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Shoulder Impingement – 3 Keys to Assessment and Treatment

Shoulder impingement really is a pretty broad term that most of us likely take for granted.  It has become such a junk term, such as “patellofemoral pain,” especially with physicians.  It seems as if any pain originated from around the shoulder could be labeled as “shoulder impingement” for some reason, as if that diagnosis is helpful to determine the treatment process.

Unfortunately, There is no magical “shoulder impingement protocol” that you can pull out of your notebook and apply to a specific person. [Click to Tweet]

I wish it were the simple.

A thorough examination is still needed.  Each person will likely present differently, which will require a variations on how you approach their rehabilitation.

But the real challenge when working with someone with shoulder impingement isn’t figuring out they have shoulder pain, that’s fairly obviously.  It’s figuring out why they have shoulder pain.

 

 

Shoulder Impingement: 3 Keys to Assessment and Treatment

To make the treatment process a little more simple, there are three things that I typically consider to classify and differentiate shoulder impingement.

  1. Location of impingement
  2. Structures involved
  3. Cause of impingement

Each of these can significantly vary the treatment approach and how successful you are helping each person.

 

Location of Impingement

The first thing to consider when evaluating someone with shoulder impingement is the location of impingement.  This is generally in reference to the side of the rotator cuff that the impingement is located, either the bursal side or articular side.

shoulder impingement assessment and treatment

See the photo of a shoulder MRI above.  The bursal side is the outside of the rotator cuff, shown with the red arrow.  This is probably your “standard” subacromial impingement that everyone refers to when simply stating “shoulder impingement.”  The green arrow shows the inside, or articular surface, of the rotator cuff.  Impingement on this side is termed “internal impingement.”

The two are different in terms of cause, evaluation, and treatment, so this first distinction is important.  More about these later when we get into the evaluation and treatment treatment.

 

Impinging Structures

To me, this is more for the bursal sided, or subacromial, impingement and refers to what structure the rotator cuff is impinging against.  As you can see in the pictures below (both side views), your subacromial space is pretty small without a lot if room for error.  In fact, there really isn’t a “space”, there are many structures running in this area including your rotator cuff and subacromial bursa.

Shoulder impingement

You actually “impinge” every time you move your arm.  Impingement itself is normal and happens in all of us, it is when it becomes excessive or abnormal that pathology occurs.

I try to differentiate between acromial and coracoacromial arch impingement, which can happen in combination or isolation.  There are fairly similar in regard to assessment and treatment, but I would make a couple of mild modifications for coracoacromial impingement, which we will discuss below.

 

Cause of Impingement

The next thing to look at is the actual reason why the person is experiencing shoulder impingement.  There are two main classifications of causes, that I refer to as “primary” or “secondary”shoulder  impingement.

Primary impingement means that the impingement is the main problem with the person.  A good example of this is someone that has impingement due to anatomical considerations, with a hooked tip of the acromion like this in the picture below.  Many acromions are flat or curved, but some have a hook or even a spur attached to the tip (drawn in red):

shoulder impingement

 

Secondary impingement means that something is causing impingement, perhaps their activities, posture, lack of dynamic stability, or muscle imbalances are causing the humeral head to shift in it’s center of rotation and cause impingement.  The most simply example of this is weakness of the rotator cuff.

The rotator cuff and larger muscle groups, like the deltoid, work together to move your arm in space.  The rotator cuff works to steer the ship by keeping the humeral head centered within the glenoid.  The deltoid and larger muscles power the ship and move the arm.

Both muscles groups need to work together.  If rotator cuff weakness is present, the cuff may lose it’s ability to keep the humeral head centered.  In this scenario, the deltoid will overpower the cuff and cause the humeral head to migrate superiorly, thus impinging the cuff between the humeral head and the acromion:

evaluation and treatment of shoulder impingement

 

Other common reasons for secondary impingement include mobility restrictions of the shoulder, scapula, and even thoracic spine.  We see this a lot at Champion.  In the person below, you can see that they do not have full overhead mobility, yet they are trying to overhead press and other activities in the gym, flaring up their shoulder.

shoulder impingement mobility

If all we did with this person was treat the location of the pain in his anterior shoulder, our success will be limited.  He’ll return to gym and start the process all over if we don’t restore this mobility restriction.

The funny thing about this is that people are almost never aware that they even have this limitation until you show them.

 

 

Differentiating Between the Types of Shoulder Impingement

In my online program on the Evidence Based Evaluation and Treatment of the Shoulder, I talk about different ways to assess shoulder impingement that may impact your rehab or training.  There are specific tests to assess each type of impingement we discussed above.

The two most popular tests for shoulder impingement are the Neer test and the Hawkins test.  In the Neer test (below left), the examiner stabilizes the scapula while passively elevating the shoulder, in effect jamming the humeral head into the acromion.  In the Hawkins test (below right) the examiner elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, grinding the cuff under the subacromial arch.

Shoulder impingement tests

You can alter these tests slightly to see if they elicit different symptoms that would be more indicative to the coracoacromial arch type of subacromial impingement.  This would involve the cuff impingement more anteriorly so the tests below attempt to simulate this area of vulnerability.

The Hawkins test (below left) can be modified and performed in a more horizontally adducted position.  Another shoulder impingement test (below right) can be performed by asking the patient to grasp their opposite shoulder and to actively elevate the shoulder.

how to assess shoulder impingement

There is a good chance that many patients with subacromial impingement may be symptomatic with all of the above tests, but you may be able to detect the location of subacromial impingement (acromial versus coracoacromial arch) by watching for subtle changes in symptoms with the above four tests.

Internal impingement is a different beast.

This type of impingement, which is most commonly seen in overhead athletes, is typically the result of some hyperlaxity in the anterior direction.  As the athlete comes into full external rotation, such as the position of baseball pitch, tennis serve, etc., the humeral head slides anterior slightly causing the undersurface of the cuff to impingement on the inside against the posterior-superior glenoid rim and labrum.  This is what you hear of when baseball players have “partial thickness rotator cuff tears” the majority of time.

shoulder internal impingement

 

 

The test for this is simple and is exactly the same as an anterior apprehension test.  The examiner externally rotates the arm at 90 degrees abduction and watches for symptoms.  Unlike the shoulder instability patient, someone with internal impingement will not feel apprehension or anterior symptoms.  Rather, they will have a very specific point of tenderness in the posterosuperior aspect of the shoulder (below left).  Ween the examiner relocates the shoulder by giving a slight posterior glide of the humeral head, the posterosuperior pain diminishes (below right).

how to assess shoulder internal impingement

 

3 Keys to Treating Shoulder Impingement – How Does Treatment Vary?

There are three main keys from the above information that you can use to alter your treatment and training programs based on the type of impingement exhibited:

Subacromial Impingement Treatment

To properly treat, you should differentiate between acromial and coracoacromial impingement.  Treatment is essentially the same between these two types of subacromial impingement, however, with coracoacromial arch impingement, you need to be cautious with horizontal adduction movements and stretching.  This is unfortunate as the posterior soft tissue typically needs to be stretched in these patients, but you can not work through a pinch with impingement!

A “pinch” is impingement of an inflamed structure!

Also, I would avoid elevation in the sagittal plane or horizontal adduction exercises.

 

Primary Versus Secondary Shoulder Impingement

This is an important one and often a source of frustration in young clinicians.  If you are dealing with secondary impingement, you can treat the persons symptoms all you want, but they will come back if you do not address the route of the pathology!

I do treat their symptoms, that is why they have come to see me.  I want to reduce inflammation.  However, this should not be the primary focus if you want longer term success.

This is where a more global look at the patient, their posture, muscle imbalances, and movement dysfunction all come into play.  Break through and see patients in this light and you will see much better outcomes.

A good discussion of the activities that are causing their symptoms may also shed some light on why they are having shoulder pain.  Again, using the example above, if you don’t have full mobility and try to force the shoulder through this tightness you are going to likely cause some issues.  This is especially true if you add speed, loading, and repetition to elevation, such as during many exercises.

 

Internal Impingement

One thing to realize with internal impingement is that this is pretty much a secondary issue.  It is going to occur with any cuff weakness, fatigue, or loss of the ability to dynamically stabilize.   The athlete will show some hyperlaxity in this athletic “lay back” shoulder position.  Treat the cuff weakness and it’s ability to dynamically stabilize to relieve the impingement.  How to treat internal impingement is a huge topic that I cover in a webinar for my Inner Circle members.

 

Learn Exactly How I Evaluate and Treat the Shoulder

If you are interested in mastering your understanding of the shoulder, I have my acclaiming online program teaching you exactly how I evaluate and treat the shoulder at ShoulderSeminar.com!

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  • shoulder seminarThe evaluation of the shoulder
  • Selecting exercises for the shoulder
  • Manual resistance and dynamic stabilization drills for the shoulder
  • Nonoperative and postoperative rehabilitation
  • Rotator cuff injuries
  • Shoulder instability
  • SLAP lesions
  • The stiff shoulder
  • Manual therapy for the shoulder

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Assessing the Shoulder Shrug Sign

The latest Inner Circle webinar recording on Assessing the Shoulder Shrug Sign is now available.

Assessing the Shoulder Shrug Sign

Assessing_the_Shoulder_Shrug_SignIn this inservice recording, I overview the two main types of shoulder shrug signs that I see.  The classic shrug sign typically involves either a rotator cuff injury or significant capsular hypomobility.  However, we also see shrugs in people that have poor overhead mobility.

This webinar will cover:

  • What are the different types of shoulder shrug signs?
  • How to tell if you have a mobility or motor control issue
  • The sequence I follow to determine what to choose for my treatments

To access this webinar:

How to Coach and Perform Shoulder Program Exercises

The latest Inner Circle webinar recording on How to Coach and Perform Shoulder Program Exercises is now available.

How to Coach and Perform Shoulder Program Exercises

How to Coach and Perform Shoulder Program ExercisesThis month’s Inner Circle webinar is on How to Coach and Perform Shoulder Program Exercises.  While this seems like a simple topic, the concepts discussed here are key to enhancing shoulder and scapula function.  There are many little tweaks you can perform for shoulder exercises to make them more effective.  If you perform rotator cuff or scapula exercises poorly, you can be facilitating compensatory patterns.  In this webinar, we discuss:

  • How to correctly perform rotator cuff and scapula exercises
  • Coaching cues that you can use to assure proper technique
  • How to enhance exercises by paying attention to technique
  • How to avoid compensation patterns and assure shoulder program exercises are as effective as possible

To access this webinar:

 

 

 

A Better Way to Perform Shoulder Exercises?

It’s pretty obvious that the shoulder is linked to the scapula, which is linked to the trunk.  So why do we so often perform isolated arm movement exercises without incorporating the trunk?  It’s a good question.  The body works as a kinetic chain that requires a precise interaction of joints and muscles throughout the body.

 

The Effect of Trunk Rotation During Shoulder Exercises

A recent study was published in the Journal of Shoulder and Elbow Surgery that examined the impact of adding trunk rotational movements to common shoulder exercises.

The authors chose overhead elevation, external rotation by the side, external rotation in the 90/90 position similar to throwing, and 3 positions of scapular retraction while lying prone (45 degrees, 90 degrees, and 145 degrees) that were similar to prone T’s and Y’s.  The essentially had subjects perform the exercise with and without rotating their trunk towards the moving arm.

A Better Way to Perform Shoulder Exercises?

EMG of the the upper trapezius, middle trapezius, lower trapezius, and serratus anterior were recorded, as well as 3D scapular biomechanics.

There were a few really interesting results.

  • Adding trunk rotation to arm elevation, external rotation at 0 degrees, and external rotation at 90 degrees significantly increased scapular external rotation and posterior tilt, and all 3 exercises increased LT activation
  • During overhead elevation, posterior tilt was 23% increased and lower trap EMG improve 67%, which in turn reduced the upper trap/lower trap ratio.
  • Adding rotation to the prone exercises reduced upper trapezius activity, and therefore enhanced the upper trap/lower trap ratio as well.

 

What Does This All Mean?

I would say these results are interesting.  While the EMG activity was fairly low throughout the study, the biggest implication is that involving the trunk during arm movements does have a significant impact on both muscle activity and scapular mechanics.  Past studies have shown that including hip movement with shoulder exercises also change muscle activity.

This makes sense.  If you think about it, traditional exercises like elevation and external rotation involve moving the shoulder on the trunk.  By adding trunk movement during the exercises you are also involving moving the trunk on the shoulder.

This is how the body works, anyway.  Most people don’t robotically just move their arm during activities, the move their entire body to position the arm in space to accomplish their goal.

It’s also been long speculated that injuries during sports like throwing and baseball pitching may be at least partially responsible for not positioning or stabilizing the scapula optimally.  I think this study supports this theory, showing that trunk movement alters shoulder function.

Isolated exercises like elevation and external rotation are always going to be important, especially when trying to enhance the strength of a weak or injured muscle.  However, adding tweaks like trunk rotation to these exercises as people advance may be advantageous when trying to work on using the body with specific scapular positions or ratio of trapezius muscle activity.

 

5 Tweaks to Make Shoulder Exercises Even More Effective

I’m a big fan of understanding how little tweaks can make a big difference on your exercise selection.  If you are interested in learning more, this month’s Inner Circle webinar will discuss 5 Tweaks to Make Shoulder Exercises Even More Effective.  The webinar will be Tuesday August 25th at 8:00 PM EST, but a recording will be up soon after.

 

 

 

How to Prepare Before You Throw – Part 1: Prepare Your Body

Working with so many injured pitchers over my career, 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.  I’m not sure if this is always the true cause of the players’ injuries, however, I hear it often enough that it has to have some significance.

throwing long toss programThis seems to make sense, though.  Throwing is very dynamic and aggressive on the body.  In fact, it is the fastest known motion that the human body performs!  If it could, your shoulder would rotate a full 360 degrees around up to 27 times in 1 second!  That is unbelievable.

I often say injury is just a simple physics equation.  Force = mass x acceleration.  The faster your body moves and the harder you throw, the more forceful it is on your body.

Because of this, you can see how just grabbing a baseball and starting to throw can be stressful on the body.  Throwing is so dynamic and forceful that you want to do your best to put yourself in a position to succeed before you start throwing.  This will help foster a long and healthy career.

To prepare before your throwing program, you really need to do two things: 1) Prepare your body and 2) Prepare your throwing.  In this two part article I will discuss both.

 

How to Prepare Before Your Throwing Program – Part 1 – Prepare Your Body

It’s funny how common sense tells us to prepare our body for common athletic activities, like running and jumping, yet people often neglect throwing.  The first three steps to prepare before your throwing program involve getting your body ready.

 

Prepare to Throw Step 1 – Get Loose

The first step in preparing your body to throw is to get loose and work on your mobility.  We’ve studied 1000’s of baseball pitchers and have found a few things when it comes to throwing a baseball:

  1. Throwing a baseball causes your muscles to tighten and you loose mobility of your shoulder and elbow
  2. Not addressing this becomes cumulative and you eventually get a little tighter and tighter over the course of a season
  3. Working to maintain your motion is effective and can prevent lose of motion

One of the phrases I use a lot with my athletes is “I want you to be you BEFORE you pick up a ball.”  What that means is, if you just threw 100 pitches yesterday in a game, I know you are tight.  If you ignore it and pick up and ball and try to throw, you are setting yourself up for trauma.  Throwing will loosen you up (before you tighten up again), but it’s a much more aggressive way to get your mobility back.

Rather, perform some self-myofascial release by using a foam roller, massage stick, and baseball ball.  Here are the ones I use the most on Amazon and because the foam roller is hollow, you can put your other tools inside and all fit nicely in your gear bag:

  • Foam roller – One of the best and hollow to put your other tools in it in your gear bag.
  • Massage stick – The best one on the market, the other more popular ones don’t compare.
  • Trigger point ball – You can use a baseball, but I also like the reaction balls.  The nubs help you get in there and hold it in position on the wall.

How to prepare before your throwing programYou should focus on the entire body with particular emphasis on your lat, back of the shoulder, rotator cuff, pec, biceps, and forearm.  You should avoid the front of your shoulder.  There really aren’t a lot of muscles there and your just smashing your rotator cuff and biceps tendons.

Hit each spot for 30-60 seconds and hold on any really tender spots for 10 seconds.

Notice how I intentionally didn’t say to “stretch” your arm or perform a “sleeper stretch” (here is why you shouldn’t perform the sleeper stretch).  Most baseball pitchers are too loose to stretch effectively and they end up torquing themselves too much and making things worse.  There is a difference between muscles and joints, it’s possible to have tight muscles and loose joints.

There is one shoulder stretch that is effective on the muscles and not too aggressive on the joint, the cross body stretch I call the Genie Stretch.  This can be enhanced even more by using a trigger point ball in the posterior shoulder muscles.  You can and should stretch your forearm, you can’t really hurt yourself here.

 

Prepare to Throw Step 2 – Warm-Up Your Muscles

Now that you have worked on restoring mobility back to your baseline BEFORE you throw, it is time to get your muscles ready to throw.  In the strength and conditioning world, we refer to this as “activating” the muscles.

You want to hit all the muscles and movement patterns that are need to accelerate and decelerate your arm.  These essentially include the scapula and rotator cuff muscles.  By turning on these muscles, the body will be better prepared for the upcoming activities and throwing.

Shoulder activation throwing programThe simplest way to do this is with resistance tubing.  We use a combination of tools at Champion, but tubing is quick, easy, and portable.

You do need to be careful of your volume of exercises.  These warm-ups are designed to prepare the muscle, not fatigue them, and are not a substitute for strengthening the muscles.  That is a completely different program to be performed at a different time.  We use tubing to simply activate the muscles with low volume sets and reps of 2×10

I use Theraband tubing with handles.  They are the best and far superior to the cheap bands you can buy at the local stores, which have odd resistance and can lose resistance over time.  They are even ~$15 on Amazon.  You can attach the band to a fence or post, or take turns holding with a partner.

I like the tubing with handles and want you to have to grip the tubing, rather that velcro strap them around your wrist.  Grip the tubing helps warm up your grip and forearm muscles and also has a reflexive stimulus to your rotator cuff to engage.

Here is a link to Amazon.com to purchase the Theraband Exercise Tubing I use in the video at the end of this article.  I recommend the green band for Little League age, the blue band for middle school and early high school age, and the black band for the older or experienced pitcher:

 

Prepare to Throw Step 3 – Getting Moving

The third step to prepare to throw now involves dynamic movements.  You can see that we are building on a logical progression here: restore mobility, activate the muscles, and perform dynamic mobility exercises for movement prep.

Throwing is a very dynamic activity, obviously, that needs elasticity of the muscles.  Stretching and mobility work alone will not turn on the elastic components of your muscles.  Similar to my comments above on stretching, I don’t want a baseball being the first elastic stimulus your body faces.  I want to slowly work up to that so it is less traumatic and aggressive of a jump in stress on the tissue.

We want to dynamically move the joints and have the muscles produce quick contractions,.  This helps prepare the muscle for  by improving mobility and activation.

At Champion, our athletes have a whole portion of their program dedicated to these three steps and assuring that the entire body is prepared to throw, however, I demonstrate a simple arm version of this in the video below.  Perform this and you’ll be head and shoulders above most other athletes.

For pitchers, we use movement prep exercises that mobilize and activate the muscles groups needed to throw, like the chest, posterior shoulder, and rotator cuff.  It doesn’t take a lot of repetitions to prepare the body.

 

My Warmup Program Before Throwing

Perform this 3-minute arm warm up program prior to starting your throwing program for the day.  This is our bare minimum program that we teach our athletes that are new to the concepts of preparing their body before throwing.  As you can see, you don’t need dozens of exercises or many sets and reps, even just performing this quick warm-up will put you in a more advantageous position to throw than most other athletes.

It is quick and easy and can be performed on the field before practice.  Look out into the bullpen next time you are at a MLB game and you’ll see many players performing this during the game.

I’ve adjusted the order of how I prepare the body a little bit since the filming of this video, so it is a little out of order per the above information, but serves as a great example of a quick and easy 3-minute warm up to be performed after your self-myofascial release and before throwing.

 

In part 2, I will discuss the next three steps involved in preparing to throw and how I actually start off my throwing programs.

 

Want to Learn More?

 

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:

How to Cue the Scapula During Shoulder Exercises

In today’s video, I share my thoughts on the common cue of retracting your scapulae together while performing shoulder exercises.  I’m not sure this is the most advantageous cue, despite it’s popularity.  Instead, I focus on facilitating normal scapulohumeral motion.  I don’t want to restrict the scapula while moving the arm.

Learn more about how to cue the scapula during shoulder exercises in the video below.

 

How to Cue the Scapula During Shoulder Exercises

Learn How I Evaluate and Treat the Shoulder

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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?  Join my extensive online program teaching you exactly how I evaluate and treat the shoulder at ShoulderSeminar.com.

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Great Exercise to Enhance Posterior Shoulder Strength, Endurance, and Overhead Stability

I wanted to share an exercise I have been incorporating into my programs lately to develop posterior shoulder strength, endurance, and overhead stability.  I call it the ER Press as it combines shoulder external rotation in an abducted position with an overhead press.  When performed with exercise tubing, it provides an anterior force that the posterior musculature must resist during the movement.  The key is to resist the pull of the band while you press overhead.

I use this drill a lot with my baseball players and overhead athletes.  I think it’s a great drill that hits many of the areas that I focus on when training a strong posterior chain of the trunk and arm.

It’s also becoming a favorite of my Crossfit and olympic lifting athletes, who are reporting that they feel more comfortable overhead and have more stability with their snatches and overhead squats.

There are numerous progressions that can be performed by simply changing the position the athlete is in, including tall kneeling, half kneel, and split squat stances.  You can also perform some rhythmic stabilizations at the top range of motion once to increase the challenge.

 

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