throwing.

Understanding what to look for is the first step, though.  Scalene hypertrophy is a subtle finding to detect on examination.

 

 

Should We Stop Blaming the Glutes for Everything?

Today’s guest post comes from John Snyder, PT, DPT, CSCS.  John, who is a physical therapist in Pittsburgh, has a blog that has been honored as the “Best Student Blog” by Therapydia the past two years.  He’s a good writer and has many great thoughts on his website.  John discusses some of our common beliefs in regard to the role of the proximal hip on knee pain.  I’ll add some comments at the end as well, so be sure to read the whole article and my notes at the end.  Thanks John!

 

Should We Stop Blaming the Glutes for Everything?

should we stop blaming the glutes

Anterior cruciate ligament (ACL) rupture1,2 and patellofemoral pain syndrome (PFPS)3,4,5 are two of the most common lower extremity complaints that physicians or physical therapists will encounter. In addition to the high incidence of these pathologies, with regards to ACL injury, very high ipsilateral re-injury and contralateral injury have also been reported6,7,8.

With the importance of treating and/or preventing these injuries, several researchers have taken it upon themselves to determine what movement patterns predispose athletes to developing these conditions. This research indicates that greater knee abduction moments9,10, peak hip internal rotation11, and hip adduction motion12 are risk factors for PFPS development. Whereas, for ACL injury, Hewett and colleagues13 conducted a prospective cohort study identifying increased knee abduction angle at landing as predictive of injury status with 73% specificity and 78% sensitivity. Furthermore, as the risk factors for developing both disorders are eerily similar, Myer et al performed a similar prospective cohort study finding that athletes demonstrating >25 Nm of knee abduction load during landing are at increased risk for both PFPS and ACL injury14.

 

Does Weak Hip Strength Correlate to Knee Pain?

With a fairly robust amount of research supporting a hip etiology in the development of these injuries, it would make sense that weakness of the hip musculature would also be a risk factor, right?

A recent systematic review found very conflicting findings on the topic. With regards to cross-sectional research, the findings were very favorable with moderate level evidence indicating lower isometric hip abduction strength with a small and lower hip extension strength with a small effect size (ES)15. Additionally, there was a trend toward lower isometric hip external rotation and moderate evidence indicates lower eccentric hip external rotation strength with a medium ES in individuals with PFPS15. Unfortunately, the often more influential prospective evidence told a different story. Moderate-to-strong evidence from three high quality studies found no association between lower isometric strength of the hip abductors, extensors, external rotators, or internal rotators and the risk of developing PFPS15. The findings of this systematic review indicated hip weakness might be a potential consequence of PFPS, rather than the cause. This may be due to disuse or fear avoidance behaviors secondary to the presence of anterior knee pain.

 

Does Hip Strengthening Improve Hip Biomechanics?

Regardless of its place as a cause or consequence, hip strengthening has proved beneficial in patients with both PFPS16,17,18 and following ACL Reconstruction19, but does it actually help to change the faulty movement patterns?

Gluteal strengthening can cause several favorable outcomes, from improved quality of life to decreased pain, unfortunately however marked changes in biomechanics is not one of the benefits. Ferber and colleagues20 performed a cohort study analyzing the impact of proximal muscle strengthening on lower extremity biomechanics and found no significant effect on two dimensional peak knee abduction angle. In slight contrast however, Earl and Hoch21 found a reduction in peak internal knee abduction moment following a rehabilitation program including proximal strengthening, but no significant change in knee abduction range of motion was found. It should be noted that this study included strengthening of all proximal musculature and balance training, so it is hard to conclude that the results were due to the strengthening program and not the other components.

 

Does Glute Endurance Influence Hip Biomechanics?

All this being said, it is possible that gluteal endurance may be more influential than strength itself, so it would make sense that following isolated fatigue of this musculature, lower extremity movement patterns would deteriorate.

Once again, this belief is in contrast to the available evidence. While fatigue itself most definitely has an impact on lower extremity quality of movement, isolated fatigue of the gluteal musculature tells a different story. Following a hip abductor fatigue protocol, patients only demonstrated less than a one degree increase in hip-abduction angle at initial contact and knee-abduction angle at 60 milliseconds after contact during single-leg landings22. In agreement with these findings, Geiser and colleagues performed a similar hip abductor fatigue protocol and found very small alterations in frontal plane knee mechanics, which would likely have very little impact on injury risk23.

 

Can We Really Blame the Glutes?

The biomechanical explanation for why weakness or motor control deficits in the gluteal musculature SHOULD cause diminished movement quality makes complete sense, but unfortunately, the evidence at this time does not agree.

While the evidence itself does not allow the gluteal musculature to shoulder all of the blame, this does not mean we should abandon addressing these deficits in our patients. As previously stated, posterolateral hip strengthening has multiple benefits, but it is not the end-all-be-all for rehabilitation or injury prevention of lower extremity conditions. Proximal strength deficits should be assessed through validated functional testing in order to see its actual impact on lower extremity biomechanics on a patient-by-patient basis. Following this assessment, interventions should be focused on improving proximal stability, movement re-education, proprioception, fear avoidance beliefs, graded exposure, and the patient’s own values, beliefs, and expectations.

 

John SnyderJohn Snyder, PT, DPT, CSCS received his Doctor of Physical Therapy degree from the University of Pittsburgh in 2014. He created and frequently contributes to SnyderPhysicalTherapy.com (Formerly OrthopedicManualPT.com), which is a blog devoted to evidence-based management of orthopedic conditions.  

 

Mike’s Thoughts

John provides an excellent review of many common beliefs in regard to the influence of the hip on knee pain.  While it is easy to draw immediate conclusions from the result of one study or meta-analysis, one must be careful with how they interpret date.

I think “anterior knee pain,” or even PFPS, is just too broad of a term to design accurate research studies.  It’s going to be hard to find prospective correlations with such vague terminology.  Think of it as watering down the results.  Including a large sample of people, including men, women, and adolescents and attempting to correlate findings to “anterior knee pain” is a daunting task.

Imagine if we followed a group of adolescents from one school system for several years.  Variations in gender, sport participation, recreational activity, sedentary level, and many more factors would all have to be considered.  Imagine comparing the development of knee pain in a 13 year old sedentary female that decided she wanted to run cross country for the first time with an 18 year old male basketball player that is playing in 3 leagues simultaneously.  Two different types of subjects with different activities and injury mechanisms.  But, these two would be grouped together with “anterior knee pain.”

What do we currently know?  We know hip weakness is present in people with PFPS and strengthening the hips reduces symptoms.  As rehabilitation specialists, that is great, we have a plan.  I’m not sure we can definitely say that hip weakness will cause knee pain, but I’m also not sure we can say it won’t.  Designing a prospective study to determine may never happen, there are just too many variables to control.

John does a great job presenting studies that require us to keep an open mind.  I’m not sure we can make definitive statements from these results, but realize that there are likely many more variables involved with the development of knee pain.  Hip strength and biomechanics may just be some of them.  Thanks for sharing John and helping us to remember that it’s not always the glutes to blame!

 

 

How to Prepare Before You Throw – Part 2: Prepare Your Throwing

As I said in part 1 of this 2-part article on How to Prepare Before Your Throwing Program, one common theme that I often hear when players describe how they got hurt was that they did not properly warm up and prepare themselves to throw.

To prepare before your throwing program, you really need to do two things: 1) Prepare your body and 2) Prepare your throwing.  If you haven’t yet, please go back and read part 1 of this article to learn how to prepare your body:

 

How to Prepare Before Your Throwing Program – Part 2: Prepare Your Throwing

Now that your body is ready to roll and start your throwing program, I want to shift gears and talk about how to use your throwing program to prepare to throw.  I think it is really import to “prepare to throw, not throw to prepare.”

What I mean by that is that you need to make sure you are properly warmed up, even within your throwing program, before you can start your throwing “work.”  You shouldn’t just jump on the mound, or throw at full intensity, or quickly progress to long tossing.  That is throwing to prepare, and as I stated in part 1 of this article, I don’t want aggressive throwing to be the first things your body feels.

To prepare to throw, you need to prepare your body (again, in part 1) and then prepare your throwing program.  There is a BIG difference between your “warm-up” throwing and your “work” throwing.

Would you ever just throw your max weight on the bar and start squatting or deadlifting without doing warm up sets?  Never, right?  In strength and conditioning we usually incorporate a gradual increase in load with the weight of an exercise before getting to the weight we want to use to train.  You have warm-up sets and then work sets.  As an example, if you are supposed to perform 5 sets of 5 reps of deadlifts at 285 lbs, if you first set is 185, second set 205, and third set 225, those don’t count as your 5×5 work sets.

The same goes with throwing.

 

Prepare to Throw Step 4 – Ease Into Throwing

I’ve played catch with 100’s of professional baseball pitchers.  I honestly only remember one that would start throwing 90 MPH at my knees by the third or forth throw (and he’s been injured his entire career).  Big leaguers get it and gradually get loose.  You’d actually be surprised at how easy they actually play catch initially as they warm up.

On the flip side, one of the more common tweaks I make to my younger athletes is to ease into throwing.  Not a week goes by without someone gunning a ball at my ankles on the 3rd throw (I love you GD…).

This is extremely stressful on the body.  Remember throwing itself is stressful.  You have to gradually apply that stress to get the tissue used to the force.

Not all throwing has to be designed to gain arm strength or velocity.  Some throwing should be more similar to just riding a bike with your arm to get blood flow and gradually apply stress to the elasticity of the tissue.

 

Prepare to Throw Step 5 – Let The Distance Dictate the Intensity

The next step to prepare to throw builds on step 4.  Now that you’ve played light catch to get loose, it’s time to start walking back and increasing the distance.

Distance in your long toss program is a variable we use to adjust your intensity.  Realistically there isn’t much difference between throwing with full intensity at 150 feet or 200 feet.  Full intensity is pretty much full intensity.

Again, resist the urge to start throwing on a line at new distances.  Rather, I tell my athletes to “let the distance dictate the intensity,” meaning throw the ball with a bit of an arc to firmly hit your partner in the chest on the descent.

If the ball would sail past your partner another 100 feet if they missed your throw, you are throwing too hard for the stretch out phase of throwing.

baseball long toss arc

 

There will be time to throw on a line, that is next step…

 

Prepare to Throw Step 6 – Get Your Work In

OK, you’ve made it!  You prepared your body.  You’re mobile.  You activated your muscles.  You did a dynamic warm up.  You eased into throwing and long toss.  Congrats!  Now you can “throw.”

Just to reiterate, there is a difference between “warm-up” throwing and “work” throwing.  Step 6 is now incorporating your “work” throwing, whatever that may be for you that day.

It could be long toss, weighted balls, bullpen work, even throwing in a game.  That is your “work” throwing and you are now ready for it.

 

By going through the proper steps to prepare to throw you’ll find that you actually get better work in and throw better, plus you’ll be much more resilient to injuries.  These are some of the key steps I outline to all of my athletes and what we follow in the big leagues.

 

Want to Learn More?

I have an entire Inner Circle webinar dedicated to detailing these 6 steps to prepare for and perform a throwing program.

 

I also have a free 45-minute video on How Baseball Players Can Safely Enhance Performance While Reducing Injuries.  Enter your name and email below and I will send you access to the video as well as a handout of the above arm care warm-up exercises that you can take to the field: