 Coming at you with the the final part of our two-part series for ensuring healthy shoulders while improving your pull-ups. In this part we’re talking about how to develop appropriate strength in the appropriate areas. For those of you who missed it, part one is super important and I highly recommend reading that before moving on with part two. For those of you who are caught up, let’s get after it. Part II: Strength In any training program, it’s important to make sure your movements are balanced and that your shoulders are working in multiple directions (ex: vertical pulling, horizontal pushing, horizontal pulling, etc). The pull-up is an excellent example of a vertical pull strengthening exercise. With most pulling exercises, your body is primarily moving through two movements: elbow flexion and shoulder extension. This means your primary shoulder extension (latissimus dorsi, teres minor, post delt) and primary elbow flexion (biceps brachii, and brachialis and brachioradialis) muscle groups need to work synergistically to perform this movement appropriately.  https://coreem.net/core/biceps-and-triceps-tendon-rupture/ Unfortunately this synergistic relationship isn’t normally the case. More often than not I find that people way over utilize elbow flexion and underutilize shoulder extension. When this happens bad things happen and those bad things usually end up manifesting themselves as pain along the front of the shoulder. As you can tell in the picture above, the long of of your biceps tendon crosses the shoulder joint and when you rely too much on elbow flexion with pulling based exercises, you can end up agitating that tendon, which leads to shoulder pain. I see the aforementioned situation happen all the time in athletes who do a lot of kipping pull-ups vs strict pull-ups, specifically in those who don’t have the requisite strength to perform consecutive strict pull-ups but are repping out 15+ kipping pull-ups at a time. Now I’m not saying kipping pull-ups are bad or that you shouldn’t do them, but kipping pull-ups should be an expression of strength, not a way to avoid a weakness. To ensure you’re not overusing your biceps while doing the pull-up you want to have strong, engaged lats (latissimus dorsi). To make sure this is the case, check out our top 3 exercises below for improving shoulder lat strength and control. Drill #1: Active Hangs 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 This one is a great example of “killing two birds with one stone” because not only are you able to improve lat strength with this drill, but because of the long eccentric phase (muscle contracting while lengthening) of this drill, it’s also a great way to improve shoulder mobility. Drill #3: Single Arm Banded Lat Pull Downs 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, PT, DPT, CSCS
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 Whether you’ve never stepped into a gym or are a diehard fitness enthusiast, chances are you’ve attempted a pull-up. That’s a good thing! It’s hard to argue an exercise that is more foundational to upper body strength than the pull-up. That being said, for how much I love this exercise and think it is something everyone should be doing (or at least a type of modification), I treat patients all the time in the clinic with shoulder pain related to the pull-up. Whether it be mobility issues, strength, or poor technique, there are a number of reasons why your shoulder can hurt during or after pull-ups and this article is the first of a two-part series that will teach you how to keep hitting your pull-ups pain-free! Part 1: Mobility First and foremost, let’s take a look at what exactly is happening at the shoulder joint while doing a pull-up. When you raise your arms over your head to get in the starting position for this exercise, your shoulder joint has to do a combination of two movements: flexion and external rotation. If you're limited in any of these two ranges of motion your body will make compensations to get your arm in position, which will eventually set you up for a higher risk of injury. Think of it this way: If your car tires are out of alignment, nothing will happen right away, but eventually there is going to be uneven tread wear and you’ll end up blowing a tire sooner than later. The same can be said for your shoulder if you're lacking requisite mobility with either shoulder flexion or external rotation. The videos below are great ways to test if you have enough shoulder range of motion, as well a favorite drill of ours to improve any range that needs work. 1. Flexion  (Shoulder Flexion Self-Assessment (Performed by Norcal Strength and Conditioning)
(Banded Overhead Opener)
(Thoracic Spine Opener)
2. External Rotation  (Shoulder External Rotation Self-Assessment - Performed by Michael Carroll)
(Chest Opener)
(Front Rack Opener)
To recap, if you have shoulder pain while doing pull-ups, or want to prevent pain from coming, the first place to start is to make sure you have enough shoulder flexion and external rotation to perform the exercise without compensation. Be on the lookout for Part II of this blog post which will dive into the common mechanical flaws and strength imbalances that can lead to shoulder problems with the pull-up. 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, PT, DPT, CSCS  Elbow pain can be one of the most irritating and inconvenient issues. I once had a patient say that the most painful part of his day was just cutting butter for his toast in the morning. Classically, we tend to blame the tissues at the joint—wrist extensors/flexors. Sure, the common insertion for these muscles becomes inflamed, but what causes that? I like to view the elbow similarly to the knee; it is a joint that is pushed and pulled on either side by very complex joints. The shoulders will largely influence the biomechanics of your elbow and the amount of torque that passes through the joint. Although somewhat simplified, we could group you as either tight and immobile or mobile and bendy. Each characteristic has its own pros and cons, but the cons are where pain manifests. With decreased shoulder mobility and/or control, the elbow will take the brunt of the force when lifting weights or swinging a racquet. Shoulder stabilization and control are important for correct biomechanics of the shoulder girdle and upper extremity. Lack of control upstream, allows more movement downstream at the elbow. The repetitive, small insults at the elbow joint will eventually result in elbow pain.  Hammering away at the soft tissue around the elbow is often where athletes start when self-treating. Don’t get me wrong, a little forearm smash with a lacrosse ball or barbell is great. But if it does not improve your problems, move on! In this case, we are going to check out the shoulder. Less mobile folks: To decrease the torque at the elbow, it would be ideal to improve both the external rotation (front rack) and flexion (overhead position) or your shoulder. Tight lats can often be the cause of the restrictions. Try these two mobility pieces:
  More mobile folks: Shoulder stabilization is going to be the key for you. A simple way to start on this is kettlebell carries, all variations! Here are two simple, yet effective stabilization drills:
  As always, do a movement screen/ form check first. Get a coach or super friend to watch you move and see if they notice any faults. Racquet sport athletes—if you constantly have elbow pain, check your grip size. Grips too small or too large can cause elbow issues as well. If you are a desk jockey, check out your work station and the ergonomics!
Try these mobility exercises and tips out. If you continue to have issues, come see us at Athletes’ Potential. We see elbow pain often and are able to effectively treat it with an evaluation! Keep devoting time to making your body work and feel better. Thanks, Dr. Jackie, PT, DPT, OCS, CSCS  Appropriate shoulder rotation is essential for overhead athletes; I want to discuss this in the context of volleyball. My bread and butter. Think of a volleyball player hitting a cut shot or winding up to swing away at a set. You will see a great amount of external rotation during the cocking phase (the middle frame in the photo above). The greatest demand for internal rotation range of motion would be the follow through for a cut shot or “thumb down” (as in the photo below).  The amount of shoulder rotation range of motion for a volleyball player is that of a normal individual but you need a balance of range of motion, strength and control. A quick side note worth mentioning: as an overhead athlete, you are likely to have greater range of motion in external rotation and less internal rotation. This is normal due to the demands of your sport. The baseline that we look for is that total range of motion side-to-side is the same. So you may look like the guy on the right in the picture below. It is also common for volleyball players to demonstrate greater internal rotation rather than external rotation strength, which may lead to injury down the road if the ratio becomes too skewed.  Let’s go through the steps of an arm swing and see where a weakness may be and how to address it:
Check your external rotation by laying on your back, arm out to the side and elbow bent. See how far you can drop the back of your hand down to the floor. Lacking here? Try this out: Subscap Smash 
The shoulder joint is one of the most complex in the body due to its high mobility demands that compromises the stability. For volleyball players, shoulder maintenance is key for longevity, pain-free function, power and control. I broke the attack down very simply to highlight a few major areas of weakness that is often found in volleyball players. Give these mobility and strengthening exercises a try and see what works best for you. At Athletes’ Potential, we believe that self-maintenance should be the first step toward managing pain and recovering properly. But if you have a nagging volleyball shoulder and cannot seem to find that silver bullet, give us a call! Thanks for reading, Dr. Jackie In the words of Jay-Z, “I’ve got 99 problems but wrist pain ain’t one.”  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.” Take a crack at fixing this stuff yourself first! If you're still having issues, come and see us at Athletes' Potential! If you don't live in the Atlanta area, check out this out the 4 Keys To Picking The Right Physical Therapist in your area. - Danny, PT, DPT, OCS, CSCS  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 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! Photos:
http://rebellion.nerdfitness.com/index.php?/topic/79212-flex-follows-the-way-of-the-iron-dragonslayer-part-1/&page=6 http://www.catalystathletics.com/article/1848/A-Different-Thought-About-Snatch-Technique-Keeping-the-Bar-C/ https://it.fotolia.com/tag/sprinter http://www.spineandsportspt.org/exercises/shld_ir_stretch_sup.php 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. |
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