Brian Schiff’s Blog

The shoulder mobility screen in the FMS often reveals side-to-side asymmetries.  It is more common to see hypermobility in female clientele, while their male counterparts exhibit more hypomobility.  Overhead athletes tend to demonstrate excessive horizontal external rotation and a relative loss of internal rotation on the dominant side.  This hypomobility can be detrimental to overhead athletes and increase risk for overuse injuries if it becomes excessive.

The following exercise is an effective way to improve shoulder mobility and optimize function.  One important point is to focus on form and move very deliberately through the motion.

Execution: Begin lying on the floor face up.  Bend the left knee up to 90 degrees and cross the right leg over top of the left interlocking them.  Roll to the left side and pin a folded towel or pad between the right knee and the floor.  Place the arms in 90 degrees of shoulder flexion with the right on top of the left in an outstretched position. Next, slowly sweep the right arm up overhead and around the body as you attempt to place the torso/back on the floor.  The finish position for the right arm will be reaching the right hand and arm up behind the back.

Exhale as you perform the sweeping motion and hold the end position for 2 seconds.  Reverse direction and return to the start position.  Perform 5-10 repetitions on each side.

Application: Limited shoulder mobility is a common finding, especially among male clientele with tightness in the pecs, lats and posterior shoulder.  Asymmetry with respect to mobility is common with greater difficulty found trying to reach the dominant arm up behind the back on the FMS shoulder mobility screen.  This exercise will help improve thoracic spine motion and shoulder mobility.  The focus should be on strict form and proper stabilization to avoid unwanted motion.  Pinning the pad (or towel roll) to the floor will help ensure better stabilization.

If hypomibility is an issue and clients score a 1, foam rolling the pec minor/major, latissimus dorsi and the posterior rotator cuff musculature prior to performing the exercise will be helpful.  Stability training can be added in later once the soft tissue mobility restrictions and movement pattern is improving.

One of the most difficult problems to treat in the clinic is chronic pain related to tendinopathy.  More specifically, the Achilles tendon, patella tendon and elbow extensors often present challenges for doctors and clinicians alike when it comes to effectively reducing or resolving pain.  Over time, people develop chronic inflammation or even little tears in the muscles running up to the lateral epicondyle.

There have been many studies done looking at PRP over the past 5-10 years.  The debate continues, however, with respect to its efficacy in terms of results, especially given the fact that patients must currently pay out of pocket for the procedure.  I have written two earlier posts on PRP that you may be interested in reading as a back drop for this one:

2011 – An Update on Platelet Rich Plasma

2011 – Platelet Rich Plasma and Rotator Cuff Repairs

Currently, my approach to treating these injuries involves an approach focused on soft tissue mobilization via instrument assisted soft tissue mobilization, stretching, strengthening and a trial of iontophoresis in most cases.  We also offer dry needling at our facility and this has been effective in reducing pain.  I will talk more about this point later as it relates to the prospective multi-center trial summarized by Mishra et al. in the February 2014 edition of the American Journal of Sports Medicine.

Before I get to the study, I thought it would be pertinent to provide some straightforward information on PRP as it is a question that comes up with patients on a regular basis.  Essentially, the process is as follows:

1. Collect 30-60 ml of blood form the patient’s arm

2. Blood is then placed in a centrifuge.  The centrifuge spins and separates the platelets from the rest of the blood.

3.  A syringe is then used to extract 3-6ml of the platelet-rich plasma

4. The concentrated platelets are then injected into the elbow (or site being treated)

The thought behind PRP is to increase the growth factors up to 8x, which promotes temporary relief and stops inflammation. The question is how successful and cost effective is this process?  Consider that opting for surgery will run between $10,000 and $12,000 figuring in costs for the surgeon, hospital/surgery center, anaesthesiologist, etc.  PRP injections will cost upwards of $1000, so one would think that would be a favorable option for insurers if surgery could be averted.

What about cortisone injections?  They are widely used as a survey of 400 members of the American Academy or Orthopedic Surgeons found that 93% had administered a corticosteroid injection for lateral epicondylar tendinopathy.  According to Bisset et al (Br  Med J 2006) and Lindhovius et al (J Hand Surg Am 2008) cortisone injections do provide short term pain improvements but also result in a high rate of symptom recurrence.  There are other potentially harmful side effects from injections including: reduced collagen synthesis, depletion of human stem cells, depigmentation, and enhancement of fatty and cartilage like tissue changes that can lead to tendon ruptures.

So, the big question is whether or not tendon needling with PRP is an effective treatment option for chronic tennis elbow suffers. Mishra and his colleagues set out to examine this with a double blind, prospective, multi-center randomized controlled trial of 230 patients.  In the study, the patients were teated at 12 different facilities over 5 years.  All patients had at least 3 months of pain/symptoms and failed conservative treatment.

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This is the fourth corrective exercise I have featured in my “Functionally Fit” online column for Personal Fitness Professional Magazine.  All of the correctives are based on screening assessments from the FMS.

The active straight leg raise (ASLR) assessment (as part of the FMS) is an essential part of any assessment I do on my athletes and runners.  It provides a great look at a client’s ability to stabilize their spine/pelvis and we observe hip separation with one hip moving into flexion and the other fixed hip moving into greater relative extension.

Why does hip disassociation matter?  Simply put, a lack of ideal separation can negatively impact step and/or stride length, reduce propulsion and create other compensations that increase energy expenditure and reduce overall running form.  Some deviations that may occur include hip drop, increased rotation or circumduction of the swing leg, excessive torso rotation, increased knee flexion and diminished stride length to name a few.

Execution: Lie on your back.  Using a doorway, place one leg against the doorway in a position that allows you to keep the lumbar spine flat while the other leg is extended and on the floor.  Next, flex the down hip to the height of the other fixed leg extending the knees.  This leg will remain unsupported.  Now, point the toes of the unsupported leg and reach out toward the ceiling.  Slowly lower the leg to the floor or the lowest point where you can still maintain a neutral lumbar spine (a bolster may be placed beneath the leg if needed).  Perform 10 repetitions and repeat 2-3 sets on each side.

Progress the activity by lowering the leg further and/or sliding closer to the doorway to increase the hip flexion and total hip separation.  Do not allow the lumbar spine to extend as this is a common compensatory motion for limited mobility in the iliopsoas.

Application:  This activity will improve active mobility of flexed hip as well as promote continuous core stability and available hip extension of the opposite hip.  It challenges the client’s ability to disassociate the lower extremities while maintaining stability in the pelvis and core.  Keep in mind it is more than just a hamstring flexibility activity as it also addresses static (pelvis/spine) and dynamic (hip) stability in asymmetrical hip separation pattern.

This separation pattern is essential for optimal running mechanics.  Poor hip disassociation can lead to asymmetrical or bilateral movement flaws, thereby reducing performance and leading to compensatory motion with an elevated risk for injury. This simple technique can be done daily to enhance hip mobility and pelvic/hip stability.

Perhaps one of the most researched topics is ACL injuries.  I have been studying and working for years in my clinical practice to find the best ways to rehab athletes following injury as well as implement the most effective injury prevention strategies.  Prior studies indicate prevention programs even when self directed can be successful.

However, on the whole injury rates have not declined over the past decade or so.  Much attention has been given to valgus landing mechanics, poor muscle firing, stiff landings, genetic difference between males and females, ligament dominance, quad dominance, and so forth.  The predominant thoughts today for prevention center around neuromuscular training and eliminating faulty movement patterns (refer to work being done by Timothy Hewett and Darin Padua).

We also know from a biomechanical standpoint that the hamstrings play an integral role in preventing excess anterior tibial translation, and as such hamstring strengthening needs to be a big part of the rehab and prevention program.  I believe in hamstring training that allows for activation in non-weaightbearing and weight bearing positions.  Common exercises I will use include:

• HS bridging patterns (double /single leg, marching, knee extension, stability ball)
• Nordic HS curls
• HS curls (stability ball, TRX or machine)
• Sliders – focus on slow eccentric motion moving into knee extension followed by simultaneous curls/bridge
• Single leg RDL (add dumbbells or kettle bells for more load)

Note: click on any of the thumbnail images above for a full view of the exercise.  From left to right: Nordic HS curls, sliding hamstring curls and single leg RDL).

A recent blog post entry by the UNC Department of Exercise and Sport Science (@UNCEXSS) has spurred my post today.  Click here to read their entry on optimizing injury prevention based on work done by Professor Troy Blackburn regarding the effect of isometric and isotonic training on hamstring stiffness and ACL loading mechanisms.  The research that was done holds promise for hamstring training designed to increased musculotendinous stiffness (MTS).

Continue reading…

This post is the third corrective exercise in a series I am doing for Personal Fitness Professional Magazine in my online column titled “Functionally Fit.”  To read more online exercise tips, visit www.fit-pro.com.

The hurdle step assessment (as part of the FMS) is designed to challenge the body’s proper stepping and stride mechanics as well as stability & control in single leg stance.  The step leg must perform ankle DF and hip/knee flexion while core stability must be present in single leg stance.

Limited hip mobility and/or poor hip and core stability restricts natural movement and leads to compensatory motion often in the form of unwanted hip rotation, hip hiking, trunk sway in the frontal and sagittal plane.   A common corrective exercise prescribed to improve core stability is a standing march (single leg stance) with straight arm pulling to engage the core.

Execution: Begin standing with the feet together while holding the cable handles with the palms down.  Select a weight that provides ample enough resistance to maintain isometric shoulder extension for 30-60 seconds.  Be careful not to select too little or too much weight as this will disrupt the execution of the exercise.

Next, pull the arms down toward the side and hold in that position.  Maintaining an erect posture, slowly lift the left leg up (ankle dorsiflexion with knee and hip flexion) and pause for 2-3 seconds.  Move the unsupported leg back to the start position but keep the arms actively extended.  Repeat this sequence for 10 times on the left leg.  Rest for 30-60 seconds and then repeat on the other leg.  Perform 2 sets.

Additional notes: I tend to focus on unilateral consecutive repetitions (as described above) especially if there is a 2/1 asymmetry with the hurdle step.  As the asymmetry is resolving, I will progress to a reciprocal pattern as this is more natural in life/sport.  If a cable column is unavailable, alternate methods include using a suspension training apparatus or resistance tubing anchored high enough to accomplish the same upper body isometric pulling.

Application:  Poor hip stability and control in single leg stance is a common cause of overuse injuries in runners and contributes to increased risk for anterior knee pain and ACL injuries.  Keep in mind that poor performance on the hurdle step movement can be related to weak hip flexors on the stepping leg, tight hip flexors on the stance leg, diminished hip stability and poor balance.

It is critical to assess the whole movement prior to assuming that there is just one problem or weak link in the kinetic chain.  Restoring symmetric, optimal stepping patterns will promote proper hip disassociation, as well as training the body to synergistically activate core and hip musculature to demonstrate optimal single leg stability in unilateral stance.