Guest Post: Biomechanical vs. Anatomical Breathing

Guest Post: Biomechanical vs. Anatomical Breathing

By Cameron Yuen

This post was inspired by a discussion I had with Aaron about the StrongFirst snatch test. This test, which basically involves snatching a 24kg kettlebell 100 times within 5 minutes, is well known for it’s ability to leave even the most conditioned athletes gasping for air. Training for this test usually involves working on technique, strength, and endurance. However, training to improve breathing efficiency is often overlooked. After all, we breathe automatically for the most part, and when we do become conscious of our breath during exercise, we generally just default to breathing harder and faster. But this doesn’t have to be the case; changing your breathing pattern is one of the easiest approaches to improving performance.This article will highlight two of these strategies. Biomechanical breathing, which is ideal for short and intense exercise, and anatomical breathing, which is best suited for exercise requiring endurance and efficiency. These breathing styles follow the idea that just as there are different movement strategies depending on the type and goal of exercise, there are multiple ways to breathe depending on the demands of exercise.

Diaphragmatic Breathing

Learning to use your diaphragm is key for maintaining tension in biomechanical breathing, and relaxation in anatomical breathing. So before getting into the nuances of each strategy, I highly recommend you check out Aaron’s articles on breathing here and here. He does a great job breaking down the anatomy and mechanics of the diaphragm, and how to start implementing diaphragmatic breathing in treatment/training sessions. To get comfortable with diaphragmatic breathing, try this quick and easy supine breathing drill:https://www.youtube.com/watch?v=qxiE-bX1FjgTry to breathe down into your stomach so that your bottom hand rises and falls with each breath. The top hand will rise automatically as the ribs expand. After you get comfortable with this, place your hands around your waist, and try to make your breath expand laterally and posteriorly to push out against your hands. Ideally, your abdomen should be expanding from all sides as you breathe in.

Biomechanical Breathing

If you have ever lifted weights, you have probably used biomechanical breathing. Inhaling is matched with the eccentric phase of a movement, and exhalation is matched with the concentric phase. In biomechanical breathing, breath is used to increase intra-abdominal pressure (IAP), and optimize force production and transfer by creating a rigid core.  This strategy works well with ballistic movements, when external loads are high, and when a lot of tension is needed for a short amount of time. Here is an example of biomechanical breathing used during an overhead press:https://www.youtube.com/watch?v=hUCcfA7acJ0Similarly, for a barbell back squat, you would begin the descent (eccentric) by bracing your trunk in a neutral position, followed by a large diaphragmatic breath. Co-contracting the muscles of the core, and then pressurizing the compartment with the diaphragm increases IAP, and creates a very stable trunk. As you ascend from of the bottom of the squat (concentric) you exhale slowly. This lifts the diaphragm and decreases IAP. By breathing in this manner, you increase IAP as you flex your hips, which protects your spine by buffering the large flexion moment created by the weight. However, this strategy can be very fatiguing since you are using your diaphragm to create core stability and breathe at the same time. Therefore, biomechanical breathing should be reserved for anaerobic exercises requiring a large amount of core stability and tension.

Anatomical Breathing

Anatomical breathing on the other hand, matches breath with movement to decrease the amount of work needed for breathing. This approach is commonly used in yoga, pilates, and some martial arts, but can really be used for any type of movement with a high endurance component and lower external loads.Simply put, any time a movement compresses the rib cage and lungs, you exhale, and naturally let the pressure exerted on your lungs drive the air out. Whenever a movement causes your rib cage and lungs to expand, or when the ribs spring back from being compressed, you inhale. This strategy takes advantage of the passive elasticity and compliance of the rib cage to drive air in and out of the lungs, and decreases the workload on the respiratory muscles.For example, if you were to do kettlebell swings for high repetitions, you would exhale as you flex your hips and swing the bell between your legs. In this position, you would be compressing your ribs and abdomen with your arms, which naturally forces some of the air out of your lungs. As you swing the bell forward and your arms float to the front of your body, you inhale. Your ribs spring back and expand as you extend your hips, allowing some air to flow into your lungs. Of course, your respiratory muscles still have to work with this strategy, but they are assisted by passive movement of the ribs, and don’t have to fight against external compression.https://www.youtube.com/watch?v=ejXajYcbFsEIn this video, I take a relaxed inhale as the kettlebell floats up, then exhale as my arms compress my ribs during hip flexion. As you progress from swings to snatches, there are quite a few different ways to implement anatomical breathing:https://www.youtube.com/watch?v=KOIEtsxtxsoIn addition to lower intensity exercise, anatomical breathing can be used to facilitate mobility drills, especially those involving the rib cage and thoracic spine. Take for example a side lying windmill movement. By taking in a large breath as you begin the movement, the rib cage expands and drives thoracic rotation as you continue reaching. This can be repeated with each inhale driving more thoracic rotation and shoulder flexion.https://www.youtube.com/watch?v=VUBtk-9GeEkIn this video, I inhale as I begin the movement, then exhale as I come back to the hands together position. I then take larger and larger breaths as my ribs and thoracic spine open with each repetition.

Summary

These breathing strategies can feel foreign at first, but give them a shot during your next training session. If you are lifting heavy weights and require a lot of tension, biomechanical breathing is a good choice. If you need more relaxation and endurance, try out anatomical breathing. It may take a bit of concentration at first, but learning to breathe differently depending on your activity can have a profound impact on your performance.

About Cameron Yuen

 Cameron is currently a PT student at New York University, and research assistant at the Human Performance Lab at Lehman College. Before moving to New York, he was a strength and conditioning coach in San Diego, California. Outside of school, Cameron enjoys reading, practicing martial arts, and spending time with his two dogs. More of his writing can be found at his website: www.CameronYuen.com      [subscribe2]

Coaching & Cueing (Part 2 - The Categories)

We need to first clarify an important concept before we go into coaching and cueing:

• NOT ALL MOVEMENT REQUIRES COACHING

To Coach or Not to Coach

If someone is performing a movement/exercise correctly, all you have to do is shut your mouth and smile.If someone is performing a movement/exercise incorrectly, you should ask yourself two questions:

1. Do they need a different environment via a sensory change/coaching and cueing?
2. Is this a professional error?  Is this the right exercise for this patient at this time?

So if someone can’t perform the deadlift correctly, they either need some coaching and cueing (a sensory change) or they need a different exercise.

3 Types of Coaching

I break down coaching into 3 different categories:

• 1) Verbal - External & Internal
• 2) Visual - External & Internal
• 3) Proprioceptive

Each of these categories are a change of the inputs from the environment.  Each section has a specific attentional sensory focus.  Below is a brief introduction to each type of cue.  For a more in depth look at specific cueing types, stayed tuned for Parts III-IV in this article series.

1) Verbal

Verbal cues are by far the most common and one of the most researched coaching cues.

External Cue

Focuses on how the body’s output affects the environment (outcomes, objects, etc.)

Internal Cue

Focuses on the body processes and internal systems (muscles, kinematics, pressure, etc.)

2) Visual

Visual cues are rarely discussed in the coaching realm.  However, there are some interesting concepts in this category that can have a huge impact on your clients’ movement.

External

Influences movement through visual input (visual field, objects, orientation, demonstrations, eyewear, etc.)

Internal / Motor Imagery

“Motor Imagery is defined as an internal rehearsal or reenactment of movements from a first person perspective without any overt physical movement. From another perspective, MI, also known as kinesthetic imagery, is an active cognitive process during which the representation of a specific action is internally reproduced in working memory without any overt motor output” -Carl Gabbard and Ashley Fox

3) Proprioceptive

Proprioceptive cues are very common in both rehab and training (whether the practitioner knows it or not).  It’s a common sense type of approach that can have more profound effects than any other sensory change.  These proprioceptive cues can be divided into MANY different sub-categories.

• Postures
• Load
• Speed
• External Stimulation (tactile, tape, surface, footwear, etc.)
• Regressions
• Progressions
• Lateralizations
• Modifications
• Modulations
• [Insert Latest Terminology]

 

Summary

Which type of cue the patient needs depends on many factors.  A greater understanding of each of these types of sensory changes will help one determine which one to use.  Keep the overall goal in mind and match your desired outcome to they type of cueing.And remember, if someone isn’t performing a movement correctly despite your coaching/cueing, you either need a different sensory change or a different exercise.

Coaching & Cueing

Part I - IntroPart II - The CategoriesPart III - Verbal Cues - ExternalPart IV - Verbal Cues - InternalPart V - VisualPart VI - ProprioceptivePart VI - Summary [subscribe2]

Andreo Spina's Functional Range Release

I was lucky enough to be invited to another one of Dan Park’s quality continuing education classes at Perfect Stride.  This time it was for Functional Range Release (Upper Extremity) with Andreo Spina.  I had been reading a lot about Spina’s work and was excited at the chance to learn about the FR/FRC techniques and principles.

Andreo Spina

Andreo Spina is the creator of FR (Functional Range Release) and FRC (Functional Range Conditioning).  He is an intelligent, articulate, and opinionated speaker.  He has a great knowledge base and a fresh perspective on the human body.  I’ve taken many continuing education courses over the years; Dr. Spina definitely set the record for most rants.  However, all of his rants have a point and are very educational.  He uses sound logic, conventional wisdom, literature, and dry humor to discuss current practices and clinical beliefs.I walked away from his course with a new perspective on the human body, knowledge of how to influence tissue at the histological level, and became a much more efficient manual therapist.*This is my interpretation of the class and how I conceptualize the approach.  For a more complete understanding I recommend taking one of Dr. Spina's course.  He provides an extensive amount of information and resources (9 on-line learning modules, quality lectures, lifetime membership, and social media support).

Bringing it Back to Histology

Neuo-based approaches have really boomed over the past decade.  And for a good reason - they improve clinical care.  While I love these neurological approaches and understand their value, I also think we can go off the deep end with it.  Sometimes it’s easy to forget there’s a physical human body with constantly adapting tissues.  Just as the nervous system has an influence on tissues, the tissues have an influence on the nervous system.  Even renowned neuroplasticty lover, Lorimer Moseley, has mentioned that we should be considering the role of Bioplasticity.Andreo Spina has done a tremendous job of expanding on this tissue concept and making histology clinically relevant.  FR/FRC focuses on addressing the human body from controlled and specific inputs to influence the histological processes and subsequently, the entire human body.To understand this concept, it is important to recognize that the body is constantly turning over at a cellular level (watch this - tissue remodeling).  I think the quote from the class was “if you look at a picture of yourself from 10 years ago, there won’t be one cell that is the same”.How these cells turnover and in what manner depends on many variables.  Specific to Spina’s work, one of these variables is force.  The force that these tissues “feel” dictates how they turnover.  Force influences cellular activity (fibroblast).  And direction is one of the most important variables of this force.This is a very detailed and scientific rabbit hole to go down.  It involves the piezoelectric effect, tensegrity, mechanotransduction, solid-state biochemistry, collagen, fibroblast activity, cellular signaling, etc.  While it's beyond the scope of this review to discuss these concepts in detail, I'll try to briefly summarize them since it is essential to understanding the FR/FRC system.The influence of force on cellular activity deals with the connections between collagen and cells.  Force is applied to the body and imparted on collagen.  Collagen connects to a cell via integrins.  Different cells grab onto the same collagen fibers (via integrins).  When collagen gets a directional force input, it transmits this signal to multiple cells (tensegrity).  This force is then transmitted from the cell cytoplasm to the nucleus (DNA/RNA).  FORCE IS THE LANGUAGE OF CELLS.  One example of this is Wolff's Law.To put it in clinical terms, your sedentary 45 year old patient that has been wearing high heels for over 30 years is going to have some adaptive tissue changes.  There’s going to be a histological tissue adaptation.  After years of not using ankle dorsiflexion, her body will remove the cells that foster normal dorsiflexion.  There isn’t a neurological trick you can do to change tissue in one session.  In fact, there isn’t any one input that will change tissue immediately.  To adapt and influence that tissue, you will need frequent, long duration, directional force inputs.

What Are We Really Feeling?

Another main concept of the course was to question our manual assessment/intervention.I think an analogy might help explain this concept.Lets take a single-leg stance assessment.  You notice that there’s a significant compensated trendelenburg.  A decade ago we may have accused a weak glute medius and then just hammered the patient with isolated hip abduction exercises (movement blunder).  But now we know there are so many possible causes of this movement pattern that it is nearly impossible to pin it on one thing.The same thing applies for manual therapy.  All we have is our hand contacting another person’s body.  There’s just a hand to skin interface and we are trying to feel for something.  But can we really say what that is?  Is it a fat pocket, malaligned collagen, a tissue anomaly, a genetic difference, or tone?  By saying it’s scar tissue or a knot are we bringing the movement blunder to manual therapy?Adreo Spina thinks so.

• “It is not logical to think that a practitioner can feel 'scar' tissue or 'adhesions.' At the level of 'micro-scarring' in connective tissue, the target is much too small for human touch. Not to mention the abundance of overlying tissue making it impossible to feel alterations in collagen directionality. Our hands can however feel forces. It is the forces generated by movement, or tension, that we attempt to feel. We can also think of it as feeling resistance to passive movement in a particular direction. We feel for aberrant tension…and we treat aberrant tension.”

By focusing on feeling for aberrant forces with movement, we have a more honest assessment.  It takes out the assumption blunder and reduces confirmation biases.

Assessment / Approach

For me, Dr.Spina’s approach is best understood from the Dynamic Systems Theory and Degrees of Freedom Problem point of view.  The premise is that there is an infinite amount of ways for the human body to move.  This is because there is a collective Degrees of Freedom that incorporates ALL the complex variables/sub-systems (in the continually changing internal & external environment) required to achieve a task.  One of these variables/systems is the state of the body’s peripheral tissues.  More specifically, an important tissue variable is the degrees of freedom of the joints (articular ROM).  If there are adaptive histological tissue changes that prevent normal joint movement, then the collective Degrees of Freedom will decrease.  The brain will have less motor control options.  The body will lose movement variability.  The attractor state will deepen.Losing degrees of freedom at the joint level can have a significant impact in the body's ability to manage movement.For an example, lets look at a simple digit lock.  It is not a complex open loop system (actually the opposite), but it'll hopefully help explain how this concept pertains to FR/FRC.Take a 3-digit-lock.  Each digit requires a specific number to match the right combination to unlock the lock.  With the numbers 0-9 and a 3 digit combination, there are 1,000 possible combinations.  If you add just one more digit and make it a 4-digit-lock, the number of possible combinations goes from 1,000 to 10,000.  Pretty significant, right?  Simply adding just 1 digit has a massive effect on the amount of variable combinations.One variable can significantly affect the whole system.You could look at the body the same way.  Having minimal joint motion may provide for some adequate movement options (3-digit-lock).  But having even just a little more joint motion can have significant impact in the movement options (4-digit-lock).  What if you needed the 1,001 movement combination to safely land from a jump?  If you only have 1,000 options, you'll compensate and risk injury.  This analogy works for the entire spectrum, from your 1-digit-lock medicare patients to your 100-digit-lock gymnast.

• Articular DOF = Nervous System DOF = Movement DOF

This is why Andreo Spina’s assessment approach is to first check every articulation of the body (joint ROM).  His philosophy is that if you don't have the prerequisite articular motion then your movement will suffer.  Why not focus on the other variables?  Because you can't build strength, stability, or motor control in ranges you don't have.  Developing the optimal ROM takes priority over developing strength in an inadequate range.Once he assesses the joint articulations, he will assess the soft tissue with palpation and passive movement.  If the person is in pain, he tries to reproduce it with palpation to determine a specific tissue diagnosis.  If there is no pain, he palpates the local area to asses how well the tissues are moving.* (=) is influence

Don’t Hang Up

Force is the input that tells the fibroblasts how to lay down.  Research has shown that it takes 2 minutes for these fibroblasts to become activated.  If you’re constantly changing direction or moving, then the cells won’t get the right input.So if you’re trying to influence tissue, you need to hold the directional force for 2 minutes.  He had a great analogy of a phone call.  You need to stay on the line long enough to get the message across.  If you keep hanging up (e.g. pin and stretch manual techniques, STM, etc.), then the communication won’t go through to the fibroblasts.Keep patients in the same posture, don’t pump through ranges of motion, hold tension longer, think directionally.

Isometrics

Isometrics are extremely beneficial.  Here's a list of 10 reasons why:

1. Gives directional force input (communication)
2. No joint shearing
3. No inflammatory reaction
4. Teaches body how to develop tension in a muscle (motor unit recruitment)
5. Increases strength
6. Least provocative strengthening modality
7. Patients can do it frequently
8. Backs up / covers manual therapy intervention
9. Resets the muscle spindle
10. Safe mechanotransduction

Spina has created a very user friendly system for applying isometrics to influence tissue and improve range of motion.  These are PAILs and RAILs (Progressive Angular Isometric Loading & Regressive Angular Isomeric Loading).  These are very direction specific interventions.  These techniques are best understood in the context of the class, but I will briefly describe them here.PAILs I (Communication)

Guiding Soft Tissue Remoulding/Healing

Does not intend on expanding range

Low level, frequent contractions

PAILs II (Expand Range of Motion)

2 minute passive, direction specific stretch

Followed by ramped isometric contraction in opposite direction (20-30 seconds)

PAILs III & RAILs (Expand ROM & Training Stimulus)

2 minute passive, direciton specific stretch

Ramped isometric contraction with 100% effort (longer duration)

Followed by RAILs (inner range hold, actively pulling deeper into the stretch)

Followed by another deep, passive stretch (and repeat)

Anatomy Pearls

During the palpation aspect of the course, Dr. Spina revealed this disconnect between what we were taught and what is actually in the body.  Here's some of these revelations.

• Levator Scapula is medial on the neck

• The "Levator Scapula TrP" that everyone has is really just where the rhomboid and erector spinae cross

• That thing you poke on the front of people’s shoulder is not the biceps tendon, it’s usually the anterior deltoid

• Teres major/minor and long head triceps is a commonly gunked up area

• The subscapularis tendon becomes transverse humeral ligament

• The long head of the triceps becomes the inferior labrum

• Deep muscle grow off bones (like chia pets) - Examples - quadriceps, brachialis, subscapularis, flexor digitorum profundus

• The pec minor, upper trapezius, and latissimus dorsi are disappointing muscles - thinner than you would think

Randoms

1) We all come from one cell - every cell has the ability to be every other cell2) Pain is a terrible outcome measure (Touch Induced Analgesia)3) Epimysial Groove is an important area to treat4) Mechanical Tension = specific aberrant force, Neurological Tension = can be felt during static palpation and is felt throughout the whole muscle (video demonstration)5) “We’re trying to palpate the forces that are restricting movements”6) In the fascia superfiscialis there are small pockets of adipose tissue - this might be the grittiness you feel with IASTM7) BioFlow - continuum of tissues - it all blends together - tissue types are just a different expression of connective tissue8) Fibroblasts - undifferentiated connective tissue cell that can become a precursor cell for many different types of connective tissue (tendons, bone, cartilage, muscle, etc.)9) It doesn’t matter which type of tissue, the response to load/signal will be similar10) “Never use a cannon to kill a fly” -Confusious11) Van Der Wal (article, video)12) No passive structures, just structures whose tension is tuned by the muscles (active structures)13) Force to one cell will cause a cascade of signaling throughout many different cells14) For plastic changes you need >2 minutes (induce thrixotropy and piezoelectric)15) Injury = Fibrosis = Friction/Loss Of Relative Tissue Motion16) After injury - the body recalibrates the stretch reflex threshold = faster activation of muscle spindles during movement = reflexive contraction, prematurely17) Don’t bring a mechanical intervention to a neurologic problem18) The more the neural drive, the less the access to the connective tissue for manual treatment19) Without direction, fibroblasts smear collagen all over the place and create fibrosis20) Deep tissues are mostly proprioceptive/afferent structures (when these are dysfunctional, superficial tissues have high tone)21) Adjust for skin slack or everything will feel like tension22) No single input causes permanent changes - “we’re not fixing anything”23) “I can’t rub someone flexible”24) Flexibility is governed by the nervous system.  You have to train it in the gym, not manually fix it with your hands.25) Inputs

• Muscle responds to NS quickly

• Connective Tissue responds to longer force inputs

26) 1st Job of Rehab = Guide the way the tissue is healing - tell the fibroblasts where to lay down collagen27) Rehab in the injured posture to repair/strengthen damaged tissues28) "Any fool can make something complicated. It takes a genius to make it simple." -Woody Guthrie

• Load > Capacity = Injury

• Load < Capacity = Rehab

• Capacity >> Load = Prevention

29) The deeper in the body, the more the connective tissue (pedunculation)30) Muscles can contract in various ways - Different fibers pull in different directions - Attachments don’t dictate all movement31) “Create the joint…THEN control the joint…THEN strengthen the joint - this concept is central to the FR and FRC systems.”32) “If you can control the scapula in space, does it matter if it’s winging?”33) Improving skin slide, especially over bony prominences, makes a big difference34) “You’re not palpating muscles, you’re palpating the connective tissues that makes muscles”35) NS only gives you access to the ROM it knows it can control36) “Adding passive mobility is where people get hurt”37) Osteoarthritic Rant

• Age doesn’t decrease flexibility, lack of movement decreases flexibility

• Joints maintain their health with movement

• If your joints moved everyday, an osteophyte can’t develop

• OA occurs from lack of motion

38) “RTC should be called the compressor cuff”39) The best way to assess joint motion is with axial rotation40) Opening vs. Closing restriction

• Opening is normal, tissues have to adapt

• Closing is not - comes from a decentrated joint, or tight opposite joint

41) The more contact you have with the patient, the better you can assess (close the circuit)42) Cyriax Knowledge - The longer a muscle is at contraction, the more the load goes to the tendon43) “Think of the body as one group of CT and proteins are added where movement needs to occur”44) One of my favorite quotes from the course

• “Changing posture is about habitual cueing”

45) Tensegrity model runs through the entire body, from DNA/RNA nucleus to ECM46) Give the cue “hold strong” (good psychological priming)47) “You don’t do PAILs for a muscle, you do it for a direction”48) Check the hands in elbow patients - It’s like the plantar fascia in achilles patients49) “Articular independence first….articular interdependence second”

Bottom Line

Overall this was one of my favorite courses I've ever taken.  It gave me a new lens on the human body, provided a simple and effective way to influence tissue, reduced my need for manual therapy, and gave me a direct treatment approach to achieve long term goals.  I highly recommend this course (or the FRC) for all movement professionals.One of the greatest things about Dr. Spina's work is that it can easily be incorporated into any approach.  You can still do all the neurological stuff, but after you get them FN/Centrated/Neutral/Whatever, just add in some inputs that will influence the tissues in the new and improved position.  It's important to work with the nervous system after an injury (motor patterns, pain, ANS, neutrality, etc.), but it's also just as important to work on the tissues themselves.  We are lucky to have so many approaches out there that identify the neurological needs of the system.  Now we're lucky to have Dr. Spina's approach to address the histological needs of the system.

Dig Deeper

Cellular/Histological/Bioflow

This is a big rabbit hole to go down.  There is plethora of research and articles.  It is difficult to just reference one.  FR/FRC Instructor, Michael Chivers, recommends starting with Helen Langevin and Donald Ingber.

Motor Control/Dynamic Systems

This is similar to researching cellular adaptations and histological changes to input.  There is so much out there that it becomes difficult to reference.  If you are new to these concepts, start by researching the different types of motor control theories.  Then research Bernstein's work and the degrees of freedom problem.  Then dive into the Dynamic Systems Theory.

My favorite article in this field is from Esther Helen and Linda Smith (Thelen, E. and Smith, L. B. 2007. Dynamic Systems Theories. Handbook of Child Psychology. I:6)

Fascia/Tensegrity

This has become a standard in the movement sciences (or at least I hope so).  Most clinicians are familiar with this approach thanks to the work of Tom Myers, Robert Schleip, Jaap Van Der Wal, and Leon Chaitow (among many others).

Andreo Spina - YouTubeSolid-State BiochemistryMechanotransduction (Jaalouk 2009, Khan 2009)Jeff Cubos - Phases of Healing & Spina's Work, Notes & Quotes from Dr. SpinaDewey Nielsen's Instagram Account (great examples of the FRC approach in practice)Jason Ross - Part I, Part IIVeeWong Course ReviewKevin Neeld - Dispelling the Stretching MythsArmstrong InterviewThe Nominalist has a ton of posts with clinical applications of FR & FRC   --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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An Open Letter to Crossfit: The 2 Mistakes (Part II)

Be sure to check out Part I for my thoughts on Crossfit and Mistake #1.

Mistake #2 = Not Training Unilaterally

Our bodies are inherently asymmetrical.  Don’t believe me?  Here are a couple examples of this natural asymmetry: we have a liver on the right, a heart on the left, 3 lung lobes on the left, 2 on the right, the stomach is tilted, one kidney is higher, the right diaphragm has a better zone of apposition, each brain hemisphere is lateralized for different tasks, and our left-otolitic dominance makes our motor system prefer the right side of our bodies.  On top of this, there are many other possible asymmetries and different morphologies due to genetics/ontogenetics.Not only are our bodies asymmetrical, but we live in a very asymmetrical world.  Everyday activities are asymmetrical; you push the car pedals with your right foot, grab your wallet out of the same pocket, open doors with your right hand, use the computer mouse on the same side.  Sporting activities are asymmetrical; you shoot with your right hand, kick with your right leg, swing a golf club to the same direction everytime.  And then there is just plain handedness.These asymmetries are normal and usually not a problem.  However, sometimes these asymmetries become too significant.  The imbalances become too much for the body to handle.This asymmetrical problem is taken to the next level when you add a symmetrical load to the system.  Symmetrically loading an asymmetrical system is the formula for injuries.  And this is one of the biggest mistakes Crossfitters make.While this applies to the entire body, it is critical in shoulders.  There are two reasons why:

1) You have a much more prominent handedness than footedness

2) Your legs benefit from some unilateral weight bearing activities everyday (walking, stairs)

Therefore, your upper extremity asymmetry is accelerated much faster compared to the lower extremity.  In other words, a right handed person can pretty much go all day without using their left arm at all.Fast forward to this person going from not using their non-dominant arm for most of their life (or past few years) and then throw a barbell at them.  It’s not going to go well.  The symmetrical external load (barbell) won’t be met with a symmetrical internal force (muscles).  Bringing a symmetrical exercise to an asymmetry is a recipe for disaster.Look at your car for an analogy.  If you car alignment is off, it’s going to cause some big problems.  Not only is most of the load going to be dumped onto one side, but it will also prevent a smooth straight path.  With the alignment off, the car will naturally want to veer from straight.  But it is being driven in a straight path, so the car has to pull (compensate) to maintain the desired direction.The same thing happens at your shoulders with barbell exercises.  One shoulder will get too much of the load, the other has to compensate to keep it straight, and it becomes an internal tug-of-war to keep the all important straight bar path.  Therefore, if you have a shoulder asymmetry, then the whole time you are cleaning, pressing, or snatching your shoulders will be compensating against each other.As mentioned in Part I, over time compensations lead to decreased performance and injuries.So what do you do about this?  Start brushing your teeth with your non-dominant arm?  Do barbell cleans with one arm?  Walk on your hands?

A Suggestion

The best thing you can do is incorporate some single arm (unilateral) strengthening into your weekly workouts.  This will not only prevent injuries, but it can also be used as an assessment.  If you can strict press 70# with your right arm, but only 50# with your left, then what do you think is happening when you strict press with a barbell?There are many different ways to work on unilateral strengthening, but in my opinion kettlebells are the best equipment to accomplish this.  They allow for the same metabolic burn, similar technique work, multi-joint strengthening, and most importantly - unilateral strengthening.  Pavel said it best "Your body has to adapt to the barbell while the kettlebell works with your body."Here’s a list of some unilateral shoulder exercises that can be done with just a kettlebell and some space:

Armbars, Bear Crawls, Quadruped T's, TGU, Single Arm Push Ups, Half/Tall-Kneeling/Standing KB Strict Press, Farmers Walks (overhead, rack, suitcase), Single Arm KB: Swing, Squat, Clean, Clean & Squat, Clean & Strict Press, Clean & Push Press, Snatch, Unilateral Suitcase Deadlift, Plank KB Pull Through

There are plenty of great coaches that can probably come up with some amazing unilateral upper extremity WODs.  There’s not just one right way to do it.  As long as you are training unilaterally and exposing weakness you will be decreasing your risk of injury and improving performance.For clinicians there is this Clinical Pearl

• If someone comes in with dominant side shoulder pain from bilateral/symmetrical training, the fix may be to strengthen the non-dominant side

Bottom Line

Like anything that becomes popular or trendy, there quickly becomes a group of people that jump on the bandwagon and a group of people that protest against it.  But this isn’t EDM, this isn’t Instagram, this isn’t the new iPhone.  This is simply another opportunity to help people stay active and exercise.  It’s not for everyone, but it’s not for no one.Medical professionals need to focus on ways to reduce injury and improve the activity rather than just pointing out what we don’t like.  Crossfit coaches need to focus on what’s best for the athletes health rather than what will give them the best workout.  And the Crossfit athletes need to be educated on the risk of lifting with poor technique and/or with a significant asymmetry.

References

Strength is a Good Thing1) Preethi Srikanthan, Arun S. Karlamangla. “Muscle Mass Index as a Predictor of Longevity in Older-Adults.” The American Journal of Medicine (2014) 2) Lauersen JB, Bertelsen DM, Andersen LB.  The effectiveness of exercise interventions to prevent sports injuries: a systematic reviewand meta-analysis of randomised controlled trials.  Br J Sports Med. (2014) Jun;48(11):871-7.3) Harridge, Stephen D.r., Ann Kryger, and Anders Stensgaard. "Knee Extensor Strength, Activation, and Size in Very Elderly People following Strength Training." Muscle & Nerve 22.7 (1999): 831-39.4) Suetta, C., S. P. Magnusson, N. Beyer, and M. Kjaer. "Effect of Strength Training on Muscle Function in Elderly Hospitalized Patients."Scandinavian Journal of Medicine & Science in Sports 17.5 (2007)5) Askling, C., J. Karlsson, and A. Thorstensson. "Hamstring Injury Occurrence in Elite Soccer Players after Preseason Strength Training with Eccentric Overload." Scandinavian Journal of Medicine and Science in Sports 13.4 (2003): 244-506) Nadler, Scott F., Gerard A. Malanga, Melissa Deprince, Todd P. Stitik, and Joseph H. Feinberg. "The Relationship Between Lower Extremity Injury, Low Back Pain, and Hip Muscle Strength in Male and Female Collegiate Athletes." Clinical Journal of Sport Medicine 10.2 (2000): 89-97.7) Peate, Wf, Gerry Bates, Karen Lunda, Smitha Francis, and Kristen Bellamy. "Core Strength: A New Model for Injury Prediction and Prevention."Journal of Occupational Medicine and Toxicology 2.1 (2007)8) Orchard, J., J. Marsden, S. Lord, and D. Garlick. "Preseason Hamstring Muscle Weakness Associated with Hamstring Muscle Injury in Australian Footballers." The American Journal of Sports Medicine25.1 (1997): 81-859) Jankowski, C.m. "The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial."Yearbook of Sports Medicine 2012 (2012): 65-66.10) Willson JD, Dougherty CP, Ireland ML, et al. “Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg. (2005) Sep;13(5):316-25.11) Hewett TE, Lindenfeld TN, Riccobene JV, et al. “The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.” Am J Sports Med. (1999) Nov-Dec;27(6):699-706.Movement Based Exercise vs. Isolated Exercise12) Gentil, Paulo, Saulo Rodrigo Sampaio Soares, Maria Claúdia Pereira, et al. "Effect of Adding Single-joint Exercises to a Multi-joint Exercise Resistance-training Program on Strength and Hypertrophy in Untrained Subjects." Applied Physiology, Nutrition, and Metabolism 38.3 (2013): 341-4413) Gottschall, Jinger S., Jackie Mills, and Bryce Hastings. "Integration Core Exercises Elicit Greater Muscle Activation Than Isolation Exercises."Journal of Strength and Conditioning Research 27.3 (2013): 590-96Exercising in Fatigued State14) Cortes, Nelson, Eric Greska, Roger Kollock, Jatin Ambegaonkar, and James A. Onate. "Changes in Lower Extremity Biomechanics Due to a Short-Term Fatigue Protocol." Journal of Athletic Training 48.3 (2013): 306-13.15) Santamaria, Luke J., and Kate E. Webster. "The Effect of Fatigue on Lower-Limb Biomechanics During Single-Limb Landings: A Systematic Review." Journal of Orthopaedic & Sports Physical Therapy 40.8 (2010): 464-73.16) Barnett S Frank, Christine M Gilsdorf, Benjamin M Goerger, et al.  “Neuromuscular fatigue alters postural control and sagittal plane hip biomechanics in active females with anterior cruciate ligament reconstruction.” Sports Health (2014) Jul;6(4):301-817) Quammen D, Cortes N, Van Lunen BL, et al. “Two different fatigue protocols and lower extremity motion patterns during a stop-jump task.” J Athl Train. (2012) Jan-Feb;47(1):32-41.18) Pau M, Ibba G, Attene G. “Fatigue-induced balance impairment in young soccer players.” J Athl Train. (2014) Jul-Aug;49(4):454-61.Imbalances Are Bad19) Knapik, J. J., C. L. Bauman, B. H. Jones, J. Mca. Harris, and L. Vaughan. "Preseason Strength and Flexibility Imbalances Associated with Athletic Injuries in Female Collegiate Athletes." The American Journal of Sports Medicine 19.1 (1991): 76-8120) Baumhauer, J. F., D. M. Alosa, P. A. F. H. Renstrom, S. Trevino, and B. Beynnon. "A Prospective Study of Ankle Injury Risk Factors." The American Journal of Sports Medicine 23.5 (1995): 564-70.21) Common Sense & Conventional Wisdom (>6 million years BC)Motor Learning22) Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.23) Schmidt, Richard A., and Craig A. Wrisberg. Motor Learning and Performance: A Problem-based Learning Approach. Champaign,IL: Human Kinetics, 2004.24) Williams, L. R., McEwan, E. A., Watkins, C. D., Gillespie, L., & Boyd, H. (1979). Motor learning and performance and physical fatigue and the specificity principle. Canadian Journal of Applied Sport Sciences, 4, 302-308.

“The body does not have the capacity to learn movement patterns when highly stressed/fatigued. This factor is not related to the specificity of training principle associated with overload adaptation in energy systems. The specificity principle of physiological adaptation does not apply to motor learning. To learn skilled movement patterns that are to be executed under fatigued conditions, that learning has to occur in non-fatigued states” — Williams 1979

 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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An Open Letter to Crossfit: The 2 Mistakes (Part I)

As many physical therapists have probably noticed, there is an increase in the amount of Crossfit athletes showing up in our clinics.  This isn’t because it injures everyone.  It’s because it’s becoming very popular and people love it.We see the same thing happen during ski season and marathon season.  It’s not necessarily the activity, it’s the increase in participation.However, that’s not to say that it’s only an increase in participation that leads to a higher incidence of injuries.  There are many other variables involved.  Some of which can be improved upon to decrease the risk of injury.I’ve noticed a few trends in my experience with Crossfit athletes.  The crossfitters that tend to get hurt are the ones that seem to make the same 2 Mistakes:

1) Constantly Training to (and Past) Failure

2) Not Training Unilaterally Enough.

I think if Crossfit could improve on these 2 mistakes they would see a lot less people getting injured.

A Disclaimer

I have nothing against crossfit and don’t think it is ruining our species like some of my peers.  In fact, I think Crossfit is great.  Some of you might agree and some of you might be angry just by reading the word crossfit.  But let me explain why I think it’s good.Crossfit changes peoples lives.  This is often an exact quote from many of my crossfit patients.  I’ve had many patients who have lost tons of weight and become motivated to stay active because of Crossfit.  This leads to changes in other parts of their lifestyle and improves their overall quality of life .  Where personal trainers, spin classes, running, and traditional weightlifting have failed, Crossfit has succeeded.  In a time where obesity and sedentary lifestyles are an epidemic, anything that gets people moving should be viewed favorably.  I’d much rather have our population suffer with the occasional sore shoulder rather than die early from heart disease.Crossfit has popularized strength training.  Too many people go on crazy diets, perform too much aerobic activity, or follow DVD fads to lose weight and get a metabolic burn.  Crossfit has helped shift the emphasis to being strong.  And strength is one of the best modalities for improving function, decreasing injuries, reducing morbidity, and decreases mortality (1-11).Crossfit focuses on movements.  Isolated muscle strengthening and machine based workouts are better than nothing, but they are vastly inferior when compared to multi-joint based movements.  Crossfit has brought functional global movement exercises such as power lifts, olympic lifts, and kettlebells back to the mainstream (12-13, 22).One last disclaimer is that I know not all “Boxes” are the same.  Not all coaches are the same.  And not all athletes are the same.  Like every other activity or profession, there is a continuum of competence among crossfit gyms and coaches. I know there are a ton of very knowledgeable and talented Crossfit coaches out there already doing all the right things.  Also, these mistakes are not just made by Crossfit coaches.  There are many trainers, strength & conditioning coaches, physical therapists, and chiro’s making the same mistakes.  The goal of this article is simply to bring awareness and offer solutions for 2 common mistakes that seem to happen often (not to attack crossfit as a whole).

Mistake #1 = Constantly Training to (and Past) Failure

I understand it’s important to test your limits every once in a while.  And I know that when you’re in a competition or going for a PR many of the rules go out the window.  But that doesn’t mean you should train like this every time.As fatigue sets in, good biomechanics, technique, and form start to fail.  Everyone that has worked out to failure knows this and has felt this.  Even if you haven’t experienced a fatigued state, there is more than just empirical evidence to support this hypothesis.  Research has shown that mechanics and proper form go out the window in a fatigued state (14-18).This is not only bad for performance, but more importantly, it is bad for your health.  The more you continue to train in a fatigued state, the greater your risk for injury.  This injury can either be an acute one or a chronic one.Acute injuries are fairly easy to comprehend.  Acute injuries occur instantaneously when the external load is greater than the tissues accepting it.  It’s a cause and effect event.Some examples of the acute injuries:  A tired and sloppy deadlift with a rounded back on the 10th rep could damage your lumbar spine.  A tired and sloppy snatch with forward shoulders and poor T-spine extension could lead to a labral tear.  A tired and sloppy box jump with a knee caved in could lead to an ACL tear.  In other words, it puts you at risk for an accident that occurs in a split second, but takes months to recover from.Chronic injuries are a little more complicated and have to do with compensations and movement patterns.Movement patterns are the stored neurological “program” that resides in the brain.  This “program” is what your nervous system fires out to make the right muscles fire at the right time to achieve the desired result.  Performing exercises with poor form and inefficient muscle activation can teach your brain poor movement patterns.  In other words, it can set in bad habits.A long winded example might help.  Lets take my favorite exercise done to failure - deadlifting.  When you finish out those last 5 deadlifts with a rounded back because you were too tired to use the right muscles, your brain stores a new motor pattern.  Now your brain has a new easier way to deadlift.  Why lift with muscles when you can just lean on passive tissues like ligaments, joint capsules, and lumbar disks?  In other words, your brain decides it’s better to save energy and rely on tissues that don’t require energy to get the job done (passive tissues).  It decides lifting with a rounded back is a good idea.  Stupid brain.  You might be able to lift more weight (temporarily), but it will be at a cost to your spine.  Overtime, this stress to your back accumulates and can lead to a slew of injuries (paraspinal strain, disk herniation, neurodynamic problems, SIJ strain, etc.).So is it really worth it to sacrifice your movement to push it to the limit at every workout?  Do you really need to do over 40 reps of every exercise on each set?  What if you did more sets instead of more reps? Wouldn’t it be better to stop the set once technique starts to waver?  What if you let people “ladder” down throughout the WOD instead of compensating through?  Why not perform AMPRAP (As Many Perfect Reps As Possible) instead of just AMRAP?

A Suggestion

Better programming and an emphasis on improving technique as well as strength is something that many Crossfitters could benefit from.Crossfit coaches can improve in this realm by emphasizing technique over numbers or metabolic expenditure.  Assessing for poor technique and over-fatigue significantly decreases the risk of injury and will improve performance in the long run (you can’t make gains if you keep having to take time off because you’re injured).  Coaches need to help athletes become aware of when their form goes bad and stop them from grooving bad movement patterns with compensatory muscle activity.  And the WODs they develop can be programmed to avoid unnecessary fatigue and sloppy form on complex movements.However, it’s important to understand that assessing for over-fatigue and poor technique is not just the coaches responsibility.  The athletes need to be EDUCATED that when they can’t maintain form they are at a greater risk for injury and they need to stop.  I think this is one of the biggest mistakes most crossfitters make.  Many of them don’t understand this concept; they don’t understand the dangerous effects of not listening to your body and training with poor technique.  Others are simply not aware of their poor form.  Either way, this mistake needs to be addressed to decrease the risk of injury.A warrior mentality often exists with Crossfitters.  However, this mentality should adopt the idiom - live to fight another day.

Click Here for Part II

References

Strength is a Good Thing1) Preethi Srikanthan, Arun S. Karlamangla. “Muscle Mass Index as a Predictor of Longevity in Older-Adults.” The American Journal of Medicine (2014) 2) Lauersen JB, Bertelsen DM, Andersen LB.  The effectiveness of exercise interventions to prevent sports injuries: a systematic reviewand meta-analysis of randomised controlled trials.  Br J Sports Med. (2014) Jun;48(11):871-7.3) Harridge, Stephen D.r., Ann Kryger, and Anders Stensgaard. "Knee Extensor Strength, Activation, and Size in Very Elderly People following Strength Training." Muscle & Nerve 22.7 (1999): 831-39.4) Suetta, C., S. P. Magnusson, N. Beyer, and M. Kjaer. "Effect of Strength Training on Muscle Function in Elderly Hospitalized Patients."Scandinavian Journal of Medicine & Science in Sports 17.5 (2007)5) Askling, C., J. Karlsson, and A. Thorstensson. "Hamstring Injury Occurrence in Elite Soccer Players after Preseason Strength Training with Eccentric Overload." Scandinavian Journal of Medicine and Science in Sports 13.4 (2003): 244-506) Nadler, Scott F., Gerard A. Malanga, Melissa Deprince, Todd P. Stitik, and Joseph H. Feinberg. "The Relationship Between Lower Extremity Injury, Low Back Pain, and Hip Muscle Strength in Male and Female Collegiate Athletes." Clinical Journal of Sport Medicine 10.2 (2000): 89-97.7) Peate, Wf, Gerry Bates, Karen Lunda, Smitha Francis, and Kristen Bellamy. "Core Strength: A New Model for Injury Prediction and Prevention."Journal of Occupational Medicine and Toxicology 2.1 (2007)8) Orchard, J., J. Marsden, S. Lord, and D. Garlick. "Preseason Hamstring Muscle Weakness Associated with Hamstring Muscle Injury in Australian Footballers." The American Journal of Sports Medicine25.1 (1997): 81-859) Jankowski, C.m. "The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial."Yearbook of Sports Medicine 2012 (2012): 65-66.10) Willson JD, Dougherty CP, Ireland ML, et al. “Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg. (2005) Sep;13(5):316-25.11) Hewett TE, Lindenfeld TN, Riccobene JV, et al. “The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.” Am J Sports Med. (1999) Nov-Dec;27(6):699-706.Movement Based Exercise vs. Isolated Exercise12) Gentil, Paulo, Saulo Rodrigo Sampaio Soares, Maria Claúdia Pereira, et al. "Effect of Adding Single-joint Exercises to a Multi-joint Exercise Resistance-training Program on Strength and Hypertrophy in Untrained Subjects." Applied Physiology, Nutrition, and Metabolism 38.3 (2013): 341-4413) Gottschall, Jinger S., Jackie Mills, and Bryce Hastings. "Integration Core Exercises Elicit Greater Muscle Activation Than Isolation Exercises."Journal of Strength and Conditioning Research 27.3 (2013): 590-96Exercising in Fatigued State14) Cortes, Nelson, Eric Greska, Roger Kollock, Jatin Ambegaonkar, and James A. Onate. "Changes in Lower Extremity Biomechanics Due to a Short-Term Fatigue Protocol." Journal of Athletic Training 48.3 (2013): 306-13.15) Santamaria, Luke J., and Kate E. Webster. "The Effect of Fatigue on Lower-Limb Biomechanics During Single-Limb Landings: A Systematic Review." Journal of Orthopaedic & Sports Physical Therapy 40.8 (2010): 464-73.16) Barnett S Frank, Christine M Gilsdorf, Benjamin M Goerger, et al.  “Neuromuscular fatigue alters postural control and sagittal plane hip biomechanics in active females with anterior cruciate ligament reconstruction.” Sports Health (2014) Jul;6(4):301-817) Quammen D, Cortes N, Van Lunen BL, et al. “Two different fatigue protocols and lower extremity motion patterns during a stop-jump task.” J Athl Train. (2012) Jan-Feb;47(1):32-41.18) Pau M, Ibba G, Attene G. “Fatigue-induced balance impairment in young soccer players.” J Athl Train. (2014) Jul-Aug;49(4):454-61.Imbalances Are Bad19) Knapik, J. J., C. L. Bauman, B. H. Jones, J. Mca. Harris, and L. Vaughan. "Preseason Strength and Flexibility Imbalances Associated with Athletic Injuries in Female Collegiate Athletes." The American Journal of Sports Medicine 19.1 (1991): 76-8120) Baumhauer, J. F., D. M. Alosa, P. A. F. H. Renstrom, S. Trevino, and B. Beynnon. "A Prospective Study of Ankle Injury Risk Factors." The American Journal of Sports Medicine 23.5 (1995): 564-70.21) Common Sense & Conventional Wisdom (>6 million years BC)Motor Learning22) Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.23) Schmidt, Richard A., and Craig A. Wrisberg. Motor Learning and Performance: A Problem-based Learning Approach. Champaign,IL: Human Kinetics, 2004.24) Williams, L. R., McEwan, E. A., Watkins, C. D., Gillespie, L., & Boyd, H. (1979). Motor learning and performance and physical fatigue and the specificity principle. Canadian Journal of Applied Sport Sciences, 4, 302-308.

“The body does not have the capacity to learn movement patterns when highly stressed/fatigued. This factor is not related to the specificity of training principle associated with overload adaptation in energy systems. The specificity principle of physiological adaptation does not apply to motor learning. To learn skilled movement patterns that are to be executed under fatigued conditions, that learning has to occur in non-fatigued states” — Williams 1979

 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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The Deep Squat (Part 1 - The Good, The Bad, & The Not So Ugly)

The deep squat (aka full squat, aka ass to grass/ATG squat) is one of the most debated, talked about exercises/assessment we have in human movement.  Some talk about the deep squat as if it's the cure to cancer, some talk about it like it's going to cause the apocalypse.  I have found that I always get mixed information and many take either a full medical approach, a full evolutionary approach, or a full performance approach.My goal here is to provide a blend of these approaches.  As a PT that loves S&C and evolutionary medicine, I hope I can give some evidence, some reasoning, and some clinical judgement on the deep squat as an exercise.Let me again emphasize this is through the lens of the deep squat as an exercise; the squat as an assessment is a whole different story (PRI, FMS, SFMA, Loaded, ADL, etc.).If you want to stop reading here, please consider the conventional wisdom of great S&C coaches:

• Squatting is not bad for you, the way you squat is bad for you

Disclaimer

I think a big part of the discrepancy with the performance with the deep squat is that there are so many variables associated with this movement pattern.  These variables include local physical impairments, movement history, exercise history, injury history, education, neuroception, structural changes, coaching, motivation, and culture.So if you took 100 people off the street and had them deep squat, you would see a smorgasbord of different movement patterns.This surfeit of human variables leads to a problem when trying to generalize one of the world's most complex exercises, let alone trying to create a study.But this abundance of variables isn't the only problems with the studies.

3 Reasons Why Evidence isn't the Gold Standard for the Deep Squat

1. The populations vary from individuals who are young and have experience with the deep squat, to older individuals with possibly no experience with the deep squat.
2. The studies don't seem to take into consideration any of the physical impairments; someone with an ankle dorsiflexion restriction is going to squat much differently than someone with a ankle motor control problem.
3. The definition of the deep squat is completely different in some papers (some have mentioned parallel femurs as a deep squat).

So you can't expect too much from PubMed due to the inconsistent populations, lack of data on physical inputs, and a poorly defined task. 

Defining the Deep Squat

I'm going to call the deep squat simply a squat below parallel with a neutral spine.If you can't get below parallel with a neutral spine, you can't do a deep squat as an exercise.Getting below parallel with spine flexion is great if it's unloaded (SFMA, PRI), but in this article I'm focusing on the act of loading the deep squat for strength, performance, & movement enhancement.

We Used to Always Squat

Tired of standing? Squat down.Need to check something out or inspect an object? Squat down.Hanging out, shooting the shit around a camp fire? Squat down.This was the life for our ancestors (and for some of our current species in different cultures).It's Phylogenetics, the evolutionary history of our species.  It's our species' "family tree" from the beginning of time.The way our bodies have evolved over time has resulted in the movement pattern of the deep squat.But it's also Ontogenetics, the developmental history of an individual.  It's how the interaction of genetics, developmental programming, and environment affects the physical form throughout a lifespan.I've mentioned in a previous post that we have culturally evolved at a rate that far surpases our physical evolution.  Meaning, the world we live in is not made for our physical structures (chairs, shoes, school/work, technology, etc.).This mismatch means that the person in front of you trying to squat should be able to squat (phylogenetics), but may not be able to because of the way they have interacted with their environment (ontogenetics).For example, think of how a 4 year old can deep squat with no problem (phylogenetics), but the 50 year old, life-long sedentary, American desk jockey that can't flex his hip past 90 degrees because of structural changes in his femur/acetabulum has no chance at a deep squat (ontogenetics).But before you start analyzing your patient's phenotype, you should first understand the benefits, risks, and drawbacks of the deep squat exercise.

A Visual Approach to Squatting

Before discussing the benefits and potential drawbacks of the deep squat, it's best to understand exactly what is happening at the knee joint through varying degrees of knee flexion.Here's a diagram with the degrees of knee flexion and the associated forces/EMG activity.This is based on several studies, listed below. * Most studies don't mention any activity beyond 135 degrees.  So this is unknown and why there is nothing beyond 135** It seems the force shifts from anterior to posterior between 50-60 degrees.  This is why there is an overlap.  Yes, I know it's impossible to have both anterior and posterior shear forces at the same time.

Why it's Good

It cures cancer!But seriously, the deep squat exercise has a ton of benefits (see chart below).In general, the deeper the squat, the greater the quad and glute activation.Plus, the deep squat spares the knee of shear forces and prevents ligamentous strain (see figure above).  Since most lower extremity injuries involve weakness and aberrant shear forces, the deep squat can provide a great exercise to help reduce injury.From a performance perspective, the deep squat provides a great exercise for increasing strength (legs, thighs, hips, core) and improving vertical (y-axis) movement efficiency.

Why it's Bad

Ontogeny

The bad often comes from ontogeny.  Everyone was able to squat as toddlers, but what they've done since then will influence what they can do now.  In other words, the way someone has chosen to live their life may make the deep squat a bad exercise for them.  Everyone was born to squat, but not everyone has grown to squat.  This is due to the body adapting to life's imposed demands (mechanotransduction, Wolffe's Law, Davis's Law, bioplasticity, etc.).  Think of it as a structural SAID principle.Someone that spends their life in an anterior pelvic tilt, wearing high heels, and sitting for 80 hours a week will have structural changes in their ankles, hips, and lumbo-pelvic area that will prevent them from a deep squat.  This person would need years of specific training in attempt to reverse some of these adaptations to allow them to squat without compensations.

Compressive Forces

Another potential danger is the high compressive forces (tibiofemoral & patellofemoral) with a deep squat.  Since there is an inverse relationship between shear and compression forces, the benefit of less shear is at a cost of more compression.  For most, this isn't a big problem if you apply the SAID principle and progress slowly.  But for some it may be an issue.

Mobility Restrictions

In general, you should avoid prescribing the squat with people who do not have optimal mobility in their ankle, knee, and hip.  Simply stated, if you do not have adequate mobility in these joints you will compensate and cause more harm than good.

Pathologies

Getting more specific and research-based, I would be very careful to squat with people who have: meniscus pathology, PCL pathology, hip impingement pathology (labral tear or bone spur), chondromalacia (depending on location of pathology), or advanced symptomatic osteoarthritis.However, you should always treat the patient, not the script/image/anatomy.

But What About...

Many times in medicine, one of the first studies that come out on a subject becomes the most popular and becomes dogmatic.  This happened with the 1961 research article by Klien.  Klien reported that squatting was dangerous and increased laxity in the knee.  Everyone jumped on the anti-deep squat bandwagon back then, and some are still dogmatically against the deep squat; even though Klien's results have been refuted in many research articles since.Here are some questions that many have about the squat and it's safety.

Isn't it Bad for Ligaments?

"Because the squat generated lower ACL strain compared with walking or jogging, it was concluded that the squat was a low risk exercise in rehabilitation of the ACL". - Henning et al.

"In conclusion, basketball players and distance runners experienced a transient increase in anterior and posterior laxity during exercise. Power lifters doing squats did not demonstrate a significant change in laxity." -Steiner et al

Isn't it Bad for the Tissues Around the Knee?

"With increasing flexion, the wrapping effect contributes to an enhanced load distribution and enhanced force transfer with lower retropatellar compressive forces...Contrary to commonly voiced concern, deep squats do not contribute increased risk of injury to passive tissues." -Hartman et al.

Isn't it Bad for the Knee Cap?

This is basic physics (Force = Pressure x Area).  There is increased compression with the deep squat, but there is also increased retro-patellofemoral contact area.  Meaning the direct pressure on the knee cap is dispersed among a greater area, thus less focal retro-patellar forces.  Just keep in mind the location of the retro-patella forces associated with the different degrees of knee flexion.

Isn't it Bad for Knees?

"The squat does not compromise knee stability, and can enhance stability if performed correctly. Finally, the squat can be effective in developing hip, knee, and ankle musculature, because moderate to high quadriceps, hamstrings, and gastrocnemius activity were produced during the squat." -Escamilla RF

"In conclusion, there is scant evidence to show that deep squats are contraindicated in those with healthy knee function." -Schoenfeld BJ

Bottom Line

The squat can be a very valuable exercise for both rehab and performance.The question isn't about whether squatting below parallel is good for people.  We know that squatting below parallel affords many benefits and few risks.The questions has to deal with what the individual's environment and lifestyle has done to them over time (ontogeny).  What are the patient's physical limitations and adapted structures developed to deal with?  Which ones can you change?  Which ones should you change?Understanding the phases of the squat and the associated forces/EMG activity will help one prescribe the exercise more effectively.Part I deals with understanding the deep squat.  Part II will deal with implications for rehab, performance, and how to train it from the ground up.

Dig Deeper

Evolution:Evolution goes much deeper than phylogeny and ontogeny.  Ontogeny is an umbrella term that includes many more detailed concepts (e.g. phenotype plasticity, epigenome, etc.).  Special thanks to the great professors who helped clarify some of these concepts for me: Daniel Liberman, Robert Boyd, Kathleen Smith, Jennifer Brisson, Jean-Jacques Hublin, Squat Stuff:Brad Schoenfeld has some of the best articles on the deep squat.  Best place to start in my opinion.  Scroll down for the articles - The Biomechanics of Squat Depth, Squatting kinematics and kinetics and their application to exercise performance .James Speck - 5 Reasons to Start Full SquattingChris Beardsley - Squat Depth for Glute Activation, Squat DepthBret Contreras - 7 Reasons to Squat Like a ManHuffington Post - Nick EnglishStrongfirst Front SquatDean Somerset - Do You Need to Squat DeeplyKevin Neeld - The Truth About Deep SquattingVincent St. Pierre - Are Deep Squat SafeNick Tumminello - 7 Reasons This is a Ridiculous MythMenno Henselmans - Partial ROM vs. Full ROMBrent Brookbush - A Kinesiological Approach to the Overhead Squat (16 Video Series)

References

HENNING, C. E., M. A. LYNCH, and K. R. GLICK, Jr. An in vivo strain gage study of elongation of the anterior cruciate ligament. Am. J. Sports Med. 13:22-26, 1985.Klein K. The deep squat exercise as utilized in weight training for athletes and its effects on the ligaments of the knee. J Assoc Phys Ment Rehabil 15: 6–11, 1961Escamilla RF. Knee biomechanics of the dynamic squat exercise. Med Sci Sports Exerc 33: 127–141, 2001.Meyers E. Effect of selected exercise variables on ligament stability and flexibility of the knee. Res Q 42: 411–422, 1971.Chandler T, Wilson G, and Stone M. The effect of the squat exercise on knee stability. Med Sci Sports Exerc 21: 299–303, 1989.Bloomquist, K., H. Langberg, S. Karlsen, S. Madsgaard, M. Boesen, and T. Raastad. "Effect of Range of Motion in Heavy Load Squatting on Muscle and Tendon Adaptations." European Journal of Applied Physiology 113.8 (2013): 2133-142.Hartmann, Hagen, Klaus Wirth, and Markus Klusemann. "Analysis of the Load on the Knee Joint and Vertebral Column with Changes in Squatting Depth and Weight Load." Sports Medicine 43.10 (2013): 993-1008.Caterisano A, Moss RF, Pellinger TK, Woodruff K, Lewis VC, Booth W, Khadra T. The effect of back squat depth on the EMG activity of 4 superficial hip and thigh muscles. J Strength Cond Res. 2002 Aug;16(3):428-32.Steiner M, Grana W, Chilag K, and Schelberg-Karnes E. The effect of exercise on anterior-posterior knee laxity. Am J Sports Med 14: 24–29, 1986.Esformes, Joseph I., and Theodoros M. Bampouras. "Effect of Back Squat Depth on Lower-Body Postactivation Potentiation." Journal of Strength and Conditioning Research 27.11 (2013): 2997-3000.Salem, George J. et al.  Patellofemoral joint kinetics during squatting in collegiate women athletes.  Clinical Biomechanics 16:424-430, 2001.Bryanton, Megan A., Michael D. Kennedy, Jason P. Carey, and Loren Z.f. Chiu. "Effect of Squat Depth and Barbell Load on Relative Muscular Effort in Squatting." Journal of Strength and Conditioning Research26.10 (2012): 2820-828.Schoenfeld BJ. Squatting kinematics and kinetics and their application to exercise performance. J Strength Cond Res 24: 3497–3506, 2010Escamilla, RF, Fleisig, GS, Zheng, N, Lander, JE, Barrentine, SW, Andrews, JR, Bergemann, BW, and Moorman, CT. Effects of technique variations on knee biomechanics during the squat and leg press. Med Sci Sports Exerc 33: 1552–1566, 2001a.

Walter, Chip. Last Ape Standing: The Seven-million Year Story of How and Why We Survived. New York: Walker &, 2013

Lieberman, Daniel. The Story of the Human Body: Evolution, Health, and Disease. New York: Pantheon, 2013. Print

 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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4 Mistakes People Make with the Functional Movement Systems (FMS/SFMA)

I am a big fan of the FMS (Functional Movement Screen) and SFMA (Selective Functional Movement Assessment).  Together these screens and their associated principles make up the Functional Movement Systems.

I've been using this system for a couple years and have had a lot of success with it.  The more efficient I become at this approach, the more my outcomes improve.

I still have much to learn and am by no means an expert, but I thought I'd share the 4 biggest mistakes I see people make with the Functional Movement Systems.

4 Functional Movement Systems Mistakes

1) It's Not a Kinesiology or Biomechanics Test

The SFMA and FMS are both seven baseline movements that are used to assess how someone moves.  The big point here is that this is not a kinesiological test or a biomechanical test.  It’s not a strength, stability, or a mobility test.  It is not a test for anything in isolation.

It’s a complex neuro-based movement assessment.  It incorporates all the peripheral inputs coming into the CNS (mobility, muscle tension, joint ROM, position, tensegrity, vision, vestibular, etc.).  It incorporates how these inputs are analyzed and processed in the CNS (movement history, expectations, motivation, ANS state, etc.).  And then, it incorporates the output of this process - the physical movement we can see.

Essentially, the top tier tests are screening your neuro-tag for a standard 7 movements.  It shows what movement looks like in your brain.  It shows how the inputs are processed into outputs.  And this happens continuously in real-time throughout the entire movement.

This isn't just a theory.  It's how human movement works.

Anytime you loosen up someone's ankle DF (inputs), it needs to be integrated in the CNS (processing) for the specific movement pattern that was dysfunctional (outputs).  Sometimes this will spontaneously happen after creating mobility, other times you need to "show" the brain the new mobility and create the new movement neuro-tag.

2) 7 General Movement Standards

One of the big complaints I hear is that “people do more than just 7 movements”.  While this is a brilliant observation, it doesn’t debunk the system.

We can all understand Bernstein's Problem (Degrees of Freedom Problem).  The amount of freedom of the joints, coupled with the kinetic pulls of all the different muscles/fascia/connective tissue, basically creates an infinite amount of possible ways to move.  Therefore, the nervous system has an infinite amount of motor programs to choose from.

In other words, with the plethora of variables in human movement, there cannot be just one "right" way to move.

And this is a good thing; it allows our species to have more options to choose from when trying to adapt to a specific environment or task.

The problem exists in the practitioners job of assessing the infinite.  How do you go about testing the infinite ways of movement in a 45 minute eval?

This is where the SFMA/FMS comes in.

It is simply the best standard we have for efficiently screening the infinite movement patterns.

It is a funnel to find the dysfunctional movement family.

How does this apply to your patient's specific problem?

Simply look at the variables associated with the movement screen and match it with the patients dysfucntional movement or functional complaint.   You should be able to find something in common with your patients specific movement problem and one of the 7 movements (FMS or SFMA).

An example may help understand this concept.

If a patient fails MSF (Multi-Segmental Flexion), it means that this individual will likely have difficulty with movements that shift their COG behind their BOS, or lengthen a their posterior chain, or involve a hip hinge, or involve lumbar flexion, or require motor control of trunk flexion, etc. (see picture below for everyday common movement patterns).

It doesn't only mean that they can't touch their toes and fail a test.  It doesn't mean they need to move exactly like the MSF screen every time they bend forward in their life.  It just means their MSF movement pattern is dysfunctional and this will likely affect many of the other infinite movements that share the same variables.

In other words, it narrows the infinite and points you towards a family of movement patterns that need work.

3) It’s More Than Screening for Impairments

A common misconception about the SFMA is that it's only used to find local impairments.

Yes, finding the local impaired segment and tissue dysfunction is important.  But what’s more important is how the local impairment affects the global movement pattern.

Impairments cannot exist in a purely isolated fashion.  Impairments only exist in the context of the whole human body.  It’s not until the impairment adversely affects a movement (or posture) that it becomes a problem.

For example, an isolated latissimus dorsi restriction doesn’t mean anything by itself.  There are plenty of people who sit at desks all day, don’t exercise, and never lift their arms overhead.  Therefore, this impairment rarely becomes a problem for them.  But if this same person goes out and tries to hit a tennis serve over the weekend, this becomes a serious impairment that affects their MSE (Multi-Segmental Extension) movement pattern.  Compensations will occur and the risk of injury will increase.

Yes, the lat restriction is important, but it only becomes a dysfunction in the context of movement.

The goal of they system is to determine the local impairment AND the movement patterns that are most significantly affected.

4) It's a Screen & Assessment, the Intervention is Wide Open

This mistake often occurs as a result of the first 3 mistakes.

Most people are able to address the local impairment, but some have difficulty integrating this new input into the movement pattern.

The movement pattern intervention is basically an application of the concepts to the individuals specific assessment.  There is no cookie cutter protocol to follow.  It's open to the practitioner, the client, the environment, and the task/goal.

If you understand that it’s a complex neuro-based movement system, then you can understand there are an infinite amount of options to achieve the same result.  First address the breakouts (inputs), then integrate them back into the global movement pattern (processing), and finally re-assess the movement pattern (output).

Gray Cook has discussed this process in his 3 R's approach: Reset, Reinforce, & Reload.

Again, it helps to first think of it as a family of movements patterns.  Try to create similar sensory inputs that are “relatives” of the top tier movement pattern.  They don’t have to be identical twins, you just have to be able to tell that they’re related.

If the patient fails MSF, address the local impairments, then integrate them back into the movement pattern.  To do this, just pick an exercise that shifts their weight back, or flexes the trunk forward, or eccentrically lengthens the posterior chain, or rounds the lumbar spine, or requires a hip hinge.  Or a combination of those variables.

The same thing goes for the FMS.  If the patient fails the hurdle step, work on something that stabilizes the stance leg in hip extension, or open chain hip/knee/ankle flexion, or the scissored position (hip flexion & extension), or work on something that stabilizes the trunk upright in the dysfunctional scissored position.  Or a combination of those.

What you choose as your intervention should depend on the results of the movement screen, the breakouts, the examination, your patient, and your own treatment style.

If this open territory makes you uncomfortable, the System has a nice 4x4 exercise progression based on the neurodevelopmental perspective.  This may be the closest thing you will find to a "protocol" for movement patterns.

In the end, it doesn't matter what approach you use to address the findings in the screen and assessment.

There are many different ways to achieve the same thing.

As long as it simulates the similar inputs of the movement pattern, you should get a positive change.  If you don’t get a positive change, the screen will tell you.

And this is may be the most valuable aspect of The System.  It allows for you to "check your work".  It gives a clear indication for which interventions work, and which ones don't.

The System allows you to methodically add and subtract interventions until you achieve the desired outcome.

It gives you efficiency and effectiveness, while taking nothing from the way you currently treat.

Bottom Line

The Functional Movement Systems is a very useful clinical tool.  There is much more to this approach than simply screening 7 movements.  Understanding the concepts and principles of this approach will help to prevent errors and increase efficiency and outcomes.

Disclaimer

I do not work for or have any affiliation with the FMS/SFMA System.  This post does not represent the System or anyone affiliated with it.  This is simply my interpretation of the system and some thoughts that will hopefully improve people's understanding of it.  --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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The New Overhead Shoulder Concept (Part I)

Traditional Down & Back

At this point we all know the importance of a stable and strong scapula for shoulder function.  Almost every PT, athletic trainer, and personal trainer trains the shoulder with a "down and back" cue.  This cue allows for a better stable position of the scapula and enables the rotator cuff to work more effectively.  Kolar has summed this concept up in a single sentence:

• "The muscle may not be weak in itself, but it may not function well because its attachment point is insufficiently fixed."

New Upward Rotation Emphasis

However, in my experience there have been many patients that don't seem to get back to their full function after a shoulder injury despite the scapula strengthening and the down and back shoulder packing.  In my search for answers I came across Eric Cressey's blog several times.  Where most clinicians are terrified of allowing a shoulder to elevate due to the Upper Trap/Lower Trap ratio that we were taught to fear, Cressey advocates the opposite.  He trains many of his clients in an overhead position with an emphasis on upward rotation using the trapezius.

• "We may have ruined a whole generation of athletes with the cue back and down" - Eric Cressey

Does the statement above bother you?  Bring up some defensive arguments?  It did for me when I first heard it.  I've been cueing people with "back and down" for years.  However, once I got past my ego and opened up to this concept my shoulder patients started to get MUCH better.

Overhead/Upward Rotation/Upper Trap Concept

While this upper trap/overhead concept may not be brand new or fully original to Eric Cressey (I know Sahrmann is an advocate of this); he is the first I've heard to discuss it with such clarity and clinical relevance.  Most of the time when you hear about a new concept it's really just somebody trying to sell something or someone just offering an interesting perspective with no clinical solutions.  However, Cressey not only helps to define this paradigm shift, but he also offers detailed strategies to address it (for free!).Much of this post series, especially the assessment & intervention (part II), is based upon Cressey's work.It's important to note that this isn't just a protocol you blindly apply to everyone.  It's a detailed concept that requires an individualized assessment to determine if they need more upward rotation (and where they need to get it from).

Why is Overhead Position Important?

We're Losing It

Our current species of the hominin is starting to de-volve.  To understand this, we have to look at where we came from.  First when we used to live in the trees our shoulders were oriented upward and forward.  Then when the climate changed and we were forced to our bipedal states in the savanna, our shoulders re-oriented less upward and more forward to manipulate objects.  Next, to increase our hunting prowess our shoulders re-oriented more laterally facing to allow us to throw objects at our prey.  Now, with all the use of technology and poor postures our shoulders are starting to regress back to facing more forwrard.

Displays Optimal Shoulder Function

The FMS/SFMA had it right with the overhead squat assessment.  For more reasons than I realized.Being able to get both arms overhead without compensatory patterns is a sign of great shoulder function.  If you have any pain, restrictions, weaknesses, or dysfunctional movement patterns you will not be able to do this.  The same cannot be said for non-overhead shoulder positions.

People Like to Use it

Even if you don't buy into the last two, you can't argue with this one.  Most of our patients love to participate in recreational activities and exercise.  For these patients to return to such activities they need to display good overhead shoulder mechanics.  You can't just have them doing sidelying ER and expect them to go out and hit a tennis serve without problems.Even if they're not athletes they'll need it for everyday tasks of putting dishes away, washing your hair, hailing a cab, slapping someone taller, etc.

What is Required for the Overhead Shoulder Position?

Before you can assess and correct the overhead shoulder, you first must truly understand what goes into an overhead shoulder.  Each of these things have their own complexity and should not be underestimated.

What You Get When You Train Overhead?

A cascade of events occur when you lift your arm to the full overhead position with a proper movement pattern.  From a simple perspective it strengthens the upward rotators and lengthens the downward rotators.  Full scapula upward rotation is paramount (increased GH congruency in overhead position).  However, it's much more complex than just upward/downward rotation.First it's important to understand that most people only have about 170 degrees of pure shoulder flexion.  Often time they'll cheat with lumbar/T-L junction hyperextension to get to the full 180.  But if you can teach your patients not to cheat and to actively get to a stable compensatory free full overhead shoulder position, a lot of good things will occur.So what happens when you try to go for the full 180?  A cascade of events occurs leading to a stable shoulder position with activated thoracic extensors, scapula stabilizers, rotator cuff, and anterior core.Load this position with a weight and a ton of great things happen.  The simple physics of it:Long Lever + High COG over Small BOS = Inherent Instability = Reactive Stability.Plus, adding a compressive load gets the reflexive stabilization of the RTC and scapula in this great position.

Is the Upper Trapezius Really a Problem?

The poor upper trap.  It gets blamed for everything.  People often say that it's too tight and too active.  Historically many people have tried to decrease the upper trapezius tone by spending a ton of manual therapy and stretches to "loosen" them up.  Then they try force the little lower trapezius and serratus anterior to do all of the upward rotation work.The problem is that the upper trapezius should be considered with the opposite point of view.  We should look at it as an important shoulder muscle that needs to be strengthened.This concept should be agitating for anyone that went to physical therapy school, as we learned about UT/LT ratio's and how much of a problem the UT can be.To accept and utilize this paradigm shift you have to understand the true function of the upper trapezius.

2 Aspects of the Upper Trap Function

1) The UT is an important part of scapular upward rotation.  Many people know this, but tend to spend all their time on the LT & SA.  If you only focus on the LT and SA then you are missing out on  33% of the upward rotators.  How can you get someone back to full function by only strengthening 66% of their muscles?2) Almost all the fibers of the UT attach to the posterior boarder of the distal third of the clavicle (Johnson et al, 1994).  This would mean the fiber orientation would actually cause medial rotation of the clavicle, compress the sternoclaviculalr joint, posteriorly tilt of the scapula, elevate the lateral clavicle, and increase upward rotation.

So have we been completely wrong all along?

Yes and no.Yes, there can be an excessive elevation during the initial stages of shoulder flexion.  So there is a movement dysfunction.But no, the UT isn't capable of elevation with the arm at the side.  The UT works synergistically with the LT and SA after the shoulder has started to flex/abduct.  The excessive elevation is from the levator scapula (the main scapula elevator with the arm at the side).To make matters worse, when the upper trap is weak the levator scapulae will jump in and try to make up for this weakness.  Unfortunately the LS doesn't upward rotate, so it just pulls on the cervical spine, jacks up the scapula, and throws off all force couples.

Bottom Line

The down and back traditional treatment of shoulders may not be the best approach for all patients.  Not to mention there is a great deal of benefit from training in full scapular upward rotation (i.e. increased subacromial space, UT/SA/LT strengthening, downward rotator lengthening, t-spine extension, anterior core stability, etc.).After reading this article you will have the necessary understanding to better assess and treat the overhead shoulder (part II).

Dig Deeper

Eric CresseyWarren Hammer - Dynamic ChiropracticAdam Meakins - Upper Trapezius James Speck - UT Doesn't Fire IndependentlyLudewig PM, Cook TM. Alterations in shoulder kinematics anda ssociated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000;80:276-91Johnson G, Bogduk N, Nowitke A.  Anatomy and actions of the trapezius muscles.  Clinical Biomechanics.  1994;9:44-50. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Pathomechanics of the Foot

Separating foot types into supinators or pronators may provide adequate assessment for treatment.  However, for a more specific treatment plan it would be advantageous to understand the possible abnormalities and pathomechanics of the forefoot and rearfoot (calcaneus).  More importantly, knowledge of these abnomalities/pathomechanics will also prevent deleterious treatment.For example, providing medial calcaneal mobilizations/releases for the overpronator would be great if the patient has a compensated calcaneal varus.  But if the patient has a compensated forefoot varus the medial mobilization/release would likely worsen their injury. It may sound complicated, but once you understand these 3 foot abnormalities and pathomechanics it will make sense.Foot Pathomechanics = compensations that occur from foot abnormalities during weight bearing tasks

The 3 Foot Abnormalities

1. Calcaneal (Rearfoot) Varus
2. Forefoot Varus
3. Forefoot Valgus

Basic Foot Knowledge

The foot can be simplified into a structure that has 2 jobs: mobility (pronation) and stability (supination).  It requires adequate mobility to adapt to ground surfaces and facilitate shock-absorption.  It requires stability to function as a rigid lever for efficient propulsion.  Failure of either of these jobs will cause great dysfunction throughout the body.This stability and mobiilty is dependent on an intricate passive and dynamic system.  The passive system of bone orientation and joint congruency help to provide static stability when aligned, and flexibility when not aligned.  The dynamic system of the muscles help to reinforce stability and allow for controlled flexibility (eccentric loading).  When there is an abnormality in the foot alignment or structural, the subtalor joint often compensates by altering the normal balance of stability and mobility.Treating the compensation may provide the patient relief.  But for full resolution of the dysfunction you will need to correct and remove the cause.

Normal Foot

Normal neutral foot alignement is compromised of 3 things: 1) Neutral Subtalor Joint 2) Vertical Calcaeus (in line with lower leg) 3) Metatarsal Heads Perpendicular to neutral calcaneus/subtalor joint.  This is the position for optimal functioning of both passive and dynamic systems.

Assessment

Postural assessments should be viewed from all angles.  An anterior view will show any sagittal plane deviation (forefoot abduction). An oblique view will give a good assessment of the arch and navicular hight.  A posterior view will display calcaneal and subtalor positions.Once you have a postural assessment, it is important to determine the foot alignment and structure.  There are many ways to accomplish this.  Finding talor neutral (anterior palpation), lower leg to rearfoot alignment, unbiased passive dorsiflexion, joint play, postural foot assessment, and gait analysis.  I find it best to use a combination of these assessments.  If you understand the possible types of pathomechanics and forefoot/rearfoot alignment it will make it easier to determine exactly which foot type your patient has.Finally, you want analyze their gait to see how the patient dynamically uses their foot alignment and structure.  The static postural foot assessment will help give you an indication of what you should be looking for during the analysis.  You want to not only look for over or under pronation, but try to assess for 3 specific aspects of the dysfunctional motion (compensation).  This is of paramount importance because it is the compensations that will dictate which structures you need to treat.

3 Aspects of Dysfunctional Motion

• Amount of Motion
• Speed of the Motion
• Timing of the Motion

Calcaneal (Rearfoot) Varus

This is the most common foot abnormality.  However, it may or may not be a clinical problem.Calcaneal/Rearfoot varus is when the calcaneas is inverted with the subtalor joint is in neutral and the forefoot is perpendicular to the lower leg.  This foot abnormality is more supinated at heel strike.  These patients often present with decreased lateral (eversion) subtalor joint play.Compnesations include overpronation or 1st ray plantarflexion to allow the medial forefoot to contact the ground.

Posture Assessment

Uncompensated

Calcaneus Inverted & Navicular Raised = Supinated

Compensations: Distal = Plantarflex 1st Ray, Proximal = Varus Tibia

Compensated

Calcaneus Vertical & Navicular Collapse = Pronated

Gait Assessment

Abnormal compensatory pronation (amount & speed) will occur at heel strike and continue until heel rise.  After the heel is off the ground the foot is able to supinate in time for a fairly normal propulsion.  These patients differ from forefoot varus in that the calcaneus does not go into excessive valgus (eversion).http://www.youtube.com/watch?v=5GYI8zA-Rz8

Forefoot Varus

This is the most destructive foot abnormality to the lower extremity.  Because of this, it is the most clinically common pathomechanical abnormality.Forefoot varus is when the forefoot is inverted (big toe higher than 5th toe) while the subtalor joint and calcaneus are in neutral.  This foot abnormality almost always causes over pronation.  Joint play is often excessive.Compensations include calcaneal eversion and navicular collapse to allow forefoot to contact the surface.

Posture Assessment

Uncompensated (very uncommon)

Calcaneus Vertical & Navicular Raised = Supination (lateral foot weight shift, 1st ray off ground)

Compensated

Calcaneal Valgus (everted) & Navicular Collapse & Forefoot Abduction= Pronated

Gait Assessment

To allow for the inverted forefoot to contact the ground there is excessive compensatory pronation (amount & timing) beginning at the foot flat phase of the gait cycle.  This continues for the rest of the stance phase, causing the patient to push-off with an unlocked pronated foot.  This is a major clinical problem since push-off requires a rigid supinated foot to use as a lever for propulsion.  These patients differ from calcaneus varus because they are not able to achieve any supination prior to push-off.http://www.youtube.com/watch?v=yua1W4GTjAk

Forefoot Valgus

This foot abnormality often presents in patients with rigid and supinated feet (unlike forefoot varus).  Since they are already in a supinated posture they are at higher risk for inversion ankle sprains.Forefoot valgus is when the forefoot is everted while the calcaneus and subtalor joint are in neutral.  The medial metatarsals lie below the calcaneus (plantar flexed in relation to the calcaneus).  There are two different types: total valgus (all the toes slope down) or 1st ray plantarflexion.  This foot type often presents with restricted joint play (midfoot, 1st ray, calcaneus).Since the metatarsals lie below the calcaneus it is nearly impossible not to compensate.  The patient must supinate to accomodate this abnormality.  This may lead to a calcaneal varus compensation.

Postural Assessment

Uncompensated

Very uncommon - would cause a significant amount of increased pressure on the first ray

Compensated

Calcaneal Varus (inverted) & Naviclar Raised = Supinated

Gait Assessment

Excessive compensatory supination occurs (amount & timing) after heel strike due to premature loading of the forefoot.  Pronation is insufficient,  but may occur at the end of stance phase to allow for knee flexion.  This foot abnormality has trouble attenuating loading forces, thus proximal joints are forced to accomodate.http://www.youtube.com/watch?v=Q0zLo420j2A

Bottom Line

It is important to note that these abnormalities and pathomechanics are not black and white.  They exist on a continuum and are often times combined.  Being able to further assess your pronators and supinators into a specific pathomechanical foot type will improve your plan of care and allow you to provide your patients with specific interventions to fix the culprit of the problem.Supinators (Pes Cavus)

Uncompensated Calcaneal Varus & Compensated Forefoot Valgus

Pronators (Pes Planus)

Compensated Calcaneal Varus & Compensated Forefoot Varus

While this post focused specifically at the local foot and ankle joint, it's important to consider regional interdependence.  Remember that the height and rigidity of the arch can be affected by tibial internal and external rotation (in closed chain).  And this tibial motion is further influenced by it's proximal structures.

Dig Deeper

Running Injuries - Foot TypesPhases of GaitSomastruct - Forefoot Varus - Overpronation - Intrinsic Foot Strengthening - Arch StrengtheningPhysioblogger - Plantarflexed 1st Ray

References

Tiberio D. Pathomechanics of Structural Foot Deformities.  PHYS THER. 1988; 68:1840-1849. (A Must Read)Donatelli R.  Abnormal Biomechanics of the Foot and Ankle. J Orthop Sports Phys Ther 1987;9(1):11-16.Brown LP, Yavorsky P.  Locomotor biomechanics and pathomechanics: a review.  JOSPT 1987;9(1):3-10 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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