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The True Hip Flexor Stretch

The hip flexor stretch has become a very popular stretch in the fitness and sports performance world, and rightly so considering how many people live their lives in anterior pelvic tilt.  However, this seems to be one of those stretches that I see a lot of people either performing incorrectly or too aggressively.  I talked about this in a recent Inner Circle webinar on 5 common stretches we probably shouldn’t be using, but I wanted to expand on the hip flexor stretch as I feel this is pretty important.

I’ve started teaching what I call the “true hip flexor stretch.”  I call it the true hip flexor stretch as I want you to truly work on stretching the hip flexor and not just torque your body into hip and lumbar extension.  When performing, most people say they never felt a stretch like that before, hence the name “true hip flexor stretch.”

 

True Hip Flexor Stretch

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Key Points

  • There is a difference between a quadriceps stretch and a hip flexor stretch.  When your rationale for performing the stretch is to work on stretching your hip flexor, focus on the psoas and not the rectus femoris.
  • Keep it a one joint stretch.  Many people want to jump right to performing a hip flexor stretch while flexing the knee.  This incorporates the rectus and the psoas, but I find far too many people can not appropriately perform this stretch.  They will compensate, usually by stretching their anterior capsule too much or hyperextending their lumbar spine.
  • Stay tall.  Resist the urge to lean into the stretch and really extend your hip.  Most people are too tight for this, trust me.  You’ll end up stretch out the anterior hip joint and abdominals more than the hip flexor.
  • Make sure you incorporate a posterior pelvic tilt.  Contract your abdominals and your glutes to perform a posterior pelvic tilt.  This will give your the “true” stretch we are looking for.  Many people wont even need to lean in a little, they’ll feel it immediately in the front of their hip.
  • If you don’t feel it, squeeze your glutes harder.  Many people have a hard time turing on their glutes while performing this stretch, but it is key.
  • Guide your hips with your hands.  I usually start this stretch with your hands on your hips so I can teach you to feel posterior pelvic tilt.  Place your fingers in the front and thumbs in the back and cue them to posterior tilt and make their thumbs move down.

true hip flexor stretch

  • Progress to add core engagement.  Once they can master the posterior pelvic tilt, I usually progress to assist by curing core engagement.  You can do this by pacing both hands together on top of your front knee and push straight down, or by holding a massage stick or dowel in front of you and pushing down into the ground.  Key here is to have arms straight and to push down with you core, not your triceps.

 

I use this for people that really present in an anterior pelvic tilt, or with people that appear to have too loose of an anterior hip capsule.  This works great for people with low back pain, hip pain, and postural and biomechanical issues related to too much of an anterior pelvic tilt.  Give the true hip flexor stretch a try and let me know what you think.

 

 

A Simple Exercise for the Scapula, Posterior Chain, and Posture

I am always a fan of simple exercises that get a big bang for my buck.  I want to be able to streamline my programs to have as little fluff as possible.

One exercise I often use for scapular control is called the “cheerleader exercise,” which my friend Russ Paine in Houston first showed me and has popularized over the years.  Russ included this exercise in one of his latest publications on The Role of the Scapula in the International Journal of Sports Physical Therapy.  The article is free to read and is a great adjunct to my recent webinar on Scapular Dyskinesis.

Russ teamed up with another pioneer in sports physical therapy, Mike Voight, to write the new manuscript.  The amazing part is that Russ and Mike wrote one of the landmark articles on scapular rehabilitation in JOSPT in 1993, twenty years ago!

The cheerleader exercise uses a piece of Theraband or rubber tubing to perform a series of reciprocal exercises focusing on scapular retraction.  You begin by grasping a piece of tubing between both hands with your arms raised forward at shoulder height.  Pull both hands apart into horizontal abduction.  Then, return to the starting position and pull one arm down and the other up in a diagonal pattern.  For those familiar with proprioceptive neuromuscular facilitation (PNF) drills, these are D2 flexion and D1 extension positions.  Return to the starting position again and switch the diagonals.

scapula cheerleader exercise

This is a great posterior chain drill that works on developing strength and endurance in a functional scapular patterns.  It is a great drill when working on facilitating a more posterior dominant posture, and getting out of our terrible anterior dominant sitting posture.

This one drill effectively combines several exercises that focus on scapular retraction, upward rotation, and posterior tilt.  But what I really like about the exercise is the reciprocal nature of the exercise.

scapula exercise

Think about it, running, jumping, throwing and other activities always involve a reciprocal involvement of upward arm movement and reciprocal arm extension.

I don’t use this as a replacement for pure isotonic strengthening of the scapula muscles, such as the YTWL exercises, but it is a nice drill to work on integrated patterns and endurance.  Next time you are looking for a drill to enhance scapular control, posterior chain strength, and postural awareness, try the cheerleader exercise.

 

 

 

The Curious Case of the Wiggles

Wow, that was a very nice response to the scapula winging video!  Great comments and discussions by many.  I read each and every one of your comments throughout the week, thanks for participating.  There were a ton of great comments.  There are probably 100’s of things we can discuss, but I wanted to share my general focus.

If you haven’t read the original post, please go back and take a peak at my original shoulder overhead elevation assessment post and read all the great comments.  Here is the video again:

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General Comments

  • assessing overhead arm elevationI would first comment and state that this is one quick video in a long series of assessments.  I chose overhead elevation because it was simple and reproducible  and showed a bunch of interesting things!  I start my assessment off by simple asking them to raise their arms over head.  That is it.  No other instructions.  I feel that it is important to assess how “they” want to move, not how “I” want them to move.  This is important to assess and often missed as we want to stick everyone in a “system.”  I like systems, they enhance re-test reliability, but sometimes they decrease validity.  
  • A test like overhead elevation in the sagittal plane, such as in this video, assumes two thing: Symmetry and Neutrality.  I don’t think either of these exist.  So it is inherently flawed.  Think about it, if his scapulae are off, then doesn’t that mean his glenoid is off?  Then technically the “sagittal” plane is just in relation to the ground, not to his body.
  • There is also a “chicken and the egg” concept here.  Did his pain create the dysfunctional movement or vice versa?  Unfortunately in retrospect we’ll never know.  Taking this into consideration I don’t think it is fair to assume that anything we are seeing is the “cause” of his pain.  Essentially it is all just the summation of where we are today.
  • I noticed many people wanted to comment on specific muscles being “tight,” “long,” “short,” “weak,” etc.  Remember all we know here is that he has a movement dysfunction.  I think it is appropriate to suggest these may be true, but you will need to take the next step and assess these assumptions.  I wouldn’t just jump in and treat based on assumptions.
  • I should also comment on the marks on his back.  One relevant, the other not so relevant.  The circles are cupping marks.  He is seeing another provider that performs this as part of his maintenance program while swimming in addition to massage etc, not for treatment of his symptoms.   However, the horizontal marks on his low back are relevant.  Those are stretch marks.  More on this later…

Static Scapula Position

  • I have commented on this before in my article on Myths of Scapula Exercises, but I don’t put a lot of emphasis on resting static scapular position.  Realistically, the scapula sits on the ribs, so it’s resting static posture is likely more a reflexion of rib and thorax position that scapular position.  I prefer to look at scapular dynamic movement quality.
  • Interestingly, you can see his dynamic concentric control of his scapulae doesn’t seem as bad as you would think based on his static resting position, especially as he gets high into elevation:

static and dynamic scapula position

The Head Wiggle and Scapula Wing

  • The first thing that really stuck out to me was his head wiggle.  I bet you missed it the first time!  A very interesting movement pattern.  In retrospect, you can find him shift his neck in this fashion quite a bit while observing him moving around and performing activities, even just talking to you sometimes.  It is not limited to just overhead elevation in the sagittal plane.  
  • We can’t really separate this from his winging scapula, they go together.  It sure looks like the head wiggles when the scapula wiggles.
  • To me, this looks like the levator scapula pulling the head with a complete lack of opposition from the lower trapezius and serratus anterior.  His head goes into side bend to the left and extension.  This is the cervical responsibility of the levator.  However, his scapula also shoots up into elevation and downward rotation.  This is my biggest indicator that levator is the one acting.  There could be more involved, like SCM, but I’m focusing on levator.
  • There is obviously some winging and lack of opposition of the levator by the traps and serratus.  This is really obvious on eccentric lower.  He also does not have a painful arc during this movement.  He is not shifting away from pain.

scapula winging

  • So while the levator may be causing the head wiggle, it sure looks like the serratus and lower trap are not doing their job and creating the scapula wiggle.
  • See how everything plays together?

 

The Elbow Wiggle

  • Many people picked up on the elbow wiggle, good work!
  • I don’t think this is really an elbow issue.  If you watch closely he keeps his hand in the same position.  He essentially fixes his hand on an imaginary sagittal plane track.  To me his shoulder and scapula want to move into adduction and internal rotation with the beginning of his scapula winging about to occur.  I feel like his glenoid may be the one the is not stabilized.  Since we have forced him to perform a strict overhead assessment in the sagittal plane, he is keeping his hand fixed and his elbow has to hyperextend to not allow his hand to horizontal adduct.  Again, just shows some of the flaws of assessments like this.

elbow compensation

  • So while this may be glenohumeral instability, I think it is still just the scapula as it occurs during the eccentric lowering and he has almost no ability to control winging.  And again, he does not have a painful arc.
  • This really illustrates a general point that I tend to make about humans in general, but even more so on high level athletes.  We are excellent at getting from point A to point B.  It’s all about how we get there.  Unfortunately the overhead elevation assessment uses an internal cue to “raise your hand up in front of you.”  Perhaps it would be better to give an external cue like “reach up and touch the ceiling.”

 

Thoracolumbar Flexion

  • So taking away all the interesting things happening from the scaps up, I also notice some interesting thoracolumbar compensations.  Remember, this client is a swimmer, and a high level swimmer.  Is it me or does his left latissimus look too small for a swimmer?
  • I mentioned earlier the stretch marks on his lower back.  When he tries to pull down with his arms with any resistance, his movement compensation was to go into a large amount of thoracolumbar flexion, which is a compensatory movement for the inability to extend his arms against resistance.  His lumbar paraspinals show hypertrophy.  So while this could be poor core control, I feel that may be too simplistic.  He goes into thoracolumbar flexion with minimal resistance.  Seems more compensatory rather than poor patterning.  In the photos below, that is not just paraspinal hypertrophy, that is also flexion:

latissimus

  • In looking at the photos above, see how he moves into thoracolumbar flexion?  These are fairly recent photos.  Here are a couple of photos from two months prior.  You can really see the thoracolumbar flexion compensation.  But also notice the dramatic increase in body composition in 2 months.  He put on 15 pounds of muscle mass in a 2-month program designed specifically for him:

thoracolumbar compensation

  • One thing I mentioned was that he feels symptoms with prolonged swimming.  He actually fatigues out well before his fellow swimmers.  Feels strong and swims well, then hits a wall quickly from 10-20 minutes in the pool, while everyone else is in there for 60-120 minutes without complaints.  While he looks a lot better.  There are still some muscles that are not coming back as expected, and he is still fatiguing out in the pool and feeling generalized symptoms.
  • This really makes me think a nerve issue that is just not allowing proper muscle function, and/or the fact that he is essentially swimming with his accessory muscles like his teres major and deltoids.  This is something we need to explore further.
  • I read some comments that taking him out of the pool and assessing him on dry land may not be the most valid assessment.  However, I would imagine that this thoracolumbar flexion occurs during every stroke in the pool as his lat is trying to pull through the water.  This is something else we need to explore further.

 

Great thoughts, comments, and discussions on this video everyone!  Thanks for participating.  We obviously still have some work to do to try to find out how exactly what is going on and how we can best help this client.  I’ll be sure to post an update if we gather any new information.

 

 

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3 Myths of Scapula Exercises

Scapula exercises are very common and usually a needed component to any rehabilitation or corrective exercise program.  Like anything else, there seems to be a few commonly accepted themes related to scapular exercises that many people take for hard fast rules.  No program is right everyone!  Here are 3 myths of scapular exercises that I thought would good to discuss.

 

Pinch Your Shoulder Blades Together

Pinch your shoulder blades.  Squeeze your scaps together.  Retract your shoulders back.  Pack your scapula.  These are all common coaching cues given during scapular exercises.  The goal of all of these concepts is essentially to get into better posture and “set” your scapula back, ultimately resulting in better posture and better movement patterns when performing exercises.  Given that as a society we have an abundance of people with posture.  The classic Upper Body Cross Syndrome of forward head, rounded shoulders.

Normal scapulohumeral rhythm requires a sequence of shoulder and scapular movement simultaneously.  Pinching your shoulder blades together is essentially contracting your middle trapezius to fully retract your scapula and then move your arm.  While this isn’t nearly as bad on shoulder mechanics as lifting your arm in a fully protracted position, I don’t think it is most advantageous to lift your arm in a fully retracted position.  By holding your scapula back, which is essentially performing and isometric trapezius contraction, you are likely limiting the normal protraction and upward rotation that occurs with arm elevation and movement.

Scapula Exercises

If the goal of this common coaching cue is to improve posture and improve mechanics while exercising the arm, maybe a better cue would be to instruct thoracic extension.  Perhaps even combine this thoracic extension with upper cervical extension such as when performing the chin nod with postural exercises like we talked about recently.  This truly improves your posture.  Realize that you can still have a very kyphotic and rounded thoracic spine and retract your scapulas.  Retracting the your scapulas isn’t a bad visual, but the goal is to really get your thoracic spine extended.

 

Work on Mobility and Strength to Improve Scapular Symmetry

Scapula StrengthWe’ve all been guilty of assessing someone’s posture, finding this forward head rounded shoulder posture, and then assuming we need to work on things like pec and upper cervical mobility while strengthening the lower trap and deep neck flexors.  These are all good things to work on, however this is likely a simplistic view.

First let’s take a step back and get something out of the way.  Your scapulas are not symmetrical.  The vast majority of people are not symmetrical and I would bet even people that are close have subtle differences.  The fact is, we are unilateral creatures.  We are typically one hand dominant and we typically function with predominant movement patterns that are related to this.  This tends to really become an issue when we start to talk about people that perform a repetitive unilateral activity all day.  I’m not just talking about athletes like baseball pitchers, you sitting there at your computer using your mouse in your right hand counts too.

This inherently creates asymmetries throughout the body, including the hips, spine, rib cage, and of course the scapula.

In my opinion, scapular position is more related to rib and thoracic position than anything else, including tight muscles and weak or inhibited muscles.  The scapula rests on the rib cage and thus moves with the rib cage.  Do you need to work on these muscle imbalances?  Absolutely.  However, proper alignment is needed as well and should be assessed first.

Everyone says “mobility before stability,” right?  Well, I’d like to add to that.  How about this:

Alignment before mobility before stability.

 

Perform Scapular Exercises Bilaterally

Ah, the old YTWL exercises.  I’ve discussed why I really don’t do a lot of the classic YTWL exercises either prone off the table or on a physioball.  I don’t love the upper trap activity needed to stabilize the head and just don’t feel like you get the proper movement pattern you are looking to achieve.  Perhaps it helps with posture.  I am sure there are pros and cons.

However, and probably more importantly, we don’t really tend to perform movement patterns that invovlve moving your arms like in this fashion.  When was the last time you retracted both arms such as during the T exercise?

If I am looking to strengthen a muscle, I am going to stick to my unilateral prone exercises and focus on strength and motor control.  That is my priority.

Then, when function and movement patterns becomes my next priority, I wonder if it is best to work on reciprocal scapular activities anyway?  Far more often we uses our arms in this fashion – one arms pulls while one arm pushes.  This can be seen in some of our most common activities like walking, jogging, and running as well as unilateral overhead sports like tennis, volleyball, softball, and baseball.  Here is a great example from Northeastern University:

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Are there times when you should work your scapulas bilaterally?  Sure.  Just off the top of my mind I would do this in swimmers (expecially for the breast and butterfly strokes) and people that have to push and pull large objects at work all day.  It goes back to specificity of training.

The take home message is that you don’t have to work your scapulas bilaterally, and there is some very clear reasons why you would actually want to do the opposite and work the reciprocal push-pull pattern instead.

 

I hope this at least stirred some thought and discussion.  There is a time and place for everything, however sometimes there seems to be an overwhelming approach in one direction.  Maybe these 3 myths of scapula exercises will make you stop and think next time your are working on improving scapular strength, what do you think?

 

 

 

Integrating Upper Cervical Flexion with Postural Exercises

chin nod with shoulder w exercise

Several weeks ago I published a quick video tip on a variation of the chin tuck exercise, the chin nod exercise.  I received a lot of nice feedback regarding the use of the nod and wanted to share the next phase of the progression, integrated the chin nod into exercises.

Just like any other aspect of our rehabilitation and corrective exercise programs, the ultimate goal should be to groove motor patterns with simple exercises and slowly integrate them into more complex functional movement patterns.  While the chin nod is a great choice to work on upper cervical flexion in those with postural adaptations and an upper body cross syndrome, it is really only a small part of the pattern.

We always talk about strengthening the lower trap and serratus and performing manual therapy on the pecs, subclavius, upper trap, and levator (just to name the big ones…).  The chin nod is also a simple way to set your posture prior to some of these activities.

As an example, I shot a quick clip on integrated the chin nod into the shoulder W exercise, which is fantastic for posterior cuff and lower trap strengthening, as well as opening up the anterior shoulder.  By adding the chin nod prior to performing the exercise, you essentially enhance the outcomes of the exercise by assuring proper alignment.

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This isn’t rocket science, but by integrating the chin nod into exercises like this, it really helps groove the correct motor pattern better.  Incidentally, this is one of my favorite exercises for those with cervicogenic headaches and neck pain.  Have them sit up tall in the car at red lights and perform this exercise.  Great, even without Theraband.  I even use this integrated chin nod and shoulder W exercise as my breaks while sitting at the computer!

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Simple Thoracic Spine Mobility Exercises Everyone Can Perform

Thoracic spine mobility is an extremely important, and often times overlooked, component to a variety of dysfunctions.  Poor thoracic mobility can affect the shoulder, neck, low back, and hip very easily.  Unfortunately, our daily habits and posture make us all very prone to poor thoracic spine mobility.

I have talked about this before when discussing my reverse posturing theory and when discussing what may be the best posture stretch that I know.  A key component to reverse posturing is working on thoracic spine mobility.

There are many variations of thoracic spine mobility exercises and drills out there on the internet.  Many of them are great, but not for everyone.  Here is a collection of thoracic spine mobility exercises that you can try with your patients and clients.  These are all great example, but at the end I will discuss my preferred technique and a simple thoracic spine mobility exercises that is easy for everyone to perform.  I think it is a great place to start when trying to enhance thoracic spine mobility.

Regardless of which thoracic mobility exercise you chose, there is one major goal that MUST be achieved during all of the different mobility drills:

[box type=”info” size=”large”]Mobility must come from the thoracic spine and NOT the lumbar spine[/box]

This is critical and the easiest way to turn a nice corrective exercise for the thoracic spine into a mobility drill for the lumbar spine that feeds into the person’s deficiencies.

 

Thoracic Spine Mobility Exercises for Extension

We should start with thoracic spine mobility exercises that work on increasing thoracic spine extension.  Here are a couple of nice examples.

 

Thoracic Spine Mobility Exercise for Extension Using Tennis Balls

Here is a nice example of a simple extension mobilization for the thoracic spine.  In this video, Michael Boyle shows us how he uses two tennis balls to act as a pivot to thoracic extension:

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Nice simple exercise that works on addressing the lack of thoracic spine exercise.  The tennis balls are positioned at various spine segments. A good place to start for many people.

 

Thoracic Spine Mobility Exercise for Extension Against a Wall

Another nice drill that emphasizes thoracic extension can be performed against a wall.  Bill Hartman demonstrates this well:

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This is another great option for many people, though may be challenging for someone with tight lats, shoulder issues, or really large restrictions in thoracic mobility.

 

Thoracic Spine Mobility Exercises for Rotation

After we work on thoracic spine extension, we can also focus on thoracic spine rotation mobility.  Here are a couple of examples of good thoracic spine mobility exercises to enhance rotation.

 

Thoracic Spine Mobility Exercises for Rotation in the Seated Position

A simple thoracic mobility drill for rotation can be performed in the seated position.  Here is a nice demonstration by Jeff Cubos:

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As you can see, the person is squeezing something between her knees in the seated position.  This is intended to help engage the core and limit the amount of lumbar stability.  This seems really simple but the majority of people with poor thoracic mobility will perform this poorly and rotate from the lumbar spine.  This one really needs to be coached and cued well to assure that technique is perfect, otherwise you will be working the wrong area!  You can see that she does a good job rotating at the thoracic spine with just a small movement, but as we all know, more is usually better in many people’s minds.  Be careful that they don’t go home and just torque their lumbar spine.

Here is another seated drill by Michael Boyle that incorporates rotation and extension:

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Thoracic Spine Mobility Exercises for Rotation in the Quadruped Position

A very common and popular thoracic spine mobility drill right now on the internet is in the quadruped position.  The quadruped position is used to put the hips in a degree if flexion to minimize the amount of lumbar spine movement.  Here is a great example from Eric Cressey:

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Eric does a good job showing his technique.  Lucky for us as the viewer you can see that Eric has some mobility issues that he is working on.  This is a good exercise but challenging for some people to get into the position due to lack of hip flexion mobility.  Realistically the quadruped position is unachievable by some people.  As you can see in Eric’s video, his hip flexion mobility isn’t great, so his hip flexion angle is not as much as it could be and subsequently he can get too much lumbar spine rotation.  This is a great exercise and Eric demonstrates it well.  This can be used in more advanced situations with people that have proper hip mobility and no concerns in the quadruped position.

 

A Simple Program to Work on Both Thoracic Spine Extension and Rotation

 My preferred technique for thoracic spine mobility exercises is actually pretty simple.  I use a foam roll to quickly combine three different drills into one quick program that is in an easily achievable position for many people:

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First, I start off with simple foam rolling of the thoracic spine.  I like to start with foam rolling to loosen up the soft tissue of the thoracic spine and reduce and potential spasm or muscle tightness that might limit my joint mobility.  My hands are positioned across my chest to protract and clear my scapulas to allow access to my paraspinals.  This video is a quick demonstration but I take my time with this and usually roll back and forth for about a minute, spending time on whatever area feels the tightest that day.

Next, I will work on extension mobility.  When the thoracic spine is in a flexed position, it is going to be very difficult to achieve rotation, so I want to work on extension first so that my upcoming rotational drills are more effective.  In the video, I demonstrate a technique very similar to Michael Boyle above.  I roll up and down the thoracic spine and try to stop at each vertebral segment and perform a few extension mobilizations.  The foam roll acts as a fulcrum, my lower half (lumbar spine) is stable, and my upper half pivots at the foam roll.  This applies a very specific thoracic spine mobilization that you can focus on individual spine levels.  I will roll up and down about an inch at a time and then work on extension.  Again, the video is a quick demonstration, I will do about 10 extension movements at each segment, but will focus on specific levels as needed.

Lastly, now that we have loosened up the muscles and increased thoracic spine extension, we can work towards increasing rotation.  I again just simply use a foam roll in the same position on the ground.  This allows for a quick progression of drills that you can bang out in sequence with ease.  Similar to the extension mobility drill, I use the foam roll as a fulcrum.  Again, my lower half is stable and my upper half pivots into thoracic rotation at the point of contact of the foam roll, allowing for a specific mobilization at the level of your choice.  I prefer to extend my hands up in front of my face.  I feel that this helps my visualize the amount of rotation achieved.  I instruct people to just rotate your hands one hour on the clock to help them visualize the small amount of movement.  Otherwise, if you are rotating more than that, you are compensating somewhere, likely with lumbar rotation below the fulcrum of the foam roll.  As your mobility improves you can try to focus on rotating and adding a small extension component, similar to Michael Boyle’s drill above.

This series of thoracic spine mobility exercises are usually where I begin with people.  As mobility increases, I use many of the other exercises demonstrated above based on the person’s individual deficits and goals.  There are a lot of options when performing thoracic spine mobility exercises, what else have you found to be effective?