The way this is laid out is that you start with your MED, progress to MAV, then MRV to overreach. However, notice that you don’t dance with MRV often, nor do you want to.

Overtime, your MRV will increase, meaning you’ll get stronger and develop more work capacity, as long as you intelligently handle your training volume.

A good rule of thumb is The 10% Rule - While there can be some variability here, staying within a 10% increase from the previous week tends to work well for a lot of people. It pushes that threshold in a progressive manner and allows appropriate recovery from the increased demand on the body.

Next week, in Part 2, we’ll take a deeper dive into load management and training volume, explore exactly what this concept means, and how to practically apply it to yourself or athletes you work with.

​
Cheers,

Dr. Ravi Patel, PT, DPT, CSCS

It’s baaaaack. The largest fitness competition on Earth, the CrossFit Open,  is finally here. Maybe you’ve trained all year for this, maybe you’re still new to CrossFit and are curious about all the excitement. Maybe you’re a seasoned vet, maybe this is your first Open you’ve ever participated in. Regardless of your CrossFit background, your fitness will be tested, your mental toughness will be challenged, and you will certainly have a blast working through these workouts with your crew at your local CrossFit affiliate.

That being said though, this is typically a time where we start seeing an uptick in the people we see coming in for CrossFit related injuries. Having an athletic background, where I had to personally sit out multiple seasons due to injuries, I speak from experience when I tell you there is nothing worse than working all year towards a goal/competition/test and not being able to perform at an optimal level, if at all, because of an injury. And, look, I get it. There is inherently an increased risk of injury when you're pushing yourself in a competitive environment. However, there are some very important things you can do to minimize this risk and allow you to perform your best. Let’s take a look at the three easy things you can do:​

#1 Don’t Be Reckless

This is huge and something I see year after year. If you’re a CrossFit coach, or even just an observant CrossFit athlete, I’m sure you’ve seen what I’m about to explain...You’ve worked all year to create movement patterns that are both safe and effective. You know the importance of good, quality movement. However, throw in the element of an international competition and it seems like all these lessons about technique go out the window.
​
For example, last year’s first Open workout (18.1) consisted of three movements:  toe-to-bar, dumbbell clean and jerks and rowing. Can you guess what type of injury we saw coming into our clinic after this workout? If you said back pain, you’re correct. But why? Well, with this workout people were trying to perform as many rounds as possible for 20 minutes. To get better scores people weren’t maintaining core control for a solid hollow position with their toes-to-bar, they stopped getting full hip and knee extension for optimal power production during the drive portion of the clean and jerks, and/or they started to over-extend during the rowing component.  All of these create situations that are destined to increase stress on your low back. Keep in mind that this was just the first workout! Now you’re either completely unable to participate in the other workouts or will not be performing at an optimal level because you’re trying to grind through an injury.​

#2: Protect Your Sleep

There are four main pillars of health care that we look at with every patient who walks in the door at Athletes’ Potential: Movement, Stress, Sleep, and Nutrition. Sleep is easily on of the biggest problems that we see out of these pillars. And check this out, Sleep affects everything you do and everything you do is positively affected by quality sleep. Good, quality sleep literally improves everything: every marker on a blood panel, weight management, sport performance and recovery, productivity, and numerous types of disease management. The list goes on and on, yet the percentage of sleep deprived Americans, particularly in Urban areas, continues to rise at an alarming rate. In fact, the U.S Centers for Disease Control and Prevention reports that more than 30% of Americans are sleep deprived getting fewer than 6 hours of sleep per night.

If you’re not getting enough sleep, you’re not giving your body a chance to recover. If you’re not recovering appropriately then you're leaving yourself at risk for injury and decreased performance. So bottom line, create an optimal sleeping environment, protect your night time routine, and get some good quality sleep sleep.

For more info on how to optimize your sleep. Check out this article we wrote.

#3: Maintain Perspective

This comes full circle with tip #1. For those of you trying to make it on to regionals, those extra few reps I mentioned could be the difference in making the cut vs staying home. However, for the vast majority of athletes competing in the CrossFit Open this is not reality. You all have careers, kids you need to take care of, and numerous other responsibilities that you need to keep rocking with once you leave the gym. Is bouncing off the top of your head to get an extra rep or two really going to mean that much if by doing so now you can’t look over your shoulder while driving? (yes this is a real scenario that we’ve worked on at our clinic...I’m looking at your 17.4). Or is that 2 position jump on the leaderboard really all the important if now you can’t bend over to pick up your kids? ​

Crossfit is meant to be a competitive, fun and challenging way to make all aspects of life outside the gym a little easier. This time of year is huge for all CrossFit athletes and it is truly impressive to see the physical accomplishments and PR’s that happen every single year in the Open. However, the Open isn’t an excuse to throw all safety out the window but it isn’t something you should be afraid of either. Following these three easy tips will ensure that you have a great time, reduce your risk of injury, and maybe even hit a PR or two.

Thanks for reading.


Dr Jake, DPT, CSCS, CF-L1

Ask questions​

Many postpartum women do not know all of the details after birthing their baby.  Some have told me they were not aware they had stitches down below until the 6-week check-up when the doctor wanted to make sure they were healing well!  The check-up at 6 weeks can be quick so arrive with questions. It is helpful to know about any tearing, episiotomies, tools used during the birth, etc.  These factors are all great to bear in mind as you return to exercise and daily functioning.

Another question to ask-- “Is there a pelvic health PT that you would recommend?”  They may know someone in the area or have worked with them prior.  However, do not become discouraged if they don’t have a name to offer.  A Google search for “women’s health PT” or “pelvic PT” should show professionals in the area.  Compare websites and reviews to see if the PT would be a good fit for you and your goals!​


​Pelvic Health Physical Therapy

Once you have been cleared by the doctor for “usual exercise” and intercourse, I highly suggest visiting a pelvic health or women’s health PT.  They will be able to further answer any questions about symptoms you may experience immediately postpartum and later.

A pelvic PT is specialized on evaluation and treatment of the pelvic floor musculature.  They can perform internal evaluations to test the strength and endurance of your pelvic floor, check for prolapse, address any soft tissue issues, etc.

For the evaluation, the therapist will use a gloved finger to palpate muscles internally. While a great deal of information can be gathered from an internal evaluation, it is not necessary for visiting a pelvic PT.   The therapist can then prescribe exercises to help relieve the symptoms and provide hands-on work to hips, back, sacrum and other involved areas. Your PT should be a huge help in getting you back to fitness postpartum!  Other areas they can treat and improve are bowel/bladder issues, painful sex, and pelvic pain.


Focus on healing and strength rather than weight loss

Social media and advertising may be all about “getting your body back” and fixing “mummy tummy,” but that is not the focus when you are postpartum.  The first step in returning to fitness is addressing foundational strength and continuing to heal from the pregnancy and birth.  Your body will go through so many changes in the months following your pregnancy and the timeline is different for every single woman.

Steer clear of programs that say at week 8 you do blank. It should all be self-paced and based on symptoms, your birth story, and prior activity level.  Do you need help starting out?  This was the number one question I received from women in the clinic.  “What can I do?  Where do I start?” So I developed programming to recover and rebuild your core after having a baby. Check out the THRIVE: Rebuild Bundle programming HERE.

​
​This drill is an all time favorite of mine for a couple of reasons. First, it allows you to feel how your lats should be contracting while you are going a pull up. Second, it allows you to strengthen your shoulders in a vulnerable/weak position. You’re only as strong as your weakest link and being strong in a weak position is a great way to prevent injuries.


Drill #2: Lat Pull Over

​Breaking up a bilateral movement (using both arms)  into a unilateral movement (using one arm) is a highly underutilized training modality that allows to balance out weaknesses. Plus, as an added bonus, you’re able to perform a vertical pulling drill at a slightly different angle which, as we talked about above, is how you train for healthy shoulders.


If you have shoulder pain while doing pull-ups, or want to prevent pain from coming, this two-part post is a great place to start. Ensuring appropriate mobility and then building appropriate strength is a common occurrence in the rehab world.

If you’re in the Atlanta area and are interested in working with a unique professional that can help you optimize your health in all of these areas, we need to talk. Being proactive and staying on top of your health will help you avoid serious health problems down the road.

Submit a contact request by clicking the button below and we’ll get you set up with one of our Doctors for a free 15-minute phone consult.​

​Thanks for reading,

Dr. Jacob, DPT

                                                                       [Credit: Barbell Physio]

But, what if you’re an Olympic weightlifter who has a competition coming up? What if you’re a runner who loves a good 5k? What if you have a stressful job and CrossFit is your outlet to relieve that stress?

Come on, healthcare - we can do better.

If these are your goals, we want to help you get there.

Here’s 5 different ways to train around pain and decrease stress on that painful area:

1. Weight
2. Range
3. Tempo
4. Variation
5. Different Exercise

MAIN GOAL: MAKE THE LEAST CHANGES POSSIBLE TO THE MOVEMENT

Now, let’s break down each one of these using knee pain with front squats as an example.

1. Weight

• This could be as simple as decreasing the weight.
• Example: Your knee pain starts when you hit 185 in your front squat, but not at 155. Dial it back, work at 155 and build back up over time.

 

1. Range
   • Change or decrease the range of motion. We use partial range of motion all the time in rehab as way to regress a movement.
   • Example: Your knee pain occurs at the bottom position of your front squat. Limit your depth to ¾ of the range, squat to a box or med ball.

                                                                   [Credit: EricCressey.com]

1. Tempo

• This is an incredibly underutilized variable in training. You can’t load much weight, but can still do the movement. Tempos allow you to create time under tension and strength through different ranges of the movement - whether that’s lowering, pausing, and/or raising during the movement. We call these the eccentric, isometric, and concentric phases of a muscle contraction, respectively.
• Example: Knee pain only occurs at 90 degrees. You can try utilizing isometric holds in that position for 30-45 seconds or doing a 3-2-3 count where you do a 3 second eccentric, 2 second isometric hold, and 3 second concentric movement. The options here are endless.

 

1. Variation
   • Use a different variation of the movement – you’re still training the same movement pattern (squat), but changing up where the load and stress is placed.
   • Example: Front squats bring on your knee pain, then try a back squat, box squat, goblet squat, zercher squat, or a spanish squat.

                                                                   [Credit: Barbell Rehab]

1. Different Exercise
   • Try a completely different exercise to help get the same training stimulus for that muscle.
   • Example: Instead of a squat variation to train your quadriceps (front thigh muscle), you do seated knee extensions, lunges or step ups.

Here are a few other examples for you: 

• Back pain with conventional deadlift:
  • Weight: decrease
  • Range: elevate on blocks
  • Tempo: pause
  • Variation: sumo
  • Different Exercise: glute bridges

• Foot pain with running:
  • Weight: decrease speed/intensity
  • Range: decrease running distance
  • Tempo: walk/run, interval
  • Variation: sprints, uphill running, downhill running
  • Different Exercise: cycling

• Shoulder pain with bench press:
  • Weight: decrease
  • Range: floor press
  • Tempo: 3 second eccentric
  • Variation: single arm dumbbell press
  • Different Exercise: Pushup

Here’s the overall concept:

Pain comes on --> scale back movement slightly --> train movement --> adapt --> progress difficulty --> adapt --> back to prior level --> continue training pain-free --> hit PR

                                                                          [Credit: kcbi.org]

I believe that any great coach or physical therapist should be able to modify and progress/regress any movement or activity.​

If you have given these methods a shot and pain continues to impact your life, then find a healthcare professional who understands your goals and doesn’t tell you to stop.

Cheers,

Dr. Ravi, DPT

                                                                  Nice front rack Mr. Farris!

Well maybe those aren’t his exact words but since I’m actively giving up using profanity (which is very hard to do) we’ll keep this quote the way it is. We know that Jay-Z doesn’t have wrist pain but in the last CrossFit Movement and Mobility Trainer Course I taught, about half of the class had wrist issues. Usually when I informally poll the class to see what problems most people are having,back pain comes up number one. This weekend wasn’t any different until the Sunday course. Wrist issues were a plague for this group, predominately in the front rack position. So we spent a ton of time working on the wrists right? Wrong, we fixed their shoulders!

How many of you have seen big strong guys/gals that can back squat a ton of weight but when you get them to front squat their weight drastically decreases? These are typically males that used to love bro'ing out at some globe gym where everyday is bench press day. They are pretty strong but have never put in some legitimate mobility work in their lives.

                                                                   Don't be this freaking guy!

Let’s be clear on one thing. There are many reasons for why someone could have a very weak front squat compared to their back squat. In this example however, we are going to focus on improving the front rack position and unloading the wrist. The higher you can keep your elbows during the entire range of motion of a front squat, the easier that movement will be. High elbows also allow for the wrist to be unloaded during the lift. 

How do we get those nice high elbows? By having enough shoulder flexion and lateral rotation. In coaching terms this allows us to keep our arms parallel with the ground and maintain a strong front rack position. There are multiple problems that occur when the elbows start to drop in the front rack. It’s a huge loss of force production potential but also puts the poor wrists in a terrible position. 

         A combination of these two movements at the shoulder makes up the front rack position.

​Here’s a quick test. Un-rack a decent amount of weight (75-90% of your 1RM front squat) and hold it in your front rack position like the example in the top section of the picture below. See how your wrists feel and see if you can hold it for 30-45 seconds. Now do the same test but hold the weight in the position like the athlete in the bottom of the picture below.  No wrist wraps allowed!

                                         Thanks to www.twinfreakscrossfit.com for the photo.

Which one were you able to hold longer? Which one felt more comfortable?

For the majority of athletes the first position will feel dramatically easier when holding the load. If you have terrible front rack mobility you will always end up in some variation of the dreaded lowered elbow position. This is wrecking havoc on your wrists and costing you PRs. If your wrists hurt, fix your shoulders!

Now how do we fix the shoulders? Here is an old school (2011) Mwod video of Kelly going over fixing the front rack position. If you haven’t checked out Mwod recently, you really need to. Mwod Pro is only $8 a month and has new mobility techniques to help improve your performance and resolve pain everyday. That’s about the cost of two lattes! In the words of Kelly himself “make a better decision”.

​During internal rotation, the ball of the joint (humeral head and femoral head) will glide posteriorly and roll anteriorly. This movement can be restricted with a tight posterior capsule or muscles around the joint.  Unfortunately, many people will have issues here due to increasingly sedentary lifestyles and desk jobs.  As you sit all day, the hip rarely reaches full extension, allowing the posterior capsule to become tight.  This in turn decreases the posterior glide and thus decreased internal rotation.  The same deal happens at the shoulder when you sit all day at the computer with terrible posture.

Interestingly, hip internal rotation deficits have been correlated with low back and sacroiliac pain.  It is better to start improving internal rotation now rather than trying to manage back pain!

How to check internal rotation

It is easiest to accurately check internal rotation of the shoulder with a buddy.  Lay on your back, arm straight out to the side and elbow bent (as in the picture below).  Your buddy should provide solid but comfortable pressure to the front of your shoulder to avoid it from raising off of the ground. Now move your palm down towards the ground.  Ideally, you would be able to get at least a fists-width from the floor! Be sure to check both sides because noting an asymmetry is important.  Also, be sure to do this same test after practicing the mobilizations below! ​

​
​To check hip IR, lay on your stomach and allow your feet to drop out to the side.  Again, we are looking for asymmetries and major deficits.  Ideally, your leg will move about 40 degrees or roughly halfway down toward the floor.

​Mobilizations to Improve Internal Rotation
​
Below are a few mobilizations for the shoulder and hip to improve internal rotation.  They are by no means an exhaustive list but merely a starting point.

Bully stretch- used to mobilize the humerus into the back of the shoulder capsule, which increases internal rotation. ​

​
​Internal Rotation Stretch- start with your foot flat on the ground and the other leg crossed over.  Slowly walk your foot out to the side until you feel a strong but comfortable stretch in the hip.  You should feel this in the bottom leg.

Simply put, no. Squatting, specifically deep squatting, is actually beneficial for your muscles and tendons.  If you simply wanted to know the answer to the question, that is the abridged version. But those “why” people (it’s ok, I am one too!) should continue reading.
Research tells us:

• The compressive forces at the knee are greatest at 90 degrees (at parallel).  So the fans of squatting TO parallel rather than past parallel are still hitting the most stressful range. 
• The body responds to the imposed stresses from deep squatting (with appropriate progression and form) by increasing the thickness of the tendons, ligaments and cartilage of the knee. 
• The greatest glute activation is in the deepest part of the squat.

​The Knee, the Middle Child

In my experience, the knee joint seems to be the most baffling to folks.  So much emphasis is put on knee position during workouts that other (more important, in my opinion) joints are virtually ignored. It may be more beneficial to understand this joint if you view it as the middle child. 
The ankle is like the oldest child.  It sets the scene for how the other joints are allowed to act.  If the older child is rebellious and does not behave as expected, the middle and youngest child will imitate the older sibling. Without the proper ankle mobility and foot strength, who cares what your knee and hip joints can do?  The foundation for these multijoint movements is already the weakest link.

The hip joint is the youngest child.  By this point, the parents are exhausted from the rebellious older child who influenced the middle child into its rebellious ways.  The youngest child can get away with anything.  Our hip joint is a large, strong joint complex that should be the prime mover during squats.  Unfortunately we get so focused on the knees and ankles that we overlook the hips and allow them to “run free”.  This presents in the form of decreased pelvic control during large movements like the squat.

Finally, the knee joint is the middle child of the family. It gets pushed and pulled by its siblings but never has a moment when it’s all about the knees.  During foundational weightlifting movements, the knees never work alone.  They are guided by their neighbors.
So what does this mean?  The ankles are the steering wheel.  If you do not have sufficient mobility in your ankle joint, your knees are predisposed to faulty movement patterns.  But it’s not your knees fault!!  ​

I don’t know what to do with my knees!

“Knees out!” is one of the most over-coached cues.  Sure, it is a quick and easy fix in the middle of the workout but it is important that athletes understand what this means. If your knees are crashing in during a workout, the weakness is at your hip.  A weak gluteus medius is often the culprit but it has an accomplice!  If your hammies and glutes are weak and you attempt a heavy squat, your adductors are going to kick in to assist with hip extension.  But the primary motion of these muscles is hip adduction, or knees together. Thus, crashing ensues. So strengthen your hip muscles and your knee position will improve. ​

Midline stabilization is heralded as the foundation of safe and successful weightlifting.  But have we been ignoring a part of the “core”?  The pelvic floor is a topic that tends to be avoided.  Most people do not casually discuss urinary frequency over coffee or admit to their coach that they pee every time they perform double-unders.  Men- if you think this one is just for the women, stick around! 
​
I only realized the prevalence of leakage after CrossFit HQ posted a video following regionals.  All of these women were saying “It’s ok, I pee during workouts too.  It’s normal!” Please do not confuse normal and common.  Urinary incontinence may be common in certain populations, especially of heavy lifters, but it is absolutely not normal. 

The pelvic floor includes a group of muscles that attach from your coccyx (tail bone) and sacrum to your pelvic ring. 
​

​When you take a breath in, the diaphragm descends.  This requires the pelvic floor muscles to descend and lengthen. When you exhale the diaphragm rises and the pelvic floor rises and tightens. 

In fit individuals, (notice I said individuals and not just women), a common pelvic floor problem is overactive muscles. Very strong back or abdominal muscles can cause increased inward pressure.  It’s been shown that when your deep abdominals contract, so does your pelvic floor. 

Imagine squeezing the can from both sides with the pressure maintained. The bottom and top will have to withstand more pressure and bulge. If your abdominals are always squeezing in then your pelvic floor is always pushing up to withstand the pressure.  It’s overworked!  The diaphragm is pretty darn good at its job.  If it does not work, we have a bigger issue on our hands. 

So often, when something’s ‘gotta give’- it’s the pelvic floor.  When all of these muscles work in concert, your canister and the force it can produce is maximized. Thus, your workout improves.

A conversation about breathing techniques regarding the glottis and diaphragm is essential to training the entire core. Here I am simply touching on one contribution but remember it does not work alone. 
Keep in mind, PFD can also manifest in ways such as pelvic pain, painful intercourse, low back pain, urinary frequency or even the dreaded butt wink. It is not just urinary incontinence. 

 “ Pelvic floor pain is only caused by pregnancy, right?” 

Wrong.  There has been no correlation shown between PFD and post-partum women.  Sure, some moms experience issues but again, it is not normal for any population.  Weakness and/or tightness of the pelvic floor can be caused by poor postural habits, extended periods of sitting, over training of the abdominals and pregnancy.  Excluding pregnancy of course, men are susceptible to all of the other risk factors.  
​
“Ok, so I pee on myself at the gym and it’s not normal.  What do I do to stop it?” 

• Minimize extended periods of sitting.  Standing is definitely superior to sitting but if you can, squat.  Hanging out in the bottom of your squat while you type an email can effectively lengthen the pelvic floor muscles. 
• Check your posture. Slumped sitting will lead to a laundry list of issues from head to toe, inside and out.  But specifically, avoid slumped or “sacral sitting” with your pelvis tucked under and your lumbar curve reversed. This causes the pelvic floor muscles to maintain an abnormal length for extended periods.  
• Train naked.  Ok, not no-clothes naked but no-gear naked.  Take off the wrist wraps, knee sleeves, weight belt, K-tape, etc.  Make training about you and your barbell.  Minimizing the amount of external support will expose your weak areas and teach your body to naturally stabilize. So you can’t PR your clean without your gear?  Keep training at that safe, lower weight where your body can appropriately respond and adapt. You’ll thank me later. 
• If you have continual issues or have specific questions, contact your local pelvic floor physical therapist.  They can help identify dysfunction and provide specific, individualized treatments. 

                                          
    Thanks for reading!
-Dr. Jackie, DPT



​
References:
Sapsford, Ruth R, Hodges, Paul W. Contraction of the Pelvic Floor Muscles during Abdominal Maneuvers. Physical Medicine and Rehabilitation, 2001, Vol.82(8), pp.1081-1088. 
Healthyplace.com 
​Presentation at CSM 2016 by Mary Massery: referencing Massery 2005 & 2006. 

So you’ve been killing it at the gym over the past month. Your body is starting to adapt and your conditioning is improving. You can do twice the amount of rounds of Cindy that you could do when you first started CrossFit. All in all, you’re the man now!

Until, one day you try and do some ring dips. Next thing you know, you wake up the next morning and the front of your shoulder hurts. This is the first minor set back you’ve had since starting CrossFit so you ignore it and continue to do the gym programmed workout for the next week. Your shoulder pain starts to get worse. You finally say something to your coach and they recommend some mobility techniques they saw Kelly Starrett talk about on Youtube. Another week goes by and the shoulder pain continues to get worse. You’re frustrated and finally your coach recommends that you come to see someone like me and get it checked out.

By this point you’ve been inflaming your bicep tendon for a couple weeks. In all likeliness, there’s nothing wrong with your bicep tendon and it’s simply getting caught in the crossfire (now the video at the top of this blog should make sense) of scapular stability weakness and tightness in the front of your shoulder.

You’re not the only one. In fact, recently injury rates in CrossFit were studied (see reference below). The results showed that the most common injury was the shoulder; approximately 25% of all reported injuries were related to the shoulder. In my own practice I have found this to be the case as well, if not even a higher percentage. Just this week I have seen 8 new patients and 5 of them came to me for shoulder pain. 

Keeping shoulders healthy while training in CrossFit can be challenging for a couple reasons:

• First, CrossFit is an overhead sport. A significant amount of movements in CrossFit involve pressing overhead or pulling from an arms overhead position.
• Second, the shoulder is complex. You have to take into account deficiencies at the neck, thoracic spine, glenohumeral joint, breathing, scapular control/mobility, rotator strength/endurance, motor control of the techniques(i.e are you just doing a pull up wrong) and postural positioning.
• Third, many of us have no background in gymnastics or olympic weightlifting. Both of these sports are heavily dominant on the shoulders. Sorry but your 15 years of baseball will not help you in CrossFit.

So what’s the solution? The best answer would be to get yourself checked out before starting some significant training to see if you have any obvious deficiencies. That’s like telling people to go to the dentist so they don’t get a cavity. I understand that many people don’t see the value in prevention so I won’t try and persuade you on that.

The next best option is to try and go after the low hanging fruit first. In my practice I’ve found that common deficiencies can be cleaned up with as few as 5 exercises. Below are videos of exercises you can do on your own to resolve and/or stop an injury from happening. Make these part of your gym routine and your shoulders will thank you.

What’s the best way to fix a shoulder injury? Not getting a shoulder injury to begin with! ​

If you’re in the Atlanta area and have been dealing with a CrossFit related shoulder injury for a while give us a call. We can help you get back to what you love to do faster than any medical group in the area. Don’t take our word for it, check out what everyone else has to say in their testimonials.