This circuit can be used by almost everyone, as I use this with cuff patients as well, but the key thing is to pay utmost attention to form.

The exercises shown in this video are:

• Bottoms Up Kettlebell Screwdriver for cuff stability
• Bottoms Up Kettlebell Armbar for cuff stability with scapulothoracic mobility
• Kettlebell Armbar for scapulothoracic mobility
• 1/4 Turkish Getup for scapulothoracic mobility and stability

*Note that for the “Getup”, I’ll always get them to perform the movement slower and post on the elbow but unfortunately I didn’t get it on video.

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*Disclaimer: I have not been formally trained in Kettlebells, so for those of you who are, your expert feedback is welcome.

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Muscle Imbalances Revealed – Upper Body

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Last year, you may have read several of my reviews on Muscle Imbalances Revealed – Lower Body, a dvd package put together by some of the top experts in the fitness industry. Well this year, I’ve had the privilege to contribute to the newest version of this product, Muscle Imbalances Revealed – Upper Body. Together with Rick Kaselj, Tony Gentilcore and Dean Somerset, we have essentially put together everything – well not everything but a whole whack-load of information – you need to know about the core, thoracic spine, shoulder, neck and arm. But for those of you really interested in what I had to say, well you probably won’t be surprised. So let me give you a quick run down:

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“Respiratory Control: Linking breathing with rehabilitation & training” 

This was my main presentation where I talked about the following:

• Nailing down your mobility and stability exercises with breathing
• “Money moves” for improved breathing
• The Stability-Motor Control Continuum
• Assessment techniques
• How to integrate breathing into movement

“Understanding Soft Tissue Management: Choosing the right tool”

This shorter presentation essentially discusses:

• The mechanism behind soft tissue injuries
• The 3 Phases of Healing
• Who’s who soft tissue world
• The “integr8r”
• The role of the Instrument Assisted Soft Tissue Mobilization in tissue recovery
• The most effective ways to foam roll the upper body

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But enough about me, what you really need to see is what the other guys had to say in Muscle Imbalances Revealed – Upper Body! Here are short clips from each of “the other guys’” presentations.

“Corrective Exercise Strategies for Athletes (and Meatheads, too)” with Tony Gentilcore

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“Myofascial Training for the Upper Body” with Dean Somerset

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“Unraveling Muscle Imbalances in the Shoulder” with Rick Kaselj

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Now I’m really excited about what we’ve put together. I truly think that regardless of whether you’re a manual & rehabilitation therapist, fitness professional, or just someone who loves to train, that you’ll benefit greatly from this package. In fact, I actually think that your friends and colleagues will benefit as well (so please spread the word)!  And the best part about it? You don’t have to spend your spouse’s hard earned money like I do and fly all over to get your con ed on. In fact, the cost is only $77.

Anyway…

-> -> HERE’S THE LINK <- <-

…and thank you in advance for your continued support!

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Over the last couple of years, I have utilized the FMS to screen each of my players prior to the commencement of the season. Having both tracked and treated their injuries year-long, it looks like one of the seven screens may be a powerful predictor of AC joint separations. Traditionally thought of as an injury that occurs due to the physical nature of the sport, AC separations are one of the most common injuries in ice hockey. In fact, shoulder injuries in general consistently rank quite high in epidemiological studies (see studies by Benson and Emery).

As per the FMS manual, “The shoulder mobility screen assesses bilateral shoulder range of motion, combining internal rotation with adduction and extension, and external rotation with abduction and flexion. It also requires normal scapular mobility and thoracic spine extension.” A loss of such normal scapular mobility and thoracic spine extension often results in any of the following presentations: sick scapula, upper crossed syndrome, scapular protraction, etc. And as a result, a shoulder girdle that may be more prone to injury.

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When thinking about AC joint separations, it is important to note that often it is the acromion that translates in a downward fashion rather than the clavicle moving superiorly. In each of the above faulty presentations, it is not uncommon for the acromion to already be trending toward an anterior-inferior position. Now when presented with trauma such as a seemingly benign body check, a protracted shoulder may indeed not be able to “cushion the blow” as well as one that is retracted, and may sustain an AC injury.

At least this is my take on it.

But what can we do to “better position” our players for increased resiliency?

Personally, I prefer dynamic and loaded correctives over manual stretching and therapy. Indeed soft tissue work may be necessary, but experience has demonstrated to me that the following correctives give me a bigger bang for my buck.

Try these out with your 1′s and 2′s and let me know what you think!

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For those of you who haven’t read their thoughts, here are the links:

• Corrective Exercise: Muscle Imbalances Revealed (Upper) – Eric Cressey
• Muscle Imbalances Revealed Upper Body Review – Mike Reinold

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Oozing with both practical and nerd-ical content, this dvd set is very comprehensive but also very user friendly. Grounded in scientific information, Eric and Mike presented various concepts ranging from the epidemiology and etiology of shoulder injuries to injury prevention and performance enhancement.

Here are some highlights from Optimal Shoulder Performance:

The importance of assessing Total Range of Motion

• Both Eric and Mike go into great detail to explain the importance of  the continual assessment shoulder total range of motion. Using the example of Glenohumeral Internal Rotation Deficit (GIRD) vs Instability, Eric and Mike explain why stretching the posterior capsule and cuff may not always be the best idea. In fact, they explain that doing so may even be pathological. So while the sleeper stretch has become a mainstay in many training centers, these two gentlemen provide their reasons why you probably shouldn’t be prescribing such exercise.

Dynamic Stability Progressions

• Supine to standing, stable to unstable, open to closed, Mike does an excellent job of introducing his exercise progressions for eliciting and achieving dynamic rotator cuff stability through rhythmic stabilization. I, myself, use his progressions quite frequently and really think this is a great way to “activate” the cuff prior to functional therapeutic exercise. In fact, I believe Eric may even use these progressions prior to training as well. The only downside with this type of exercise is that while gains can readily be made in clinical settings, there really wasn’t a similar exercise (that I knew of) to send the patient home with…until now. After several months of using this technique, especially early in the progression, I realized that bottoms up kettlebell work was a great way to repeat the objective at home. So here are two exercises that I now often sent my patients home with. The screwdriver and the armbar.

I believe Dr. Snell also uploaded this exercise on MyRehabExercise.com

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Note: For the complete exercise progression continuum for training dynamic cuff stability through rhythmic stabilization, I would highly suggest Mike’s Treatment of the Shoulder Joint Complex: Principles of Dynamic Stabilization DVD. You can pick it up at AdvancedCEU.com which, unsurprisingly, is an affiliate link to fund my “continuing education for life” endeavors.

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Impingement

• Going back to assessments, Eric and Mike use the differentiation between internal and external impingement ESPECIALLY as they relate to specific demographics to illustrate the importance of comprehensive assessments prior to training. Knowing your athlete history and choosing the most appropriate assessment recipe is can be a difficult thing to master but a trainable skill to practice nonetheless. It is often stated that if you’re not “assessing, you’re guessing” but how easy is it for us clinicians to simply assume and treat? Shooting for perfection 100% of the time will make us better practitioners and assessing will help us get there.

Practical Labs

• In the lab portions of the dvds, while Eric and Mike don’t dump the exercise tool box and give you all their exercises, they do spend plenty of time teaching proper form and optimal cueing strategies. I think this approach is far more important and effective than demonstrating hundreds of exercises. Because in each exercise, the principles stay the same – perfect form and proper joint positioning. That said, for those of you who are seeking an exercise database, they’re at your fingertips on each of their respective youtube channels. In fact, Mike has come out with some great exercises as of late so be sure to check out his page.

Finally, there were countless pearls embedded deep in the Optimal Shoulder Performance ocean. One specific pearl I liked was the fact that during rhythmic stabilizations, Mike almost wants the athlete fail on some of the reps. This is showing him that the exercise is difficult enough for the athlete to force an adaptation. Because like the clinical audit process, only with a significant but controllable challenge will a new pattern emerge.

All in all, I really enjoyed Optimal Shoulder Performance. It has provided me with excellent principles for effectively managing not only my 74 year old cuff patients but also my varsity swimmers. So if you work with overhead athletes, make sure you check it out.

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Well here’s a simple exercise with a superband that Jimmy Smith threw down not too long ago.

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This is a good and practical exercise to strengthen the scapular retractors. The only thing different I would do is ensure that the athlete maintains rib cage depression. Other than that, you’re good to go.

But what about those who work 9-5 in a chronically slouched posture? You know that they’re in sustained creep. So how do we slow this down or creep the creep?

I would suggest you simply take the exercise that Jimmy demonstrated above, and throw the band around the back rather than the front. Eliminate the contraction and have them chill out at home for 20+ minutes at a time in that position. It should engage a nice stretch to the pectorals. I’ll admit that I’ve never tried this myself but I think it’s worth a shot. Just make sure that you monitor for any arm symptoms as the thoracic outlet is a delicate place.

Doing both of these should set your athlete/patient on their way.

But aside from that, here’s another exercise I commonly prescribe.

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This first exercise is one that I learned from Michal Truc. If you don’t own a pair of Valslides or a slideboard, you need to right now.

If you’re watching closely, you’ll notice that I need to improve stability of my own right shoulder girdle.

This second exercise is a commonly performed exercise using the TRX. However, the importance here is to maintain a packed position of the shoulder. The reason I am posting this exercise is to demonstrate that we can start to progress into upright positions via kneeling and eventually to standing.

As always, you can use any exercise you wish, but the principles that must stay the same.

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Most of my time spent with these kids and their parents generally turn out to be lessons in parenting for when my own children come around but this day was somewhat different. This day was a lesson in scapular stability.

For those of you in the musculoskeletal rehabilitation setting, scapular stability will probably be an everyday concept used in your practice. Additionally, letters such as Y, T, W, and L and words such as Blackburn may be commonplace as well. But how many of you think of the word quadruped when considering the concept of scapular stability?

Well, seeing Grace and Nathan spend close to 90 minutes crawling around the floor pretending to be puppies immediately made me think of how much scapular stability they’re likely to have when they get older.

You see, playful childhood activities such as creeping and crawling promote the development and integrity of the scapulothoracic joint and lacking such stability often is a result of abnormal central nervous system development. Surely, the sedentary lifestyle may contribute to such dysfunction but it should be noted that this degree of maturity is never attained in 30% of children whereby faulty posture and muscular imbalances begin at early stages of their development (Kolar P, Rehabilitation of the Spine)…or lack thereof. Therefore, the reason I prefer quadruped-based activities for scapulothoracic stability over contemporary exercises such as YWTLs and Blackburns is due to their closed kinetic chain, neurodevelopmental nature. Isn’t Janda’s test for scapular winging performed in a closed kinetic chain position with the hands on the floor? Now I recognize that we, as humas, are bipedal in nature however, the development of motor control is largely based on the concept of the “Punctum Fixum”.

The “Punctum Fixum” as taught within DNS by the Prague School are the specific areas where movement begins. The direction of muscle pull, in general, project toward these regions and the choices of support zones that our body makes depend on the initial position of that body. Thus, such “fixed point” will be dictated by whether a specific movement pattern is of the open chain or closed chain varieties. Additionally, as Dr. Kolar states in Dr. Liebenson’s text, “Rehabilitation of the Spine“,

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“The muscle may not be weak in itself, but it may not function well because its attachment point is insufficiently fixed. A muscle must have a punctum fixum.”

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So when it comes to the playful activity of crawling like a puppy, the punctum fixum, the hand, creates the support zone upon which the body is pulled toward. Therefore, in order for the body to locomote itself forward, it must create stability in the scapulothoracic region in an instinctive fashion. And isn’t natural, subconscious movement what we’re truly after in rehabilitation? I mean, have you ever thought of the “birddog” exercise as a scapular stability exercise?

So next time you rehabilitate a shoulder for dysfunctions in scapular stability, ditch the YTWLs and get your patients and athletes on the floor to act like puppies. In all seriousness, getting your patients quadruped may truly be a better way of promoting scapular stability. You already test it that way (pushup on the floor or against the wall) so why don’t you treat it that way? There are many ways of doing so choose any exercise you wish. But just to get you started, here are a few examples:

Take note that the first exercise above is the correct pattern while the second is the faulty pattern. The correct pattern promotes scapular retraction throughout and respiratory control at end range. You are welcome to follow this up with unilateral thoracic rotation with the hinge point at the scapulothoracic region rather than the spine (proper) as commonly seen in mobility-based exercises.

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This exercise that Tony is performing here obviously isn’t quadruped but I think you get my point.

This kid never played "puppy".

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“We’re having a injury-ridden season this year, and we’ve been trying to determine why. We do see very common trends among the men, and we believe it’s the guys’ lack of scapular stability and endurance in the stabilizer muscles, and general thoracic cage stability…We see a lot of mid-back injury and especially rib injuries, and very commonly rib stress-fractures.

Now, these guys have the best Strength and Conditioning team around, however the medical team feels that they’re…not getting enough stability and shoulder blade mobility exercises (they basically need to improve the stability of the scap to work in a large range of motion).

Anyway, I was wondering what you thought were the best couple of exercises for scap stability and serratus anterior activation. Now these guys are elite athletes, they’re amazing machines actually, so they can probably do some advanced stuff, but I think we need some activation exercise, and then followed by integrating this into some advanced functional movements!”

Admittedly, I have never worked with a rower in my life. However, having examined some of the current literature (Vinther et al, Warden et al) it seems as though the exact causal mechanism for such injury is not clear cut. That said, first things first.

Stress Fractures = Bone Resporption > Bone Repair

(at sites of microfractures secondary to repetitive loading)

While certainly stress fractures may be associated with abnormal (low) levels of bone mineral density and its associated factors, several causal mechanisms have been proposed to describe its etiology. Namely:

• Sheer forces resulting from co-contraction of the serratus anterior and external oblique
• Increased co-contraction levels of the serratus anterior and lower trapezius
• Poor eccentric control of shoulder flexion
• Faulty motor patterning (timing) between the lower body and the upper body
• Inadequate knee-extension strength to elbow-flexion strength ratios

From a training and periodization standpoint, it is quite easy for those on the outside to immediately suggest that such athletes are “doing too much too soon”. However, seeing that such fractures are quite common regardless of the level of athlete, we cannot simply point the finger at loading parameters. Anything and everything from biomechanics and motor control to poor nutrition to improper rest is fair game. Certainly a thorough assessment must take precedence but with respect to the above question posed, here are some recommendations for simultaneously improving scapular mobility and stability.

Scapular Mobility:

(I really like this video)

Assisted Push Pull / Twister (sorry, I couldn’t find a video on youtube)

Scapular Stability/Eccentric Shoulder Flexion:

With respect to motor patterning between the lower and upper of the body, I would consider utilizing such exercises as deadlift and jump squat variations, however, I will leave this for another post. Hopefully some of the above strategies will prove useful when incorporated into the overall training programs of these athletes. Certainly several of the exercises above are anterior chain dominant however, these athletes are exceptionally strong posteriorly and so ensuring balance between the two seems prudent. They are by no means definitive, but when indicated for the right individual, I think they can be helpful. What are your suggestions?

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And this one is never appropriate! (Even he gives the "thumbs down")

For the athlete, the best exercise he or she needs is the most appropriate one for that given training session, of that given microcycle, of that specific training block, for that…well you get my drift.

And for the patient, as I’ve mentioned previously, the best exercise is the one that is the most relevant, non-painful, and challenging  exercise that they can perform well…and very often the one that demonstrates within session improvement in mechanical sensitivity.

• Relevant meaning along the continuum of exercise progressions (and regressions) for their specific condition. Remember, relevant doesn’t necessarily mean that you are mimicking a particular movement in their activities of daily living. It simply means that it is relevant to their presentation based on your assessment.
• Non-painful because in the presence of pain, it is known that we develop high-threshold strategies that result in neuromuscular compensations…and we don’t want to perpetuate compensations, do we?
• Challenging and one they can perform well to maximize the potential of myelination within the brain. This is neuroplasticity. This is motor learning.

Does that mean they only need one exercise? No. But each exercise prescribed should have a purpose. When it comes to “corrective exercise”, shouldn’t we be “correcting” something?

Having said all that, the majority of my work pertains to the injured population. Athletes and non-athletes, I work with them both and while some may view them as two separate populations, very often the means to which we progress their care (especially in the early stages of rehab) are quite similar.

Take for example a patient who demonstrates poor neuromuscular control of the shoulder. Let’s say we’ve followed the rules of whatever system we subscribe to but for that given presentation, the individual warrants neuromuscular retraining of the shoulder. We have already addressed the other 9 principles of rehabilitation for the shoulder, we have applied our spidertech tape to enhance neural drive to this region, and we have utilized a biospychosocial approach to care to ensure that we are comprehensive in our approach.

In addition, we (may) have performed some manual rhythmic stabilizations with this individual because, as mentioned earlier, this demonstrated positive results with respect to decreasing mechanical sensitivity or improving function.

But if the above manual intervention brought about meaningful change then what type of exercise should we send them home with? Well how about the Bottoms Up Kettlebell Screwdriver and Armbar?

The reason I think these exercises are relevant is because they elicit rhythmic stabilization and proprioception without cognitive input. The glenohumeral rotations and the medial-lateral excursions of the scapula on the thoracic cage are great but the true value of these exercises come from the following:

• Increased neural drive via forceful gripping of the kettlebell (see this post by Carson Boddicker for more information)
• The constant, ever changing, and unpredictable stimulus elicited by the bottoms up kettlebell that warrants dynamic stability. This is neuromuscular control!

But who owns a kettlebell? Well who owns a foam roller? They really aren’t that different in price. Check out Elite Fitness Systems,  Perform Better and Dragon Door. You really don’t need a heavy weight because if your patient, client or athlete is at the stage where they need rhythmic stabilizations, they probably won’t need more that 16kg. I often start with 4-8 kg and once they get it, I move on…on to the next exercise required for that individual. Perhaps it may be this progression…

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What a fascinating joint complex. But complex it is, and hats off to Mike Reinold, Eric Cressey, Dale Buchberger, Michael Chivers, and others who really have a true appreciation for understanding the role of this region in human movement and athletic performance.

Another one of those individuals who truly understands the shoulder is Eric Beard. A corrective exercise specialist and manual therapist, Eric was one of Rick Kaselj’s team of experts in Muscle Imbalances Revealed.

Muscle Imbalances Revealed

I recently provided a summary of Bill Hartman’s lecture on Mobility and Muscle Imbalances which can be found here. This post, however, will focus on Eric’s lecture. So sit back and enjoy!

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Secrets and Staples of Training the Athletic Shoulder with Eric Beard

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• If you have yet to listen to one of Eric talks, you are missing out on such an entertaining and engaging speaker. It was really my pleasure to “sit in on his presentation”. Often times you will encounter boring, monotone speakers that have you constantly asking yourself (or the computer) “when do we get to the good stuff”? With Eric, this doesn’t happen. He provides relevant and important information that ultimately results in seamless transitions from one slide to the next. His passion for the shoulder certainly does not go unnoticed.

• Eric begins the lecture with a brief epidemiological literature review to provide the rationale for corrective exercise (CEx) for the shoulder. That is, the importance of using prudent strategies to minimize or prevent unwanted sequelae (i.e. secondary to impingement). He goes on to outline some everyday causes of shoulder impairment and states,

"Our bodies are NOT designed to wear man-satchels!"

• He also provides a thorough review of the anatomical structures of the shoulder, the implications of abnormal biomechanics to specific tissues, as well as some typical mechanisms of injury and tissue failure of this complex joint complex.

The shoulder is a complex joint complex!

• He then proceeds to cover some important assessments and tests for the shoulder that fitness professionals can utilize in “healthy” populations to direct one’s corrective exercise strategies. *note: I’ve been known to frown upon shotgun approaches to corrective strategies since corrective exercise should be…well…CORRECTIVE. In my opinion, giving everyone the same thing is not only lazy, but also time-wasting.

• As a health care practitioner (LMT), Eric also shares some important precautions and clinical tidbits that many fitness professionals may not be aware of when prescribing self-care strategies such as self-myofascial release. Some important information that everyone should know!

• All in all, Eric does an excellent job with this lecture. If I may suggest: when watching this presentation it is important to not focus on the slides but on his dialogue as he provides a wealth of information. This is not dissimilar to sitting in on a Gray Cook or Stu McGill lecture…you need to put the pen down and JUST LISTEN. You’ll likely have to watch this presentation multiple times, first with the eyes closed to just listen to the wealth of information he provides and second with the eyes open to appreciate the beauty of the slide show that he complements his dialogue with.

For more information on this educational resource, please visit Muscle Imbalances Revealed.

Because even the fist pump deserves optimal mechanics!

*Please note that the above link is an affiliate link but one that I highly recommend.

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• Improving Thoracic Mobility
• Money Moves

Unfortunately, they may not work for everyone. If this is the case, or if you are simply looking for another tool to add to your arsenal, take a shot at performing the “Wall Slide”. This is one of those exercises that aims to improve both your thoracic posture and scapular positioning. It’s not an easy exercise…but it sure is effective.

Performing the following exercise:

• The individual starts in a seated position on the floor with the buttocks and back flush against a wall.
• The knees and hips are flexed as much as possible, paying attention that the buttocks do not round away from the wall.
• The neck is in a neutral position
• The shoulders and elbows are in a 90 / 90 position with the elbows and hands in constant contact with the wall at all times.
• The individual is asked to press his/ her lower back as close to the wall as possible to “lock out” the lumbar spine and minimize arching throughout the movement. This is especially important when one reaches the top of the exercise.
• The individual is asked to slide his / her arms up the wall, ensuring that they are not shrugging their shoulders.
• Upon reaching the top of the movement (this is where they feel that they cannot go any further), they are asked to take one diaphragmatic breath, both inhaling and exhaling with minimal tension. Note: this breath was not included in the video below but is highly recommended.
• The arms are brought back down following the full breath and the movement is repeated.

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Performing the following exercise:

• The arms are at 90 degrees to the side with both palms facing upward
• The hips are flexed to greater than 90 degrees and depending on your level of ability, the knees can either be flexed or extended.
• The legs are then rotated to one side and while doing so, the same side palm turns downward to face the floor.
• While doing so, the opposite shoulder blade should actively be retracting (pulling) toward the ground.
• Repeat to the opposite side.

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