One of my favorite quotes from a well known fitness professional, Alwyn Cosgrove, is: “Exercise is a drug. If we give the right drug in the right dose – everything works. But, if we give the wrong drug or even the right drug in the wrong dose, we cause more problems than provide solutions.” In essence, dosage matters a whole lot. This means that getting it just right is also not by accident, but by careful analysis and exacting prescription.
After a thorough evaluation, exercise selection and progression must be predicated on the end goal for the athlete. Where are they now? How do I get him/her back to 100% Understanding the injury itself, training and medical history as well as inflammation and healing time frames is important, but that is just one part of the equation.
For those with experience, you already know athletes heal differently and no two injuries are ever just alike. Addressing the mental components outlined in my previous post, Return to Play: Part 1 (The Athlete’s Mindset), is the starting point. Next, you must formulate a plan to physically mend, challenge and prepare the athlete’s body to return to its previous functional level.
Below are some BIG mistakes I have either made along the way or witnessed in my career:
Now, on the my next big point. I strongly believe you need to know how HARD the exercises you suggest are in order to effectively prescribe them. One of my primary philosophies is that I will not prescribe exercises I cannot do. Not only is this critical for teaching proper form, it is a must to gage fatigue, workout demand, recovery needs and so on.
Possessing a solid grasp of volume and intensity is also essential. For example, having an athlete who is 6 weeks post-op with a bone-tendon-bone ACL autograft reconstruction do too much eccentric quad loading will inevitably lead to anterior knee pain or patellar tendonitis. Would you do 10 separate eccentric quad exercises (2-3 sets of 10-15 each) in one hour ? I do not do this type of volume on my healthy knee, but I have seen rehab done this way. We must always keep a watchful eye on load, time under tension and overall volume throughout the rehab process. The proper balance is critical.
Working with athletes of many disciplines affords me an opportunity to look at many shoulders week to week. Increasingly, I am seeing more Crossfit athletes for various shoulder problems. In many cases, they have rotator cuff tendonitis, impingement, AC joint pain, labral pathology or a combination of the aforementioned issues. The other big group of athletes I see is throwers.
These two groups share many of the same dysfunctions including posterior shoulder tightness and decreased mobility. Tightness in the pecs and lats is commonplace. I feel latissimus tightness often goes unnoticed or perhaps is not an area of emphasis in prehab/rehab plans. Tight lats will restrict elevation and contribute to postural dysfunction.
With restricted elevation, athletes may turn to excessive spinal extension and/or rotation to achieve elevation necessary (e.g. overhead squats, snatches, throwing) and this can contribute to poor movement patterns. I have also seen this impact volleyball players asymmetrically with serving and hitting.
Lat tightness can easily be assessed by placing the athlete supine and simply asking them to bring the arms completely overhead. While most people do not have 180 degrees of flexion, I feel working to achieve elevation greater than or equal to 160 is completely reasonable. The body often uses abduction and external rotation to make things work (and this is natural for throwers), but the more pure elevation capacity we have the the better.
Crossfit involves lots of pull-ups and throwing heavily utilizes the pecs and lats for acceleration. It only follows that muscular tightness in this region may need to be addressed. Step one often involves soft tissue mobilization/compression techniques. I prefer to use a Trigger Point ball or Grid to work on the soft tissue mobilizing it on the wall (TP ball) or floor (Grid) in an elevated position.
Next, I like to employ active mobility work. I recently featured a simple exercise using the BOSU Ballast Ball in my PFP column. The pictures below reveal a rolling double arm version, as well as a single arm method/progression. These active movements can also be complimented by sustained holds as desired.
For a more detailed description and application of this exercise, click here to read my “Functionally Fit” column. I had one Crossfit enthusiast see me for limited shoulder mobility as it was hindering his overhead lifts and causing back pain. He had about 130 degrees of shoulder flexion. Daily STM using the foam roller, mobility work and some stretching increased his elevation by 10 degrees in 2-3 short weeks.
So, the take home message is that overhead athletes should assess and address this limitation if it is present as it may cause kinetic chain issues and energy leaks. Improving mobility will better enable utilization of proper muscle activation and optimal movement patterns.
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Below are two videos demonstrating some sliding exercises I like to use in training and rehab. The first video reveals one of my tougher hamstring exercises I prescribe, while the second video displays some shoulder/core stability variations using sliding discs. I have included links to the PFP columns that better explain the set-up, execution and application for each exercise.
I work with lots of patients and clients who consistently demonstrate inadequate hip and core stability. I see this show up routinely as asymmetrical 1’s for the trunk stability push-up, in-line lunge, hurdle step and rotary stability movements on the FMS. Unfortunately, this has been a recurring them in many of my females recovering from ACL reconstruction as well as runners with persistent pain/dysfunction in one lower extremity.
I am always looking for better ways to train the body in whole movement patterns as well as functional positions. One of my preferred positions is to test and challenge my clients in a split squat position. I begin with an isometric split squat cueing proper alignment and muscle activation. As clients master isometric postural control, I will allow them to add an isotonic movement by squatting in the position.
As they progress, I will add in perturbations to stimulate changes or challenges to their center of gravity. Often, you will see them struggle much more on the involved side. But to be honest, I find most people have an incredibly hard time maintaining proper alignment for long without cheating or falling forward or to the side. Allowing clients to lose form is okay provided they are cued to fix their alignment or they naturally self correct.
An additional wrinkle I throw in for this training is using the BOSU Balance Trainer. Below is a video that shows how I use this progressing from shin down to just the toes as a support on the trail leg. The second version will burn up your clients’ thighs and quickly become one of their least favorite exercises. The great thing is that you do not have to offer much resistance to create a significant perturbation.
For more detail on this exercise and application, click here to read my PFP column featuring it this week.