Often times, external rotation is the focus in athletic movements. When the shoulder is externally rotated, it can be packed into the back of the capsule to improve stability and congruence. It also rotates the humerus in a way that the anterior structures of the shoulder have room to move without being pinned between bones. Many of the stretches people gravitate towards for the hip involve external rotation: sitting figure 4 stretch, pigeon, etc.
What is internal rotation and why do I need it?
Internal rotation is one of the movements of a ball and socket joint, such as the shoulder and hip. In the shoulder, it allows you to reach behind your back and pull your wallet from your back pocket or tie your bikini behind your back. More importantly for athletes, it allows you to keep the bar close to the body during Olympic movements and arrive at the bottom of a ring dip safely. Hip internal rotation is needed for athletes for proper biomechanics during any form of a squat or while running. Without full internal rotation, you will likely have a “butt wink” or your low back will slightly round at the bottom of the squat. It is also important for runners to have full internal rotation, coupled with extension, to allow correct biomechanics in the trail leg.
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.
Pec smash- nearly everyone has a tight pec minor due to the poor postures we often keep throughout the day. This muscle is located in the front of the shoulder, so if it’s tight it can easily restrict the posterior glide!
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.
Lateral Hip Opener- this does not have to be banded if you do not have access to one, you will still feel a stretch!
I hope this gives you a better understanding of what internal rotation means, how we achieve it and why it is needed. More importantly, I hope these videos give you a good idea of how to begin to manage internal rotation deficits!
At Athletes’ Potential we want to help every athlete remain healthy and meet goals. You don’t have to be in pain to come see us. If you find asymmetries with tests such as these or know you have movement deficits, we can help you with proper movement and self-maintenance. We also have recovery options to further augment your fitness and health. We look forward to hearing from you!
Thanks for reading,
Dr. Jackie, PT, DPT
If you're in Atlanta and you have questions about our Physical Therapy or if you're frustrated with your current situation, contact us and let us help you!
The human body is an impressive and complex system. We are resilient, quick learners and infinitely adaptable. We also have had technological changes occur very quickly that have changed the day to day of many of us. This day to day currently involves large amounts of sitting and very little non-exercise based movement.
In our attempts to restore our movement patterns one of the first areas that is addressed is mobility. If you have issues squatting, we mobilize your ankles and your hips. If you can’t press overhead, we mobilize your shoulders and your upper back. But, what if that problem isn’t a mobility problem?
Here’s an example of a change we were able to get with one of our athletes in about 20 minutes with no mobility work at all!
I have had this scenario come into my clinic frequently: A 30-40 year old ex-athlete that is still very active doing CrossFit or training for a triathlon/marathon. They sit all day and have had a sedentary job for a very long time. They get into loaded squats because they have read in multiple publications that say squats are a great way to build strength (which is true). Their knees and lower back now both hurt them when they do loaded squats. They stumbled onto a video of Kelly Starrett talking about mobility for the hips to improve the squat. They start mobilizing their hip with a big green jump stretch band and do so daily for a few months. Very little change occurs and they get frustrated.
This person eventually ends up in my office seeking out a better mobility plan. What mobility techniques should they do and how much MORE per day do they need to do? What other ways can they smash their tissues into submission so they can finally have a normal squat again?
One of the first things I want to delve into when I see a case like this is what type of movement work have you been doing? Is there any prioritization of moving into the new range they are working on after mobilizing? Do they have any huge roadblocks that we need to address, i.e. surgery from 10 years ago to the knee that was never fully rehabbed.
Once those questions are answered, I want to assess their squat in an unloaded position. I will look at a few areas: The ability to get the hip into flexion; the knee into flexion (this is rarely an issue); and the ankle into enough dorsiflexion that we can achieve a parallel depth squat.
For hip flexion, you can use the supine test in the picture below. Leave one leg out straight and pull the other leg up to your chest. You can even use your hands to pull the knee to towards the chest. Once you feel like your butt is coming off the table, that's all the room you have in that hip. We’d like to see 125 degrees in this direction. In order to achieve a parallel squat, you really only need about 90-100 degrees.
Picture courtesy of MHHE
For the ankle, I’ll have my patient do a quick wall test. They can either do this standing or kneeling. With your foot in contact with the ground, drive your knee forward toward the wall. You want your knee to be able to touch the wall with the front of your foot 3-5 inches away. The farther away you get, the more mobility you have in the ankle.
Often, both of these correlation tests are passed showing enough movement availability to be able to perform the squat correctly. We’ll do one last test with them to see what the squat would look like unloaded in a hands and knees position.
In the picture below, the athlete is assuming what is called the quadruped rocking position. If you were to rotate the picture, this athlete would look like he was in a variation of a squat. This is an unloaded way to assess someone's ability to get their hip to parallel, or past, and see if they are able to maintain spinal neutral. His toes are up to mimic ankle dorsiflexion in the squat as well. Once I assess this and an athlete shows the capacity to get as far back in a quadruped position as the picture shows (hip crease farther back than the knee), we can move on to fixing this.
Picture courtesy of Foundry Sports Medicine
Here’s a list of all the information we’ve gathered so far:
-They have sufficient hip flexion to achieve a squat.
-They have sufficient ankle dorsiflexion to achieve a squat.
-They have the capacity unloaded to maintain a neutral spine in a squat form (in quadruped).
At this point I can be pretty confident that this is not a problem that is going to be solved with crushing a lacrosse ball into their hip or band distracting their ankles. This is a control problem and it requires a completely different approach to restore the pattern.
This is where motor control work comes into the equation. Motor control simply put is technique. Here’s a more specific definition of motor control as well.
Motor control is the process by which we use our nervous system (brain, spinal cord, nerves) to activate and control the muscles/limbs involved in the performance of a skill.
So how do we get better at motor control? The answer is practice, in particular, blocked practice when we are trying to master a skill.
If you’ve played a sport, you’ve done blocked practice. Blocked practice is fundamental work. If you were a basketball player, you could improve your skills by just playing a bunch of pick up games. If you wanted to be a really good basketball player, you wouldn’t just do that. You would spend time working on dribbling with your non-dominant hand. You’d practice shooting free throws for hours. You’d practice the subtle nuances of a bounce pass vs a chest pass vs a lob pass. These are individual components of the overall game and you practice them individually so you can master the fundamentals. This is the most effective way for beginners to learn a new skill, but it’s also very effective for advanced athletes to maintain their mastery of the skill.
For the purposes of this article we will assume we are all beginners because the reality is many of us NEED to relearn this skill. Sadly, we were all probably much more efficient squatters when we were 5 years old and now we need to relearn that skill.
We’re going to start with breathing because it’s one of the most underrated portions of the squat and it has a dramatic effect on hip/spine positioning.
To start with, we will have athletes assume what is called the 90/90 position. This is essentially an unloaded squat pattern. We want our athletes to adopt a position similar to what they are trying to improve. We’ll try and get 10 reps through on this exercise prior to any other squat practice. It’s a great way to feel what we want our rib cage to feel like when we are squatting. It’s an easy way to also get a little prep work in for the diaphragm which is also a major stabilizer of the spine. Watch the video below for a more detailed explanation of this drill.
Step two is we want our athletes to understand how we want them to organize their spine during the actual squat movement. Here’s the general explanation I use:
First, I like to cue thinking about creating a steel tank and then pressurizing it with air. Think of a propane tank as an example. Our torso should be the steel tank and the air you breath in should pressurize it.
Here are the steps:
-Squeeze your butt.
-Screw your feet into the ground.
-Take a big breath in and blow all the air out until you feel like your ribs are pulled down flat with your abdominal muscles.
-Maintain tension and breath into it.
The amount of tension you need is dictated by the task. For example, if you’re squatting something really heavy, you want to have a lot of tension. If you’re doing a bodyweight squat, you do not want or need a ton of tension. You want just enough to be able to complete the movement safely and effectively.
Now that we have breathing down and we have an understanding of how to brace our spine, it’s time to move. We’ll start with something unloaded and then move to a somewhat loaded exercise. Also, just to be clear, this is not your workout, this is practice. Treat this as practice, take it seriously and your squat will improve dramatically.
The wall squat, “squat therapy”: For this drill I’ve picked a video that Rich Froning himself put together. I think this video does a good job of demonstrating a commonly used squat drill. As an added bonus, Rich is not wearing a shirt - you’re welcome!
One subtle change I like to make to this drill, is to have my athletes pause half way down. They will pause, take a big breath in, both the air out and then breath back into the tension they create. This is essentially making them go through the torso bracing sequence twice during the squat. If you feel your spine shift significantly when you do this, chances are you are over extending your lower back. We want your spine in neutral, not in a extremely arched lower back position. Your lower back should not look like a banana!
Also, make sure to pause in the bottom and control that position. Imagine you are hovering over the grossest toilet in the world! This should be a very active position in the bottom of the squat.
Start by performing 10 of these squats a comfortable distance away from the wall. It should take you 3-5 seconds to descend, pause for 3-5 seconds and stand up in 1-2 seconds. Next, move a little closer to the wall so it’s moderately challenging for you to hold the position. Perform 10 more repetitions with the same tempo as the first 10. Lastly, move a little closer to the wall so it’s difficult for you to maintain the squat position. Again, use the same tempo. Don’t rush this, the struggle is where progress is made!
For the next drill we’ll throw in some real nervous system trickery! We’re going to use a band to help create something called Reactive Neuromuscular Stabilization. It’s a big term for exaggerating the problem.
Ever wonder why your coach or PT has you squat with a band around your knees? Well, it’s because if we force you into a bad position, the body naturally tried to correct it by firing in the opposite direction. So if we pull your knees in with a band, your body with activate the hips to engage the knee outward into the pressure.
We’ll do the same thing with your torso to help correct excessive forward leaning. In the video below, I explain how I use this with my patients. I show this with one arm at a time but you could absolutely do it with both arms at the same time.
Keep the same tempo as the squats above for this one. That would be 3-5 second decent, pause 3-5 seconds, and then stand up in 1-2 seconds.
It is also very important that you maintain control of your torso/spine while you do this. We are not trying to reinforce a bad pattern of firing too much into spinal extension. Video yourself from the side just to make sure you don’t instantly start the movement by overextending your lower back.
Perform 2 rounds of 5 reps on each side.
Lastly, let’s get some weight in your hands. We’ll use a dumbbell or kettlebell as we do a squat variation called a goblet squat.
The goblet squat is one of my favorite squat training drills. I’ve heard some coaches say they hate the goblet squat and that’s mainly because you are semi-limited on how much weight you can load with. For the purpose of building pure strength, there are definitely better squat options. For learning/improving the loaded squat pattern, I think the goblet squat is the best squat variation.
A few things happen with the goblet squat that are interesting. First, we add weight to the body in front of the torso. This creates a really unique counterbalance that allows us to be more upright and sit down a little bit deeper into the squat. It also creates some inherent need for “anterior stability” or tightness in the abdominal region. Loss of control in the abdomen is one of the biggest faults I see in loaded squatting. It creates countless issues in the hips/back/knees and can be retrained well with the goblet squat.
Pick a semi-light weight but something heavy enough to counterbalance you. 10 pounds will probably not be enough for most people but grabbing the 100 pound meatball kettlebell isn’t the best idea either.
Once you pick the up the kettlebell go through the same bracing sequence we talked about earlier:
-Squeeze your butt.
-Screw your feet into the ground.
-Take a big breath in and blow all the air out until you feel like your ribs are pulled down flat with your abdominal muscles.
-Maintain tension and breath into it.
Perform 10 reps at a faster tempo than our unloaded squats. Try 2 seconds on the decent, pause 2 seconds and then stand up. We’ll go through this two rounds as well.
Here’s the prescription:
3x per week perform this practice session:
1 round not for time
-90/90 breathing 10 reps, 5 seconds in, pause 5 seconds, exhale 5 seconds
-30 reps wall pause squat to a target, getting closer to the wall after each sequence of 10 reps
-Overhead RNT banded pause squats 2 rounds 5 reps each side
-Goblet pause squat light to moderate weight 10 reps
So, when can you plug this into your training? You have a few options, but in my opinion it’s best to do this prior to a training session. Think about incorporating this into part of your warm up on squat days. If we go back to the basketball reference, it would be like practicing shooting from different spots around the 3 point line prior to a game. There is a carry over effect in that motor pattern to the actual game where you have less than ideal conditions(people trying to stop you from shooting).
Practice the skill and then use the skill. Your workout is the game but your practice is what makes you dramatically better.
Step one is to help tease out if you have a mobility problem or not using the tests we described in the beginning of the article. If you don’t have a mobility restriction, then it’s time to practice the movement. Give it a solid 4-6 weeks of practice and see how much more comfortable it feels to squat.
Don’t spin your wheels thinking you have a mobility problem. It’s not always the case and movement really is medicine!
-Dr. Danny, PT, DPT, OCS, CSCS
Still have questions? Contact us at firstname.lastname@example.org to see how we can better help you.
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 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!!
Sad stick man on the right does not have great ankle mobility which causes his femur, the thigh, to be pushed backward. From this position the torso has nowhere to go but forward if he wants to remain standing. Throw a barbell in the front rack and the stress in concentrated on the knees, low back and upper body. With a barbell on the back rack, it will be harder to maintain spinal alignment, particularly in the bottom of the squat. This is often the position athletes attain when their hips raise well before their knees begin to straighten in a squat.
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.
If squatting is not bad for my knees, why do they hurt?
Undoubtedly, this will be the next question. There are several reasons that your knees may hurt during a squat. Some irreversible arthritis or previous injuries may be contributing but even these populations should be able to return to pain-free squatting. They just may need to try a different flavor than the traditional back squat.
Essentially, squatting is not bad for the knees but it is how you are squatting!
Do I squat through the pain?
No! Our body is very good at letting us know when something is not right. Now, I am not referring to muscle fatigue pain but true pain. If the back squat is causing knee pain today, try another variation. There are plenty of flavors of squats that can be used for training while you work on mobility or strength deficits. Be sure to look out for my next article about finding the best squat flavor to suit you!
Moral of the story: squatting, even below parallel, is not bad for your knees. The squat is a fundamental movement pattern that all humans should be able to attain. If pain arises from this movement, remember it is how you are moving. Decrease the weight, video yourself performing a squat and pay attention to which muscle groups are doing the work. If you continue to have pain, contact us at Athletes’ Potential so we can watch you move and delve deeper into your individual movement patterns! Most importantly,
Thanks for reading,
-Dr. Jackie, PT, DPT, CSCS
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.
These muscles are important for bowel and bladder function, organ support, and stability of the pelvis. Although pelvic floor dysfunction (PFD) was thought to be largely a problem of women, it is becoming apparent that men have similar issues. The pelvic floor may seem very foreign and uncomfortable to discuss, but when it properly functions it can improve your workouts. Here’s how:
I like Mary Massery’s description of the core as a “soda-pop can”. The front of the can is the abs, the back is the multifidi, the pop top is the glottis and the bottom of the can is the pelvic floor. The core pressure is maintained by a functioning glottis and pelvic floor, with the diaphragm acting as a pressure regulator.
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?”
Thanks for reading!
Dr. Jackie, PT, DPT, CSCS
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.
Presentation at CSM 2016 by Mary Massery: referencing Massery 2005 & 2006.
Hi, I’m Doc Danny Matta. I’m a physical therapist, strength coach and an instructor on the MobilityWOD team. I’ve worked with countless CrossFit athletes, soldiers and weekend warriors over the past 6 years as a physical therapist. These are just my views. If you don’t like them, stop reading and start your own blog.
Last year during the 4th workout of CrossFit Open Week, I saw an epidemic. That epidemic was a ridiculous increase in acute neck injuries. I thought to myself, did everyone get in a car accident and sustain a whiplash injury in the same week? I quickly realized that it wasn’t car accidents crushing people’s necks, it was handstand push ups!
Don't be this guy!!
If you don’t remember the 4th workout last year it was as many rounds as possible in 8 minutes:
3 cleans (men use 185 pounds and women use 125 pounds)
3 handstand push ups
6 handstand push ups
9 handstand push ups and so on for the entire 8 minutes.
I actually really liked this workout when I saw it. It’s a nice push pull couplet. It’s moderately heavy but light enough where many people would be able to at least do a few rounds. What I didn’t expect was that I would see people pile driving themselves into the ground to get one extra hand stand push up!
Let’s be real with each other, if you’re reading this and you honestly have a shot to go to the CrossFit Regionals or Games I understand why you might sacrifice your neck to achieve a long term goal. Look, I’m as competitive as anyone. I once kicked a guy off an intramural flag football team I was on mid-game because he sucked. Do your thing, and I hope you achieve your goal.
The rest of you, honestly probably 99% of you reading this need to look at this from another perspective. You are not going to the CrossFit Regionals, let alone Games. You are doing CrossFit because you’re trying to be healthy, look good and have a supportive community to keep you motivated. You need to look at the Open as a way to test yourself, try new things, have fun and compete with your friends/family.
I only have one person that I compete against when I do the CrossFit open- my brother. I bet you thought I was going to say myself. Sorry but that’s cliche bullshit! You need to compete against another human being if you really want some competition. In my case it’s my older brother and I look forward to crushing him again this year because I know he and his wife just had a baby and he’s going to be in less than ideal shape!
So, for those of us falling into the non-CrossFit Games/Regionals category here’s my advice: Do not do something that subjects you to injury that can limit your ability to function at work or with your family. Get with your coach and get a game plan for the workouts. Maybe you do your best with the RX weight but don’t do something stupid. You still get a score. After you do that, scale what you need to scale and then get a good solid workout in.
Go to your gym’s Friday Night Lights workouts. Get involved in the fun of the Open and enjoy it. Have a fun 5 weeks, this is your season. You’ve been training all year for this. Once it’s over, get back in the gym and work on your weaknesses. Follow my advice and you’ll get to that point without breaking your neck!
-Dr. Danny, PT, DPT
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:
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.
-Dr. Danny, PT, DPT
Hak, P.T., et al. "The nature and prevalence of injury during CrossFit training."
“Look up when you squat, Matta!” Coach Pettis, high school football coach
Most people who played sports in high school or college have received some coaching on some basic strength movements like the bench press, squat, deadlift and power clean. In fact, thanks to programs like the Bigger Faster Stronger program, high school athletes have been doing these big compound movements for years. I remember going through this exact program when I moved to Columbus, GA as a junior in high school with our football team.
The quote above is something I remember well from all of my strength coaches, but in particular one of my coaches in Columbus. He was the one that implemented using the Bigger Faster Stronger program and he would constantly yell at us to look up when we were deadlifting, power cleaning or squatting. We all got bigger, we all got faster and yes, we all got stronger. Were these changes all beneficial? Looking back it’s hard to say but I would have to say no they were not. In my opinion, we just were adding strength to dysfunction.
So what’s my problem with this cue of looking up when pulling and squatting? I think it’s a cue gone wrong in many ways. I see the rationale behind not wanting the spine to be in flexion when pulling and squatting. You want the spine to be in neutral during these movements. Cueing people to look up is designed to get people out of a flexed position. More commonly, you’ll hear the coupling of two cues, 1) look up and 2) butt back. The problem is many athletes will drive excessively into extension and this can be an even bigger problem.
When we drive our spine into end range extension it’s very stable. The reason it’s very stable is because the facet joints in the spine are getting pressed into each other and it’s literally a bone block that stops any more movement from occurring. As stable as this might be it’s very irritating to the spine and can even cause local spinal fractures called spondylolisthesis. These are most common in young female gymnasts and young male wrestlers. One sport has a ton of arch positions in it and typically landing in arched positions and the other teaches wrestlers to bridge/arch to stop someone from pinning you. Both of these put the spine into end range extension with load.
Am I saying you are going to get a local spinal fracture from squatting while looking up and arching your back? No! But you sure as hell will aggravate your back by doing this. In fact, I would say 90% of the lower back injuries that I see in my practice are directly related to extension based back injuries.
We have to fix this problem through control. The control must come from engagement and strength of the anterior torso, inparticular the internal obliques (IO) and transverse abdominus (TA). These are deep anterior stabilizers of the spine and when we put ourself into an over-extended spinal position they are essentially weakened. Strength and control in this area in particular is the best way to gain lasting control of the anterior spine.
Now let’s fix it. Below are a few videos that directly work on correcting this area and getting you out of an overextended position. Add these in daily at home to reclaim some lost control and when you do squat, actively try and mimic the same muscle contraction that you get with these corrective drills as you do when you squat.
CrossFit is polarizing. It seems like these days you either love it and it’s all you want to talk about or you hate it and you wish you could slap your friend that can’t shut up about how much he loves CrossFit.
Initially, my experience with CrossFit was something that didn’t involve lululemon shorts, chalk everywhere and some specialized pack of vitamins to help me WOD harder. I was introduced to it by two Rangers at the Center for the Intrepid in San Antonio, Texas.
The two guys were both CrossFit coaches that had been in blast injuries and both had lost a leg. They were both below the knee amputees and were very high level. I saw these guys doing muscle-ups as part of their WOD one morning and spoke with them after. They told me they were doing CrossFit and invited me to train with them the next morning. So the next morning, that's exactly what I did. I got through the training session and at the end eventually had to puke into a trash can. As I wiped the puke off my face, they both laughed because they had been there before and I realized I had found something pretty awesome!
Back when I first started CrossFit, it was more underground and less mainstream than it is today. CrossFit has grown and evolved with it’s success over the years, as it has to (and should) do. I think you need to give credit where credit is due, however, and CrossFit at least deserves credit in these 3 areas:
1. Adults started doing Gymnastics
As a parent I feel some type of movement base needs to be developed in our kids (read more here). You could use a martial art, dance or something like gymnastics. The fact that grown adults are trying to learn hands stands, hollow holds and kipping movements is phenomenal. If we can all agree that gymnastics is a great movement base for our kids, why aren’t we working on it ourselves? We absolutely should work on gymnastics skills and CrossFit made that one of the central foundations of it’s training.
2. It Saved American Weightlifting
When people say the word weightlifting most people think bodybuilding. Shit, 5 years ago I was one of those people. I couldn’t have told you the difference between lifting weights and weightlifting. Through CrossFit, I’ve been exposed to a sport that involves arguably, the hardest movement in sports, the snatch.
When the last summer olympics were on I looked specifically to see when weightlifting was going to be shown. The summer olympics before that all I would have cared about was swimming and track and field (because we dominate those sports! #merica). I only wish I could have gone back and started weightlifting when I was much younger.
So, is it fair to say that CrossFit saved American weightlifting? Yes it is and if you don’t believe me here’s a podcast I did with Glenn Pendlay and one with Don McCauley. They both give all the credit in the world to the fact that CrossFit has made weightlifting matter again.
The last bit of proof, if you even need anymore, would be the the young weightlifting phenom CJ Cummings hitting a 175kg clean and jerk (video below) at the US Nationals this month. It’s an unofficial youth world record for his weight class. Where did he get his start into the sport? At a CrossFit gym!
3. Brought Back Real Training
Last week my wife and I went to see the movie Jurassic World. As we stood in line at the movie theatre in Atlanta, we had to stand next to a gym with a ton of huge glass windows. This gave us a significant amount of entertainment and helped pass the time in a relatively long line. Why was it entertaining? It was entertaining because I look back at how I used to train and I see it’s the same as what these people were doing at the gym by the theatre.
Too often people go to a nice air conditioned facility, grab a towel for the off chance that they actually sweat and head straight for the elliptical. They plug their headphones in and watch Paula Dean describe why you need 4 kinds of cheese in your macaroni and cheese to really make it correctly. Thirty minutes later after having maintained their fat burning zone it’s time for some leg extensions, bicep curls and possibly some dumbell bench press if there’s time. Grab your post workout smoothie on the way out and in your mind you’re the fucking man!
Training should be hard. Training should encompass large compound movements. It should get your heart rate elevated; who cares what your so called fat burning zone might be. Training should allow you to go hiking, swim with your kids, do yard work for 2 hours and run away from a dog that would love nothing more than bite your leg off. Maybe there were other people that were training in this fashion before or during the time CrossFit came around. What CrossFit did was make it mainstream. I’m glad they did and so are thousands if not millions of other people around the globe.
I know this is a polarizing topic. If you have an opinion leave a comment. Thanks for reading.
-Dr. Danny, PT, DPT
“The fear of pain is worse than pain itself” Arntz and Peters, 1995.
Back in the day when I was still active duty in the Army, I had to attend what was called a Joint Operational Deployment Course. It’s a week-long course where myself and other active duty medical providers learned how to take care of trauma related issues predominantly. It was great training and I learned a ton. I also learned I’m terrible at giving an IV.
One of my colleagues was unlucky enough to have me as a partner as we learned to hook up an IV bag. To make matters worse he was deathly afraid of needles and blood. In fact I’ve been around him when he had to sit down for a few minutes after getting a routine shot otherwise he would have passed out.
The process for hooking up an IV bag is pretty straight forward. Step 1: put on tourniquet. Step 2: insert needle. Step 3: attach IV clamp/bag to needle port. Step 4: take tourniquet off and open IV. Much to my friend’s dismay, I mixed up the steps and accidentally took the tourniquet off before attaching the IV bag.
My partner was intentionally looking away the entire time because if he saw the needle he would pass out. As the blood started running out of his arm through the IV port I had just placed in his vein I said the worst thing I could have at the time, “Oh Shit!!”. He immediately looked at me and then at his arm which was now next to a rather large pool of blood on the table. He immediately passed out as I fumbled to attach the IV bag and stop the bleeding. He’s still very much alive and still very much afraid of needles. I reminisced with him about this event a few weeks ago when he and his family visited my family in Atlanta. Yes, I’m not the best person to call if you need and IV put in but the real question is why is this person so afraid of needles/blood and I can watch blood be drawn or even stick needles in myself without a similar response?
The answer is directly related to the opening quote: The fear of pain is worse than pain itself. Maybe this person had a memorable traumatic experience with a shot when he was a kid. Maybe his mom or dad were really afraid of giving blood/needles. Maybe he had a sibling that told him how terrible it would be to get a shot just to mess with him. Either way it eventually leads to a pain experience.
After a pain experience, we start catastrophizing the event, in this case shots or needles. That leads to more pain related fear and eventually avoidance of the painful event again. All of this leads to more and more perception of pain with the activity.
So why am I putting this on a blog that typically talks about performance improvement and injury treatment? Because, for people that have had pain for more than a few months they have to stay away from falling into this vicious cycle.
I had a patient recently that came in to see me for pain in the front of his knee. He had no explained onset except that he had tried to take up running and had to stop because his knee hurt whenever he would run. It also hurt to go up/down stairs if he led with the injured leg. He resorted to only going up stairs with his non-injured side one step at a time. This is an incredibly slow way of going up/down stairs and I’m sure he aggravated countless people that were behind him in stairwells.
What’s the first thing we did? Talked about how his leg was healthy and had him start going up stairs with what he perceived to be his injured leg. We also had him start box squatting the first week. When I told him we were going to squat his face looked like I had just told him we were going to fight a grizzly bear. We had to expose him to those activities he was avoiding and afraid of. Sure he gained some strength back and that is obviously a contributing factor to him getting better. However, the biggest factor was the realization that his leg wasn’t broken, it was functional and he needed to start using it correctly again.
With chronic injuries we can become very sensitized and aware of any little thing that happens in a painful area. Sometimes the best treatments are the ones that prove to our own mind that we are still functional!
-Dr. Danny, PT, DPT
June 2014 July 2015
Testosterone- 802 Testosterone- 421
HbA1c- 5.3 HbA1c- 5.7
HS CRP- 0.9 HS CRP- 2.6
Let’s face it: we live in the information age. You can find out pretty much anything by searching for it on the internet. There has also been a massive shift toward data driven decisions. I see it first hand in my business when I look at our website analytics. We even see it with things like Wodify as athletes start tracking all their workouts, strength numbers, training sessions and making training changes based off actionable data.
Think of this blood panel like a snapshot of what’s happening internally. As part of the initial testing phase to work out the kinks, my wife and I both went through the process to get blood drawn and see how long it would take to get our results back. When I got my results back, I was shocked!
Last June, as part of my transition out of Army, I requested some blood panel work from my Physician Assistant. I wanted to start doing a more in-depth panel of blood tests yearly just to see where I stood and to gauge my nutrition/training based off that. For me, I used that as my initial data to compare this lastest to. Here are the tests that were grossly different:
A good number more tests were performed besides these three but these were the ones that had the most noticeable changes. What does this even mean? In the past year my testosterone production had decreased by 50%. Testosterone is very important for recovery, building muscle, maintaining a lean body and many more very important tasks. According to a 1996 study by Vermeluen et. al, the average testosterone levels for someone my age (30 years old) is 617. To make matters worse, in the same study he found that the average testosterone levels of males age 75-84 was 471. Talk about kicking me while I was down! This basically shows me that there’s a decent chance my 90 year old grandfather and I have the same testosterone production at this time.
Next is the change in HbA1c. This is a marker of average blood sugar levels over the past 3 months. Most of you have probably heard of diabetes. It’s basically a disorder of high blood sugar levels in the body. It can either be genetic type I or developed type II. The range for HbA1c is pretty clear. Anything below 5.7 is normal, between 5.7 and 6.4 is prediabetic and over 6.4 is full blown diabetes. My number is elevated quite a bit and it technically puts me in the prediabetic range.
Lastly, was the change in my HS CRP. This is a marker of global inflammation in the body. To be clear, inflammation is not a great thing to have in the body. Increased values on this test in particular have been drawn to increased risks for cancer, heart attacks, neurologic disorders and type II diabetes. My HS CRP was elevated compared to where it was a year ago going from 0.9 to 2.6.
Now, when you see these big changes in values your physician should ask you a few things. First, did you do some crazy workout that day or the day before? Did you go out with your friends the night before, end up at the Clermont Lounge and down PBRs all night? Have you had a week of really bad sleep before this test cluster? All of these things are important to know because it can give us false values. By the way, my answer to all these questions was no.
Here’s what all this means. In the past year my health, internally at least, has slowly been trending in the wrong direction. So how did all this start to go wrong? I would have to attribute it to a number of factors. First, I started a business. For any of you that have ever started a business I probably need no further explanation. For those of you that haven’t, it’s the most difficult and stress-inducing thing anyone could ever do. Not only that, but I teach for another group (MobilityWOD) and in the past 12 months, I’ve accumulated about 70,000 miles on an airplane. I also have two small kids under the age of 4 and I typically sleep an average of 5-6 hours a night.
It’s not all bad news though. Mom, if you’re reading this don’t freak out and call an ambulance for me! I’m glad I did these tests because I had been feeling fatigued and like I was recovering poorly from my training sessions for about the past 6 months. Now I have some quantifiable data to help me make changes and retest to see what’s working. Changes will be made and I will retest in about 1-3 months. All of these markers are reversible with some supplementation changes and behavior modification. I’ll write up a follow up post once I’ve done my blood testing again. It’s time to make some changes!
-Dr. Danny, PT, DPT
Dr. Danny and staff's views on performance improvement, injury prevention and sometimes other random thoughts.