Brian Schiff’s Blog

As a therapist and fitness enthusiast, I always want to know the “why” and implications for exercises.  I have posted on modified push-ups in the past, but I felt compelled to share some information that was published in the October 2012 Strength and Conditioning Journal.  Bret Contreras et al. discuss the biomechanics of the push-up and provide an excellent overview of the different types of push-ups and what research has to say about them.

I was most interested by the parts on unstable push-ups as I tend to use the BOSU Balance Trainer and BOSU Ballast Ball in many of my programs.  Here are some key points that the authors point out that are worth mentioning:

• BOSU push-ups have been shown to increase activity of some of the scapular stabilizers namely upper, middle and lower trapezius fibers compared to standard push-ups, while serratus anterior activity is diminished (Tucker et al. Arch Phys Med Rehabil 2010)
• Lehman et al. (Man Ther 2008) reported that elevating the feet above the hands had a greater stimulus on scapulothoracic stabilizing musculature than placing the hands on an unstable surface
• Lehman et al. (Dyn Med 2006) found that push-ups w/hands on a stability ball significantly increased the triceps brachii activation as well as invoking increased activation of pec major, rectus abdominus and external obliques compared with push-ups on a bench from the same angle.  However, note that feet on the stability ball did not affect muscle activity compared to push-ups with feet on a bench at the same angle
• According to Marshall and Murphy (Apply Physiol Nutr Metab 2006) triceps brachii and abdominal EMG activity was much greater when performing push-ups off a stability ball compared to stable surfaces from flat and elevated positions

Takeaways:

1. Using unstable surfaces for push-ups when the primary base of support is the stability ball, BOSU, or BOSU Ballast Ball is more effective in increasing muscle activation of aforementioned muscles
2. Placing the feet on an unstable surface does not add much benefit in terms of increasing muscle activation
3. Maintaining a stable torso and spine angle is key and should not be compromised with an unstable surface

Other thoughts of mine:

Mastering form, alignment and strength with stable push-ups is common sense, right?  So, do not advance to unstable push-ups without pre-requisite strength and satisfactory technique in a stable environment.  Wrist mobility, shoulder stability, and core strength are just a few other key factors that should weigh in your decision to implement unstable push-ups.

Considering some isometric work with slightly bent elbows or even some small pulses can be effective in progressing toward these more advanced unstable push-ups.  Clients need to understand the point of no return and I prefer to spot closely particularly when using a stability ball or BOSU Ballast Ball.  Working with the BOSU (dome side down) is generally safer and allows for easier modification with the knees on the ground for those with less upper body strength or diminished control.

I also like to add a plus (scapular protraction at the top) to help counter the loss of serratus activity seen with BOSU push-ups. In the end, I really like using the unstable surface as the point of balance and have for some time.  There are many ways to do push-ups, but considering some unstable work has a good return for those clients whoa ready for it.

Below is a picture of the BOSU Ballast Ball – I prefer it over the stability ball as it is less likely to slip out from underneath the client.  It provides excellent shoulder and core stability work – my primary goals when electing to use it.  Reps, sets, progression and recovery will be dictated by fatigue and form at all times.

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.

It has been a while since my last post.  To be honest, I have been busy with preparing/presenting my live seminar last week and webinars, as well as fulfilling my writing obligations and clinical role.  So, I have been taking a “break” from blogging and recharging the battery so to speak.

Now I am getting back to it.  The great thing about presenting though is that I am consistently reading and reviewing the latest research on topics related to my presentations and closely examine my rehab and exercise philosophy.  In my clinic, I treat many runners for knee pain.

The average profile is an experienced runner b/w the ages of 25 and 50 who logs 20 – 35 miles per week and routinely competes in half marathons or some sort of triathlons.

Common injuries include IT band problems versus lateral meniscus tears versus patellofemoral pain.  Often, I uncover the following things related to kinetic chain deficiencies:

• Elevated or rotated inominate
• Ankle dorsiflexion restriction (OH squat assessment)
• Poor single leg stance
• Weak lateral myofascial chain
• TFL dominance
• Excessive femoral internal rotation/adduction with single leg squats
• Tightness in hip flexors, ITB and soleus

Many currently debate the efficacy of foam rolling.  Is it worthwhile?  Some say yes, while others say no.

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It is no secret that proper scapula alignment and muscle activation makes for a healthy shoulder.  There are many forms of dysfunction that may be present.

Generally speaking problems revolve around muscular tightness/weakness and faulty movement patterns.  The term “SICK” scapula is often used and refers to Scapula Inferior Coracoid Dyskinesis.  Common examples of a “sick”  scapula include:

• Type I – Inferior border prominence.  This is typically related to tightness in the pec minor and weakness in the lower trapezius.  Keep in mind the upper trapezius will naturally dominate the lower trap in the force couple with the serratus anterior for upward rotation.  You may also see increased thoracic kyphosis which will inhibit the normal resting position of the scapula.
• Type II – Medial border prominence.  In this case the scapula is internally rotated or protracted and there is liekly weakness present in the rhomboids and middle trapezius.  The serratus anterior may also likely be weak with evidence of scapular winging.  This position places the humerus in relative internal rotation and increases risk of impingement with arm elevation.
• Type III – Superior border presence.  Here the scapula appears elevated in the face of an overactive upper trap and/or levator scapulae.  With active arm elevation, you may notice excessive shrugging or superior humeral head migration in light of the imbalance.  Again, the lower trapezius is probably weak and being overpowered.

Click here for a great graphic display from the Journal of the American Academy of Orthopaedic Surgeons of how the scapular muscles work collectively as a force couple to promote optimal movement in the shoulder.

In many of the throwers and overhead athletes I see in the clinic, they often exhibit either medial border prominence of inferior border prominence.   Additionally, I frequently observe GIRD (glenohumeral internal rotation deficit) values of 20 degrees or higher in those patients who come in with symptomatic shoulders (rotator cuff and/or labral issues).  What does this mean?

Well, in a nutshell, it means addressing posterior capsule tightness in the throwing shoulder is important for avoiding internal impingement and SLAP tears.  Tightness (or too much GIRD) can increase the load/tension in the late cocking phase of throwing thereby contributing to friction between the cuff and labrum, as well as excessive torsion on the proximal biceps tendon.  Any excessive humeral head migration with repetitive throwing is a recipe for injury over time.

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Disclaimer: This post is a small rant from me.  I normally don’t use this blog as a medium for that purpose. However, I feel so strongly about this topic that I decided to share my thoughts on it.

I had an interesting email exchange with a health care practitioner (HCP) this past week.  She had some questions about one of my products and asked specifically if I had done a clinical trial comparing my treatment method to leading national PT organizations.  My answer was no.

I explained to her I am not a researcher, nor do I have the time (or money for that matter) for such things as I am in the trenches every day treating patients and training athletes.  Her response was very interesting.  According to her I was defensive, and she suggested I check out a DPT program so I could in essence become a better clinician.

Hmmm………  Suffice it to say I completely disagree with her on this one.  I graduated from PT school at the Ohio State University in 1996.  Their program was very well respected at the time (over 500 applied and they took 60 in my class) and two of my professors (Lynn Colby and Carolyn Kisner) wrote the text on Therapeutic Exercise that is still used in many curriculums today.  On top of that, I worked at the top outpatient ortho clinic in the city as an aide my junior and senior year in college.

At the time of my admission, OSU only offered a B.S. degree, so I never had a choice for more at that point.  The university quickly adopted a Master’s program shortly after I finished and later became one of the first institutions to offer the full DPT program.

Upon graduation, I went to work at the same top ortho clinic and spent 5 years working side-by-side with some of the brightest PT’s and next door to what was considered by many to be the best surgical group in town.  I saw surgeries, sat in on MD appointments with my patients, participated in journal clubs and worked at a feverish pace.  Let’s just say I saw lots of patients and gained what felt like a fellowship experience for 5 more years.

Now, as I reflect upon this email from said HCP, I can honestly say that I believe experience and results matter more than just those three letters behind a name.  That is in no way meant as a slam or any disrespect to the DPTs out there, clinical research trials or the doctorate degree itself.  Students today have no choice but to take the DPT route.  To be honest, they really only have (1) more year of structured curriculum than I had in my program.  They leave school with a lot more debt, and afterward they still have no clinical (real world) experience when they first start out.  You simply can’t buy experience in school.

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