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.

 

 

Anterior Pelvic Tilt Influences Hip Range of Motion and Impingement

One of the most common postural adaptations that I see on a day to day basis is anterior pelvic tilt.  In fact, it’s getting more rare to find someone that isn’t in a large amount of anterior pelvic tilt.

I blame it on our seated culture.  The human body is excellent at adapting, and the seated posture produces an anterior pelvic tilt.

 

Anterior Pelvic Tilt Influences Hip Range of Motion and Impingement

Anterior Pelvic Tilt Hip Range of Motion ImpingementA recent research study published in the American Journal of Sports Medicine looked at the effect of changes in pelvic tilt on range of motion and impingement of the hip.

The authors looked at CT scans of the hips of  50 subjects with femoroacetabular impingement and simulated range of motion using 3D-generated models.

A 10 degree increase in anterior pelvic tilt, which I would say is something we see clinically, resulted in a significant loss of 6-9 degrees of hip internal rotation and increase in FAI.  This increase in anterior pelvic also resulted in a loss of 10 degrees of hip flexion.  Subsequently, an increase in posterior pelvic tilt resulted in greater hip internal rotation, less impingement, and more hip flexion.

 

Clinical Implications

The results of the study have several implications

  • Assessment of hip ROM should take pelvic position into consideration.
  • FAI symptoms may be reduced by decreasing anterior pelvic tilt.
  • People with limited hip internal rotation or hip flexion may have too much anterior pelvic tilt.  Focus on alignment before starting to torque the joint.  This is a fundamental principle I talk about in Functional Stability Training of the Lower Body.
  • People with poor squat mechanics, especially in the deeper positions, may have an underlying pelvic position issue.  People with excessibve anterior pelvic tilt that are squatting deep maybe impinging and beating up their hips.

 

I talk a lot about reverse posturing, my terminology for focusing on reversing the posture that you assume for the majority of your day.  But there is a big difference between reducing static anterior pelvic tilt posture and dynamic anterior pelvic tilt control.  You have to emphasize both with dynamic control being arguably more important.

Keep these findings in mind next time you see someone with a large amount of anterior pelvic tilt.

If you are interested in learning more about how I work with anterior pelvic tilt, I recently outlining my integrated system of manual therapy and corrective exercise in my Inner Circle webinar on Strategies to Reduce Anterior Pelvic Tilt.

 

 

Is Perfect Squat Form a Myth?

Over the years I have helped 1000’s of people squat better.  As a physical therapist, my career has evolved over the years from working with injured people to working with healthy people looking to optimize their body and maximize their performance.  In fact, I’m starting to refer to it more as “performance therapy” than “physical therapy.”

Lately, I’ve seen more and more people come to me to learn how to improve their squat.  Often times it’s one of two reasons why they can’t quite get find perfect squat form:

  • Something hurts when I squat
  • I can’t squat with perfect form

After going through a full body assessment, I always assess their squat form.  I don’t mean a rigid deep squat test, such as the one within the FMS of SFMA assessments, but an actual loaded squat.  I don’t say a word, I just observe.  Well, I actually record a video of it, but the point is I don’t want to cue the squat at all so I can see how the set up and how they perform their squat without my coaching.

What I often find is that many people are trying to squat with perfect form, or least what they believe is “perfect form.”  Perhaps they just picked up a copy of Starting Strength, or just attended their level 1 weekend certification, or just went through a foundations course at their box.  The quest for “perfect squat form” probably isn’t that simple.

I’m starting to wonder if there really is a such thing as perfect squat form.

 

Is Perfect Squat Form a Myth?

Don’t get me wrong, you have to start somewhere.  I personally recommend people read Mike Robertson’s article on How to Squat and the book Starting Strength is worth every penny.  My point isn’t that you should throw away any attempt to squat with perfect form, there are good ways and bad ways to squat, you have to start somewhere.

But I almost feel like we are over-coaching and using the same coaching cues during the squat with everyone.  Yes, there are many faults the can occur during squatting that should be avoided.  Bret Contreras has a nice article about solving 7 squat dilemmas.    But there is a big difference between correcting faults and overcorrecting people without faults.

Here is a good example, imagine you are squatting with your knees caving in towards each other, or tracking medially into a valgus knee position.  This would be a great time to cue someone to force their knees out.  However, it is possible to force your knees out too far and I’m not sure I want to cue someone that is squatting with decent form to aggressively force their knees out.  It’s a good thought to prevent knee cave in, but don’t go too far in the opposite direction.

But more importantly, I’m not sure there is a textbook way to squat, simply because we are all built different and have different daily habits.  There is a textbook perfect squat form for YOUR body, but it may be different for the person next to you.

This is why proper coaching and an individualized program built for you is the best way to succeed at perfecting your squat form.  There are several limitations that we all have that may be limiting our ability to achieve a perfect squat form.

 

Anatomical Limitations

The first thing we need to understand is that everyone’s anatomy is unique.  Bret Contreras does a nice job discussing our how our anatomical differences impact our squat mechanics and Ryan DeBall has a great article as well.  In fact, our pelvis and femurs are completely and vastly unique.

Look at these photos of several different pelvis and femur bones by Paul Grilley:

Femur neck variations

Femur Torsion Variations

Acetabular pelvic bone variations

Looking at these photos, it is striking how different we all really are on the inside.  The angles of how the femur bone forms as well as how it sits in the socket can be dramatically different between people.

This is what I find to be the biggest factor impacting why people can’t perform a squat with perfect form.  How can you say there is one way to squat when you look at these photos?  The spectrum of variation is so wide.

Unfortunately there isn’t a quick fix for anatomical limitations.  Rather, a detailed biomechanical assessment can be used to determine what may be the best squat mechanics based on your anatomy.  Sometimes this means that you will need to limit depth.  People never want to hear this, but sometimes you just simple run out of anatomy and can’t physically flex your hips enough to achieve deep squat form, at least without significant low back compensation.

 

Mobility Limitations

Luckily, not everyone has significant underlying anatomical variations.  Some just have mobility restrictions of their joint capsules and muscle tissue.  This is common in the person that assumes a frequent postural position over several years, such as sitting.  Most adults will have postural and mobility limitations that can be improved and subsequently improve their squat performance.

So, keep this in mind if you are a coach at a gym with adult fitness clients that are looking to start squatting.  Chances are they won’t be immediately able to perform a squat well until you clean up some of their movement patterns.  Rushing this process is how newbie adult fitness clients tend to hurt themselves while squatting.  They don’t have the mobility to squat with proper mechanics, and without this mobility, you are just going to compensate and put extra stress somewhere else, like this guy, who probably doesn’t have the mobility to be squatting:

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A detailed assessment process can accurately determine if you have an anatomical or simple mobility limitation.

I also want to briefly comment on squatting like a baby.  I know many people have commented that if babies can squat perfectly, why can’t adults?  Dean Somerset wrote about this recently, but this concept is really ridiculous.  There are many factors that make babies able to squat well, including their head to body size ratio, femur height, acetabular position, but most importantly the simple fact that their bones aren’t fused!  Adults will never have the mobility of a baby, this has nothing to do with motor control.

 

Motor Control Limitations

perfect squat formAnother possible area of limitation that can be negatively impacting your squat performance is poor motor control.  I again tend to see this in adults that have been sitting for the majority of the day the last 10-30 years.  When you sit all day, you don’t need abdominal control, lumbopelvic control, or posterior chain activity.  The chair simply does all of this for you.  You essentially learn how to turn all of these off!

This can be seen in someone that has poor movement patterns, however during my clinical assessment have no real mobility restrictions of their joints or muscles.

Sadly, however, I also see this often in my younger athletes.  I’m amazed at how poor our high school students move.  I blame it on sitting and staring at the TV, Xbox, or iPhone all day, but kids can’t even touch their toes anymore!

We have close to 100 high school athletes training with us at Champion Physical Therapy and Performance, and a large portion of them are performing corrective exercises and goblet squats until their motor control improves!

 

Your Perfect Squat Form

It’s always going to be in your best interest to work on your mobility and motor control limitations to improve your squat form.  However, realize that we all have different anatomical factors that may also be limiting your squat form.  This is why getting a proper assessment and individualized program is important if you are serious about enhancing your squat performance and reducing your chance for beating yourself up.

A custom program of mobility drills, corrective exercises, and individualized squat mechanics can really help you.   Sometimes you have to work within your own unique anatomical limitations.  Perhaps you just need to toe out a little more or widen your stance by an inch.  That may mean that you don’t perform the textbook perfect squat mechanics, but that may be OK, it’s your perfect squat form.

 

The Influence of Pain on Shoulder Biomechanics

The influence of pain on how well the shoulder moves and functions has been researched several times in the past.  It is often though that impaired movement patterns may lead to pain the shoulder.

A recent two part study published in JOSPT analyzed the biomechanics of the shoulder, scapula, and clavicle in people with and without shoulder pain to determine in differences existed between the groups.  Part one assessed the scapula and clavicle.  Part two assess the shoulder.

The subjects with pain were not in acute pain, but rather had chronic issues with their shoulders for an average of 10 years.  The authors used electromagnetic sensors that were rigidly fixed to transcortical bone screws and inserted into each of the bones to accurately track motion analysis.

The studies were interesting and worth a full read, but I wanted to discuss some of the highlights.

 

The Influence of Pain on Shoulder Biomechanics

In regard to the scapula, the authors found:

  • Upward rotation of the scapula less in subjects with pain
  • This decrease in upward rotation was present at lower angles of elevation, not in the overhead position

It is important to assess scapular upward rotation in people with shoulder pain, particularly emphasizing the beginning of motion.  Realize that no differences were observed in upward rotation past 60 degrees of elevation, implying that the symptomatic group’s upward rotation caught up to the asymptomatic group.  This may imply that there is a timing issue, more than a true lack of scapular upward elevation issue.  They are upwardly rotating, but perhaps just too late?

The study also found the following in regard to shoulder motion:

  • Shoulder elevation was greater in subjects with pain
  • This increase in shoulder elevation was present at lower angles of elevation, not in the overhead position

Noticed how I intentionally presented it similar to the scapula findings?  if you put the two finings together, it appears that people with shoulder pain have a higher ratio of shoulder movement in comparison to scapular movement at the beginning of arm elevation.  The shoulder caught up again overhead, so it appears that the timing between shoulder and scapular movement may have an impact.

The Influence of Pain on Shoulder Mechanics

As you can see, it is important to assess both shoulder and scapular movement together, and not in isolation, as movement impairments at one join likely influence the other.  The brain is exceptionally good at getting from point A to point B and finding the path of least resistance to get there.

I should note that in studies like this, it is impossible to tell if the pain caused the movement changes or the movement changes caused the pain.  So keep that in mind.  Regardless of causation, our treatment programs should be designed with these findings in mind.

There are so many other great findings in the study that I encourage everyone to explore these further, but I thought these findings were worth discussing.  Based on these findings, it appears worthwhile to assess the relative contribution of scapular and shoulder movement during the initial phases of shoulder elevation.

Interested in advancing your understanding of the shoulder?  My extensive online program teaching you exactly how I evaluate and treat the shoulder at ShoulderSeminar.com is on sale now for $150 off!  That is a huge discount that you don’t want to miss!  Click here to enroll in the program today, the sale ends at the end of the month!

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Laxity Does Not Mean Instability

Several years ago, when Eric Cressey and I released Optimal Shoulder Performance, I discussed the Beighton Laxity Scale and how I use it to determine the amount of laxity that individuals may possess.  This is just one of the many factors that go into how I design my rehabilitation and performance programs, as an individual’s amount of laxity influences program design.

Since then, I have started to hear comments from people that their clients may have Ehlers-Danlos syndromeLoeys-Dietz syndrome or Marfan syndrome because of their Beighton score.

 

Laxity is Normal

Beighton Scale Laxity InstabilityIf you Google “Beighton Score,” you see that this is a scale often used to diagnose the above hypermobility syndromes, however each has their own specific features.  A Beighton score is not the only factor involved, and actually is probably not the most important finding in any of these syndromes.

Laxity is not a syndrome, in fact, laxity is normal.

We all have a certain degree of laxity, you’ve probably seen many people along this spectrum from the really tight to the really loose.  A high Beighton score does not indicate that they have a syndrome or problem, it just helps determine where they sit in the laxity spectrum.

 

Laxity Does Not Mean Instability

While joint laxity is normal, a high amount of laxity does not necessarily mean you have instability.  Stability is a combination of the function of your static and dynamic stabilizing systems.  Instability is when you have an issue with either (or both) of the static and dynamic stabilizers.  Functional stability is the ability to dynamically stabilize a joint during functional activities to allow proper control and movement.  This is the basis behind our entire Functional Stability Training programs.

Check out this video of my friend Sam’s Beighton score.

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As you can see, Sam has a high Beighton score and a lot of joint laxity.  But Sam can deadlift over 2x her body weight.  That is laxity combined with functional stability.  She doesn’t have any problems because she can control her laxity.

Don’t automatically assume a lot of laxity is a bad thing, in fact many professional athletes possess a high amount of laxity.  Remember laxity is normal, does not mean instability, does not mean you have a clinical syndrome, and something you can control with the right program.

 

 

Assessing Scapular Position

The latest Inner Circle webinar recording on the Assessing Scapular Position is now available.

Assessing Scapular Position

Assessing_Scapular_PositionThis month’s Inner Circle webinar was on Assessing Scapular Position.  While I have openly stated in the past that assessing scapular position is not as significant as looking at dynamic mobility, I do feel it is worth starting your assessment with position.  You have to know where to start to know where to go.  This is a great follow up to my past talk on Scapular Dyskinesis.

Here is how I assess scapular position, but more importantly how I integrate it into my assessment.

To access the webinar, please be sure you are logged in and are a member 0f the Inner Circle program.

How Does Laxity Influence Program Design?

Today’s article is a guest post from Sam Sturgis regarding the influence of joint laxity on program design.  This is an important concept to understand when individualizing programs to achieve the best results.  People can fall on both ends of the laxity spectrum, from super loose to super tight.  Knowing this information will help you develop the best programs that are specific to the needs of each person.  Thanks for contributing Sam!

 

How Does Laxity Influence Program Design?

A heavily debated topic in the strength and conditioning world involves stretching.  It seems like there are never ending questions about stretching, such as “Who needs to stretch?,”  “When is the best time to stretch?,” “Does stretching even work?,” and many more.  Often times I will have clients mention to me that they “want to get more flexible” and that they “always feel tight”.  While this may be true in some instances, other times this feeling of “tightness” can be protective muscular tension since other structures aren’t quite working properly.

Being too tight obviously isn’t good, but neither is being too loose. It’s important to strike a balance of joint mobility and stability.

In our bodies we have two types of stabilizers: static and dynamic.  Static stabilizers are inert structures like bones, ligaments and joint capsules. These are non-contractile structures that do not create movements, they are simply there to create joint articulations and hold them together.  Dynamic stabilizers are the muscles. By contracting during a joint movement, they actively hold our joints in position so that they can move freely.  Laxity is a normal occurance.  Each joint has a certain amount of laxity.  However, in joints that have a lot of laxity, the static structures that hold the joints together may have a more difficult time keeping the joints in a neutral position.  Therefore, the muscles must work harder to create dynamic stability.

This laxity can either be congenital, meaning that you were born with it, or secondary to injury or repetitive activities.

During your assessment, one way to determine how lax a client may be is to use the Beighton Laxity Scale.  Mike Reinold and Eric Cressey mention this in their DVD Optimal Shoulder Performance and show how they use a Beighton Score when designing their programs.

 

The Beighton Score

The Beighton Scale is a 9 point scale that goes through a series of passive ranges of motion where a point is given for each indicator:

Beighton_scale

 

  • Hyperextension of the 5th finger MCP joint beyond 90 degrees
  • Apposition of the thumb to the flexor aspect of the arm
  • Hyperextension of the elbow beyond 10 degrees
  • Hyperextension of the knee beyond 10 degrees
  • Toe touch with the knees straight, touch the palms flat on the floor

A score of 0-4 would indicate an individual who is within normal levels of joint stiffness whereas a score of 5-9 would indicate joint laxity.  (photo from Physio-pedia.com)

Note From Mike: In Optimal Shoulder Performance, I teach how I actually use a 5-point scale.  In my mind if one of your elbows can hyperextend, for example, than you get a point.  If you perform a lot of unilateral activities, like throwing a baseball, you may have some chronic adaptations that may alter your score.  If you non-throwing arm has the laxity, then your throwing one probably had it too!

 

How to Use a Beighton Score

beighton-score-dynamic-stabilizationNow that you have determined how someone scores on the Beighton Scale, how should you change your program design?  Someone that scores 5 or higher on this scale should not be focused stretching! They need joint control and dynamic stability. For example, a baseball pitcher with a high Beighton score and 200 degrees of total ROM at the shoulder won’t get ANY shoulder mobilizations, they need to learn how to stabilize within those 200 degrees rather than try to gain more motion.

Conversely, someone who scores a 0 on the Beighton scale may be a candidate for more soft tissue and mobility work because they may need to create more range of motion to move freely and safely.

There is a continuum that clinicians should assess for and use to rationalize their decision making.  If a client presents with joint laxity outside of the normal limits, act appropriately and promote better proprioception and dynamic stability. Stretching or mobilizing someone who is already loose could make their issue worse. That protective tension is there for a reason, to keep the joint from getting injured! On the contrary, if someone presents as tight outside of normal limits, focusing on increasing their range of motion may be the most appropriate solution. If you can know which side of the fence each person falls on, this will help you individualize everyone’s program to maximize their training results.

 

About The Author

Sam SturgisSam Sturgis holds a Bachelor’s Degree in Athletic Training from Quinnipiac University and Master’s Degree in Strength and Conditioning from Springfield College.  A skilled Strength Coach and Athletic Trainer at Pure Performance Training in Needham, MA, Sam works primarily with baseball athletes and clients rehabilitating from injury.

 

 

Assessing Shoulder and Scapular Dynamic Mobility

Assessing Shoulder and Scapular Dynamic MobilityA thorough assessment of the shoulder must look at the posture and dynamic mobility of both the shoulder and scapula.  More importantly, we need to assess the interaction between the shoulder and scapula and not look at the two in isolation.

Assessing Shoulder and Scapular Dynamic Mobility

Altered scapular dynamic movement can be influenced by many things, so a thorough assessment is needed.  Here is a clip from my brand new educational program with Eric Cressey, Functional Stability Training for the Upper Body. This is part of a lab demonstration of Eric Cressey and I assessing overhead arm elevation and the quality of shoulder and scapular mobility.  In this clip you can clearly see a side-to-side difference and we discuss some of the potential implications:

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This is just a very small clip of some of the great information we cover in our new program, which is on sale for $20 off this week (sale ends Sunday May 18th at midnight EST).   Click here or the image below to order now before the sale ends!

Functional Stability Training for the Upper Body