It's ONLY bursitis, nothing a little cortisone won't fix...

I've heard this a few times. And it really really annoys me.

What people fail to understand, is that cortisone is like a pain-relieving Band-Aid and that the problem is likely to recur somewhere down the track. If you don't figure out the WHY behind the bursitis, you probably will struggle to overcome it. Don't get me wrong, cortisone can be beneficial for some chronic conditions but the mechanics of why the problem started in the first place still needs to be investigated.

Bursitis in the shoulder is one of the most common causes of shoulder pain and the sub-acromial bursa is usually the culprit. The sub-deltoid bursa can also be a cause of shoulder pain but is less commonly seen.

So what is a bursa exactly?

A bursa is a fibrous sac located around tendons and the underlying bones in numerous locations in the body. Its main role is to act as a cushion between the tendon and bone, providing a smooth surface for the tendon to glide. When the bursa becomes inflamed, it fills with fluid, causing pain and restriction of movement.


There are a few things that can cause sub-acromial bursitis in the shoulder:

• repetitive overhead movements - overuse injury
• trauma - such as a fall
• poor shoulder biomechanics - poor posture, rounded shoulders, etc.
• weakness of scapular stability muscles such as rhomboids, lower traps
• weakness of rotator cuff - particularly subscapularis**
• tightness of the posterior capsule of the shoulder
• bony abnormality such as osteophytes, hooked acromion (primary external impingment)

I'm not going to discuss each of the points listed above, but do want to talk about the subscapularis muscle, which is a muscle of the rotator cuff, most commonly known as an internal rotator of the shoulder. However, the most important role of this muscle is to compress the humeral head into the glenoid fossa and prevent anterior and superior translation of the shoulder during functional activities. Restriction of the subscapularis muscle will limit external rotation ROM and trigger points in this muscle can refer pain into the back of the shoulder and down into the wrist.

Subscapularis trigger point referral pattern

There are a few tests to assess the subscapularis for tears - check out the link for the tests.
http://eorif.com/subscapularis-physical-exam. However, the subscap push off test is more a test of subscapularis strength. Try this at home to see if your subscapularis is working or not:

• Stand 3/4 of a foot length away from a wall
• Place one hand behind you, just in your lower back
• Keep your head and thoracic spine against the wall
• Bring your elbow forward so it is NOT resting against the wall
• Now, using only the heel of the hand (not the fingers), attempt to lift yourself away from the wall WITHOUT ALLOWING THE ELBOW TO DRIFT BACKWARDS
• Do not use your fingers or wrist to initiate the movement and do not allow the body to lean forward or head poke

 An inability to perform this test may be indicative of a weak subscapularis muscle.  If you cannot get your hand behind your back for this test, you either need to work on your internal rotation ROM or perhaps get further investigation for possible tear of subscapularis. For athletes requiring good rotator cuff strength, i.e. Crossfitters, you should be able to perform this movement properly 8-10 times. How many can you do??

So, if you are suffering with shoulder pain and the diagnosis is bursitis, I would think long and hard about getting that cortisone shot your Doctor will likely offer you. Yes, it may relieve your pain in the short term, but if you want it fixed permanently you need to address your faulty biomechanics and a lazy subscapularis.

Lower back pain

If you have ever suffered a lower back injury, you know it is something you never want to experience again. I, for one, can vividly remember all the time I spent suffering with crippling back and leg pain and feeling as though I would never be able to play sports again.

My story goes back a long time, to when I was playing volleyball at College. I don't actually remember doing anything to my back during practise, but can remember the walk back to my car afterwards. By the time I got to my car, I couldn't stand up straight without pain. 2 weeks later after numerous visits to the Chiropractor I recall my roommate at the time saying to me "It can't be THAT bad, just stand up and get over it". Years later, when she suffered a disc injury, I got an apology: "Now I understand what you went through all those years ago and I'm sorry for being so unsupportive".

Unless you have suffered with a back injury, it is difficult to understand what that person is going through.

My back eventually got better but every couple of years it would flare up. The next time was when I took up snowboarding. This time I saw a Physio for treatment who explained it was my SIJ and a pelvic rotation problem. Commence "core strengthening" exercises. A couple of years later, I dove for a ground ball playing softball and once again was crippled with pain, this time the pain started shooting down my leg - "sciatica". The Physio I saw this time suggested it may be a disc bulge. I was 24 at the time. The next time my back "went" I was living in Australia and when I saw a GP demanding a CT scan to figure out the problem once and for all, he hesitated and said "I was too young for such a back problem" but relented and wrote a referral for a CT.

Turns out I had a "severe L5/S1 disc herniation causing considerable deformity of the thecal sac". Hmmm, too "young" for a back problem hey Doctor?!?

MRI of my lumbar spine in 2005.

Three visits to three different surgeons resulted in three different answers:
Doctor 1: "Let's operate".
Doctor 2: "You're nowhere near bad enough to require surgery".
Doctor 3: "I'm surprised you're functioning at such a high level considering your scans. But lets wait 6 months and see what happens".

All I can say is that I am happy that I didn't listen to Doctor 1.  Even though at the time I couldn't sit for more than 15 minutes without pain and was honestly wondering if I would ever be able to play a sport again without reinjuring myself.

Fast forward to today. I have been participating in Crossfit for 4 years and can probably count on one hand the number of times my lower back has been a problem. I am doing all the exercises I remember avoiding at the gym for fear of hurting my back eg. deadlifts, situps, GHD situps, heavy squats, etc. So what's the secret to rehabbing/"fixing" a dud back? Here are my top tips:

1. Get it checked out by a professional and don't be afraid to get a scan (CT, MRI). It is the only TRUE way you can get an accurate diagnosis.

2. Do what your therapist tells you to do. If this involves not lifting for awhile, listen to them. If they give you exercises/stretches to do - do them consistently. It isn't going to help doing them for a week then going back to training because "you feel ok". If you have a disc injury it WILL take weeks to heal. Going back to training before you are ready will only set you back in the long run.

3. STOP if you feel a "niggle" during training. That niggle is your body warning you that something isn't quite right. So many times I get told by patients that they felt "something not right" but kept going, just before they hurt themselves. Stopping in a workout will not kill you. Push the ego aside and listen to what your body is telling you. Last week I overcooked a split jerk and threw it back over my head too far and landed with my lower back extended. I felt it niggle straight away and opted to stop the workout even though I wanted to keep going.

4. Get your technique right. Deadlifting 200kg with a bent back only makes you look like an idiot.

5. Do regular mobility. 

6. Get your glutes STRONG and functioning PROPERLY. This means that they should switch ON during squats, deadlifts, kettlebell swings, Oly lifts, push ups, etc. If you feel your back during any exercise then your glutes probably aren't working properly. And if your hip flexors are too tight (from sitting all day....), your glutes probably aren't working properly.

Tennis elbow

Thanks to everyone who requested a topic for the blog on the MobilizeMe Facebook page!

So, your elbow started hurting a couple weeks ago, just a dull ache on the outside of the arm. Nothing major, just a bit niggly after lifting. So you ignore it and keep on lifting. A couple months goes by and the pain gets a bit worse and now hurts when trying to open a jar at home. You try doing a few stretches here and there and consult Dr. Google to try and figure out the problem. You’re pretty sure it’s tennis elbow; satisfied with a “diagnosis” you buy a brace, wear it sometimes and keep on doing all your normal activities, maybe supplement your diet with a few painkillers or anti-inflammatories to dull the pain. Next thing you know, you can’t shake someone’s hand without pain and you have to ask someone else to open that jar for you.

 Sound familiar??

Tennis elbow or lateral epicondyalgia  is a repetitive “strain” injury (or RSI) that affects the lateral (outside) part of the elbow and is not limited to those who play tennis. It is an injury that limits your ability to grip with the hand, extend the wrist and pick up objects even as light as a cup of coffee and can last for a couple of weeks up to a couple of years.

Lateral epicondyalgia is commonly caused by chronic, non inflammatory changes in the extensor carpi radialis brevis (ERCB) tendon. This muscle of the forearm is responsible for extension of the wrist and its tendon attaches to the lateral epicondyle of the humerus.

Signs & Symptoms of Lateral Epicondyalgia:

·         Pain over the lateral part of the elbow that may or may not radiate down the forearm

·         Pain with gripping or shaking hands

·         Pain with wrist extension

·         Pain with extension of the 3^rd finger

·         Pain with lifting, especially with the palm pointing down

·         Reduced grip strength when compared to non-affected arm

Causes of Lateral Epicondyalgia

·         Repetitive gripping, typing, twisting movements of the forearm (using a wrench/hammer)

·         Repetitive wrist extension (such as in the backhand in tennis)

·         Trauma/direct blow to the outside of the elbow

·         Compression/constriction of the radial (C5/6) nerve

·         Tightness of wrist extensor muscles

·         Cervical pathology – C6/7 disc injury/radiculopathy may be associated with tennis elbow

Management of Lateral Epicondyalgia

·         Conservative management  has been shown to improve symptoms in 90% of patients (Hay et al., 1999)

·         Modification of activity: avoiding movements/activities that aggravate symptoms is necessary for treatment success.  This means that returning to Crossfit and continuing on with your daily WODs will NOT get rid of the problem...!!!

·         Stretching of tight muscles

·         Eccentric strengthening of extensor muscle group

·         Manual therapy

·         Acupuncture/Dry Needling

·         Deload Taping

·         “Tennis elbow” brace worn distal to lateral epicondyle

·         Neural glide exercises if indicated

·         Corticosteroid injections       

·         Autologous blood injections or Prolotherapy

 

All the gripping and lifting we do in Crossfit can cause lateral epicondyalgia and ignoring the problem will not make it go away. The longer you leave initiating treatment, the longer you will suffer.  Most cases of tennis elbow can be managed conservatively (without surgery) so get it sorted before it keeps you out of training.

 

 

How's your form??

I know that for the most part, I tend to go on about mobility and how important it is to achieving good performance and longevity in Crossfit. But something I heard yesterday made me realize that no matter how much mobility you do, if you aren't performing the movements with correct form and technique, you will probably end up injuring yourself.

Imagine yourself turning up at the box and seeing your WOD for the day:

It has a weight for a movement that you KNOW you can just smash out. You want to get a killer time and beat every other person at your box. This is YOUR workout and has your name just written ALL over it. So you hit the workout with all your energy and gusto and leave everyone in the dust. But your form is crap. You don't care, you just want to go as fast as possible. You are a lion ripping the head off a zebra and NO ONE can stop you. Until you feel a "pop" in your lower back and next thing you know, you're on the ground, looking at the ceiling wondering WTF just happened. Getting up off the floor is a struggle and you can't stand up straight. Shit.

Your technique/form should not change regardless of the weight on the bar or how fast you want to go. No time on the whiteboard is worth sacrificing your form for. Especially considering you now have to spend a couple weeks at the physio getting your back sorted out.

I know most people have watched the Crossfit Games and have admired Rich Froning's physical abilities. But have you noticed that regardless of how many workouts he has done, how tired he may be, his form DOES NOT CHANGE. Have a look at him doing the Cinco WOD with the weighted pistols. His form is flawless. http://www.youtube.com/watch?v=KXGybheNPMU (Have a look at how Jason Khalipa's knee drops in while he does pistols).

There are really not many people out there who have the strength and stability to be able to perform single leg squats without losing pelvic/hip control, let alone with weight, at the end of FOUR days of gruelling competition. The single leg squat is actually a test that physios use to assess a person's ability to control the pelvis. The majority of people I see struggle to maintain control dropping into a 1/4 single leg squat.

If you are struggling with injuries, you probably need to get someone to really have a look at your technique, especially under load/fatigue with varying speed of movments. Videoing your movements is a great way of seeing what really happens as you get tired. You may have to push the old ego aside and scale all your weights right back, in order to get your movments perfected before you conquer the Crossfit world. It will take time and effort, but it will be worth it.

1st Rib Funkiness

I was asked to do a post on 1st rib dysfunction on the MobilizeMe page so here goes!

How do you know if you have a problem with the 1st rib?

• Neck/shoulder pain
• Upper trapezius tightness/spasm
• Headaches
• Jaw pain
• Referred pain into neck, shoulder, chest or arm
• Pins & needles into neck, shoulder, chest or arm
• Chest pain



Scalene trigger point referral

The first rib serves as an attachment point for your scalene muscles (anterior, middle and posterior), subclavius and serratus anterior. If your scalenes are  too tight, they can pull the 1st rib superiorly (upwards) and cause the joint to become stiff. Trigger points in the scalenes can refer pain into the chest, thoracic/scapular region and into the shoulder, arm and hand.

Upper Crossed Syndrome

First rib dysfunction is usually (but not always) the result of poor posture, which is commonly referred to as "Upper Crossed Syndrome" or "Forward Head Posture". This frequently seen posture occurs when the head sits anteriorly on the spine, which loads up the posterior musculature (upper trapezius, levator scapulae, etc). The normally lordotic cervical spine becomes more kyphotic, the shoulders round forwards due to tight pectoralis major/minor and the thoracic spine becomes stiff and hyperkyphotic. The deep neck flexors at the front of the neck become long and weak, as do the rhomboids, middle and lower trapezius. In addition, this posture results in altered biomechanics at the shoulder joint which can ultimately cause rotator cuff injuries, impingement, etc.

Thoracic Outlet Syndrome (TOS) is another condition which can be the result of a hypomobile or elevated 1st rib in which the nerve and blood supply from the superior thoracic outlet is compromised. The compression usually occurs between the anterior and middle scalenes, and can result in pain, paresthesia (pins and needles) and weakness of the upper limb. There are other mechanisms, such as a cervical rib, a Pancoast tumor or abnormalities of the clavicle, that can also cause thoracic outlet syndrome.

So what can be done about this?

• Stretch/trigger point release/mobilize/massage your scalenes, upper trapezius, levator scapulae, pectoralis major/minor
• Strengthen your lower trapezius, rhomboids and deep neck flexors
• Mobilize your thoracic spine (foam roller, massage balls)
• Mobilize the 1st rib  -->  http://www.youtube.com/watch?v=RfiTL-0sW_c
• Work on improving your posture
• Take regular breaks from your computer if you work at a desk
• Keep your head back against the headrest whilst driving. Girls - take your hair out of a ponytail (if you wear your hair in one) whilst driving.
• Strengthen your rotator cuff muscles

If you are experiencing any neurological symptoms (referred pain into the shoulder, chest or arm), pins & needles, weakness or loss/change of sensation - it is highly advised that you seek out Professional advice from your Physiotherapist, Chiro or Osteopath. They will be able to assess you thoroughly to figure out what is going on and then provide you with treatment to help ease your pain!

There is scalene and upper traps stretches in the MobilizeMe app - go check them out on the App Store or Google Play.


https://itunes.apple.com/ca/app/mobilizeme/id576108153?mt=8

https://play.google.com/store/apps/details?id=com.hongji&feature=nav_result#?t=W251bGwsMSwxLDMsImNvbS5ob25namkiXQ

Why Pec Minor can be a major pain

The pectoralis minor muscle isn't one that is often discussed, probably because it is overshadowed by it's larger and more superficial (closer to the surface) friend, pectoralis major.  Pec major is that big muscle on the surface of the chest that is responsible for bench press type movements. Pec minor is the smaller muscle underneath that arises from the 3rd, 4th and 5th ribs and attaches to the coracoid process of the scapula and contraction of this muscle causes the scapula tilt anteriorly (forward and down).

If this muscle is too tight, it can potentially cause the following:

• rotator cuff impingement
• forward head posture leading to neck pain and dysfunction
• increase in trigger points through the upper traps and levator scapulae which may lead to headaches
• referred pain into the shoulder and arm
• thoracic outlet syndrome



A. Normal
B/C. Tight pec minor

Try rounding your shoulders forwards and downwards to contract the pec major (like in diagram C above) and then attempt to lift your arms overhead. Notice how your ROM is majorly limited? That is, in effect, what happens when pectoralis minor is too tight. Combine that with tight pectoralis major and you pretty much have no chance at achieving full ROM of the shoulders. However, our bodies are pretty clever and will try find a way around this, forcing the shoulder to get into those positions. Do this thousands of times and it is a recipe for shoulder impingement, bursitis, rotator cuff tears - you get the picture.

The trouble with pec minor is that it is a difficult muscle to stretch and trigger point due to its location. That is where your Physio or Massage therapist comes in handy! You can try doing some trigger point releasing to your pec major but if the problem is really lying underneath, no amount of lacrosse ball smashing is going to help. You need another set of hands (literally) to get in there and release it.

Pec minor trigger point referral pattern

 

Set your scapulas free

Full shoulder range of movement not only requires good mobility at the glenohumeral (ball and socket) joint of the shoulder, but also at the scapulothoracic joint and the thoracic cage.

We need good shoulder mobility for so many different movements in Crossfit - Olympic lifts, push press/jerk, pull ups, muscle ups, thrusters, etc. If you are lacking in your shoulder ROM, chances are good that at some point, you will end up with an injury.

What is your shoulder flexion ROM? Can you lift your arm straight up in front of you and bring your arm past your ear? Make sure your arm stays straight and close to your body the whole time.

Normal shoulder flexion = 180 degrees

 

 

If you cannot achieve this, we need to figure out why. The WHY is what your physiotherapist is good for, as many of the tests we perform to work it all out cannot be performed easily on yourself. There could be many reasons why your shoulder range is lacking: stiffness of the glenohumeral joint, stiffness of the scapulothoracic joint, stiffness of the thoracic spine, weakness of the glenohumeral muscles and/or weakness of the scapular muscles.

 

One of the reasons you may be lacking full shoulder flexion may be due to a tight/overactive levator scapulae muscle. As the name suggests, the levator scapulae muscle elevates the scapula. It attaches to the border of the shoulder blade and the transverse processes of vertebrae C1 to C4. Try doing some trigger point to this muscle by lying on your back and placing a lacrosse ball at the corner of your shoulder blade, near the spine (this is called SHOULDER SLACKING in the MobilizeMe app). Then take your arm and bring it up over your head, keeping the elbow straight. Keep the arm moving for 2 minutes, then re-assess your shoulder flexion ROM.  If it has improved, you can attribute at least some of your problem to tightness in the levator scapulae.

 

 

 

If you got no joy from this, then it's probably a wise move to get a professional to check it out. Don't use Dr.Google. Good luck!

 

 

Don't forget to check out the MobilizeMe app! Available for iPhone and Android!

https://itunes.apple.com/ca/app/mobilizeme/id576108153?mt=8

 

https://play.google.com/store/apps/details?id=com.hongji&feature=nav_result#?t=W251bGwsMSwxLDMsImNvbS5ob25namkiXQ

 



 

 



 

 

 



Walk before you run

In the past couple of weeks, we have been travelling around BC/Alberta on a little holiday, visiting Crossfit boxes to say hi, let them know about MobilizeMe  and even do a couple mobility seminars! I tend to pay attention to the stuff I see posted on people's whiteboards as I go. Lots of places just post the daily WOD's, others post clients PR's and goals. One of these stood out to me, as it read on the Goals board: "Kipping pullups". Then directly underneath it had "do overhead movements without pain".

Anyone see an issue with this?

If you cannot do an overhead movement without pain, then kipping pullups should not even be a blip on your radar.

I see this so often it's not even funny anymore. On one hand I love how people are so passionate and eager to get better at Crossfit, on the other hand I cringe. Crossfit has transformed the lives of countless people out there, many of whom have never been active a day in their lives but has it turned us into fanatics who don't know or understand our limitations?

99.9% of people who Crossfit are NEVER going to make the Games. And I don't say this to be cruel or unkind. I love that so many people have aspirations of making it to the top but for the average Crossfitter, it just isn't going to happen. So why the need to do movements or skills that are beyond our limits? I'm not saying that you won't ever be able to do these skills, it's a matter of time and many hours of practise, but maybe just have a look at the reasons you want to develop them.

We are all so keen to be able to do all the movements we see performed by the elite athletes at the Games level that I think we forget we need to develop the strength, stability technique and mobility required for these skills.

If you are limited by pain, go and get it checked out. Don't bury your head in the sand and pray it will go away. Pain is there for a reason, people, and generally doesn't develop overnight (unless you have suffered from an acute injury). Hundreds or thousands of repetitions done with even slightly faulty mechanics will wind up your tissues which eventually cause...PAIN.

If you are limited by strength, work on developing it. Keep in mind it takes roughly 8 WEEKS to notice muscle hypertrophy (growth) at a cellular level. Concentrating on doing your skills STRICT eg. pullups, ring dips, push ups, etc. with absolutely PERFECT form will help.

If you are limited by mobility, work on your mobility! Remember that flexibility is one of the fundamentals of Crossfit. It's not nearly as fun as PR'ing your Clean & Jerk but every bit as important. And go out and BUY YOUR OWN mobility equipment. Don't rely on your coach/box to supply it. You should have at least a roller and a lacrosse ball in your gym bag. You don't use someone else's knee sleeves do you???

Keep in mind that if you are constantly mobilizing and not getting noticeable improvements, you may have issues with your STABILITY. For example, if your shoulders are chronically tight, your rotator cuff muscles and/or scapular stabilizing muscles may be weak. I would advise getting an assessment by your Physio/Physical Therapist or other qualified professional. Make sure that you get an exercise program based on the assessment and stick to it! One coach I talked to while overseas mentioned that they now regularly include rotator cuff/Bulletproof shoulder exercises in their warm up and/or cool down.

Most of those athletes you see competing at the Games have been doing Crossfit for a few years and/or have a highly competitive athletic background. Their rise to the top hasn't been instantaneous. Walk before you run peeps. You'll still get there in the end.

Make sure you head to the App Store or Google Play and check out our Mobility App for Crossfit!

https://itunes.apple.com/ca/app/mobilizeme/id576108153?mt=8

https://play.google.com/store/apps/details?id=com.hongji&feature=nav_result#?t=W251bGwsMSwxLDMsImNvbS5ob25namkiXQ

Why does it feel like I'm walking on shards of glass?

Earlier this week on the MobilizeMe Facebook page I shared an article regarding plantar fasciitis and just wanted to share a few tips/mobility ideas to help prevent and treat this painful foot problem.

Plantar fasciitis is actually an overuse condition of the plantar fascia. The plantar fascia is a thick band of tissue that provides support for the longitudinal arch of the foot and assists with shock absorption (like when running, doing double unders or box jumps).


Causes of plantar fasciitis are numerous and can include:

• low arches in the foot (pes planus)
• high arches in the foot (pes cavus)
• over-pronation (flat foot)
• excessive plantarflexion of the foot with dorsiflexion of the toes (eg. running, box jumps)
• unsupportive footwear
• being overweight
• tightness of the calves, hamstrings and glutes

The introduction of flat-soled footwear (eg. Nano's, innov-8, etc) into mainstream wear can be partly to blame, especially if there no period of adaptation. Most people are used to wearing shoes that have moderate arch support. Going from these type of shoes to a minimalist-sole type of shoe can lead to conditions like plantar fasciitis. If you pronate/have flat feet and want to wear these types of shoes, I would advise that you wear them 1-2x/week initially, and build up slowly over time to give your feet and lower limbs a chance to build the muscular strength and stability required.

If your feet are already suffering and you feel like you're walking on glass, I would recommend getting back into a pair of supportive shoes and avoid walking barefoot or in thongs.

Treatment can include the following:

• avoiding activities that aggravate the pain
• ice post activity (a frozen water bottle is great for this - roll out bottom of foot with the frozen bottle)
• stretching/trigger point release/foam rolling of the plantar fascia, calves, hamstrings and glutes
• self massage with a golf or lacrosse ball (we have some awesome blue ones on our Facebook shop!!)
• strapping of the foot
• Kinesio-tape
• acupuncture/dry needling
• Scenar therapy
• massage
• night splints
• biomechanical correction (orthotics)
• strengthening exercises for the intrinsic muscles of the foot (see links below)

https://www.youtube.com/watch?feature=player_detailpage&v=GY-mJjXmeIc








If you are in need of a lacrosse ball, head to our Facebook shop and get yours!
https://www.facebook.com/mobilityforcrossfitters/app_251458316228
 

Shoulder extension - the missing link?

Over the weekend I was at a Crossfit competition where there was 2 big pull up workouts (team event). While watching one of the events I had a conversation with someone who said they couldn't do butterfly pull ups because their shoulder didn't like the movement. Further into the conversation I found out that they had suffered a bicep tendon rupture performing a front lever and in a previous life had spent a lot of time doing bicep curls. I asked them to show me their shoulder extension ROM and they had about 20 degrees...normal shoulder extension should be 40-60 degrees.  They were missing at least HALF to 2/3 of normal ROM. Any wonder why butterfly pull ups were not their friend?

 

 What muscles are involved with limited shoulder extension?

• Long head of biceps brachii
• Coracobrachialis
• Pectoralis major
• anterior fibers of deltoid

What movements will be affected if lacking shoulder extension?

• Pull ups (particularly chest to bar and butterfly)
• Muscle ups
• Ring dips
• Push ups
• Burpees
• Bench press/floor press

Biceps trigger point referral pattern

The long head of biceps in particular is prone to overuse and trigger points can cause referred pain into the shoulder itself. This is due to the fact that its tendon inserts into the labrum of the shoulder joint. The biceps is responsible for flexing the elbow and shoulder and also supination of the forearm (turning the palm upwards).

Some people complain of a snapping or clicking sensation with long head of biceps problems. Often, rotator cuff injuries and issues with the long head of biceps go hand in hand.


Try rolling out/trigger pointing the biceps, front of the shoulder and pecs and stretching prior to workouts that involve pull ups, muscle ups, ring dips, push ups or burpees and see if it makes a difference. I saw a lot of people over the weekend making good use of the barbell to smash out their biceps!

If improving the mobility of these muscles isn't helping, you may have a problem with scapular stability and/or shoulder joint positioning (like a forward head of humerus) and you should make an appointment with your Physio for an assessment!

No more excuses

There is so much information out there these days with regards to training, mobility, stretching, recovery, nutrition, etc. We have everything we need at the  palm of our hand, at the touch of a screen and yet it is still hard to get the things done that we really need to work on.

When is the last time you heard someone say "Well, I just PR'd my snatch so I'm done! Don't need to keep working on that!" Probably never. But when it comes to doing rehabilitation exercises or mobility, it gets easily left off the list of things to do. Why is this the case? I think I have maybe heard all the excuses in the world: it takes too long, it hurts too much, I have no time, I forgot, I didn't know what/how to do it, I couldn't remember how, I had to cook dinner/watch the kids/mow the lawn. The list of excuses goes on and on.

If you want to get better at something, you need to practise it. I don't know of anyone that could pick up the barbell and snatch perfectly the first time. It takes time, practise, sweat, tears. Mobility is no different. If you want to get better at it, you need to practise at it. And once you get better at it, you don't just stop.

If you have time to Facebook, Twitter, Instagram or watch TV, you have the time to do mobility. Stop making excuses and just do it. If not, stop complaining about your increasing number of injuries and how you can't overhead squat.

Get your roller, lacrosse ball or other favorite instrument of torture and put it in front of the TV. Whenever an ad comes on, roll out something that hurts. Take your lacrosse ball to work and mobilize your hammies. Get to the box 10-15 minutes early or stay after class. Stop making excuses and start putting the work in.

Tight abs = lower back pain?

The rectus abdominus = the 6-pack that we all want, strive for and drool over. But tightness/overuse of this show pony muscle can be driving lower back pain.

The rectus abdominus is a broad, flat muscle that runs vertical on the wall of the front of the abdomen. It extends from the pubic symphysis, pubic crest and pubic tubercle to the xyphoid process and costal cartilages of the 5th to 7th ribs. This muscle is important posturally; it's actions include flexing the lumbar spine (like when doing a sit-up), posteriorly tilting the pelvis and assisting in hip flexion. It also assists with breathing, as in forceful expiration (breathing out), keeping the internal organs intact and creating internal abdominal pressure.

Trigger points or tight spots in the lower rectus abdominus have been found to refer pain into the lower back - like a thick band of pain around the lower back and into the top of the glutes. Trigger points higher up near the ribs have been found to refer pain higher up in the back, closer towards the bottom of the scapula.



A. Trigger points in rectus abdominus and their referral pattern in the mid/lower back.

It is important to note that if you have tightness in your rectus abdominus, your iliopsoas (long hip flexor) is most likely going to be tight also.



Trigger points in iliopsoas and referral pattern in lower back and front of hip/thigh.

 

If you are suffering from lower back pain, try releasing both your rectus abdominus and iliopsoas. Lie on with a lacrosse ball, baseball or softball under your abdomen, off to the side, about a fist length away from the belly button. Contract/relax your abs as you lie on the ball and make sure to move it up/down the length of your abs.

 

Another method is to get a heavy kettlebell and place the handle lengthways or crossways under your tummy. Then get on all fours and jam the handle of the kettlebell into your stomach, trying to find any tender/tight spots. Contract/relax your abs as you need to.

 

This is a highly unpleasant and somewhat interesting position to be in; I was told that it's referred to as the "Kettlebell Hump" because that's what it looks like when you're doing it....but it is very effective. (Thanks Antony Lo - The PhysioDetective for this one!!!)

 

Maybe try it in private first....and good luck.





Pull your head in

The past weekend was spent at the Australian Crossfit Regionals watching the best Crossfit athletes from Australia and New Zealand battle it out for for a ticket to the Crossfit Games in July. While for the most part I saw efficient and skilled movement, there was one workout in particular where I saw a number of competitors displaying what I call "poke neck".

Poke Neck aka Upper Crossed Syndrome

Poke neck can be the result of shoulder/upper thoracic mobility issues and/or weakness of the deep neck muscles and scapular stability muscles, otherwise known as Upper-Crossed Syndrome. This syndrome is particularly evident in people who have desk/computer jobs. It has been found that for every inch (or 2.54cm for the metric peeps) your head is forward of your spine, an additional 10lbs (or 4.5kg) is added to the weight of your head (Kapandji, 2008). This additional weight places stress on the muscles of the neck and upper back and can put extra pressure on the suboccipital nerves, causing headaches.

To combat poke neck, mobilize the following areas:
- Thoracic spine
- Neck: particularly upper traps, levator scapula & scalenes
- Chest: pectoralis major/minor

And, strengthen the following areas:
- Deep neck flexors
- Middle back: lower trapezius & rhomboids (Bulletproof shoulders by Crossfit New England is a great resource).

http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&cad=rja&ved=0CC0QtwIwAA&url=http%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DACAz6HFj1xE&ei=UOSmUcHIG8qCkQXM7YGIDw&usg=AFQjCNFrYsBdOTd65IYqEZ6ryttYOm1qVA&sig2=8f8_zkSmcG3e4pa5ZM2S0g

 In addition, have a look at your biomechanics while you are training. Get your coach to film you from the side the next time you are doing a pressing movement, kettlebell swings or thrusters/overhead squat to see if you are excessively throwing your head through at the top of the movement.

Throwing your head through is a green light to a neck injury.

So pull your head in.

Knee pain?

There are a few different types of knee injuries and my goal here isn't to discuss every single knee injury, but more to make you aware of the structures that may be contributing to your pain. Acute injuries, such as ligament tears, meniscus injuries, patellar dislocation etc. are probably not as common in Crossfit as those of more a chronic/repetitive type injury (patellar tendinopathy, bursitis, etc).

The knee is actually made up of two joints: the tibiofemoral joint (the joint between your tibia and femur) and the patellofemoral joint (the joint between your patella and your femur) which are stabilized by the collateral ligaments, cruciate ligaments and mensicus. The quadriceps, gracillis, iliotibial band, popliteus, sartorius, hamstrings and calves provide muscular stability and assist in movement of the knee (flexion, extension and some rotation).

Knee pain can be associated with injury to any of the structures directly connected to the knee, but can also be from other structures upstream (lumbar spine, SIJ, hip) and/or downstream (ankle).

Two of the most common causes of knee pain (anterior/front of knee) is patellofemoral joint problems and patellar tendinopathy. The signs and symptoms of each problem help to distinguish the diagnosis.

Patellofemoral Pain
- comes on with running/weight bearing activity involving bending of the knee
- pain aggravated by activities that load the knee eg. squatting, jumping
- sometimes associated with clicking and "crunchiness" under the kneecap
- knee sometimes gives way
- weak VMO (inner quads)
- tight vastus lateralis (outer quads), TFL
- often associated with foot pronation (flat feet) and valgus knees (knock knees)

Patellar Tendinopathy
- comes on with jumping/change of direction/squatting
- pain is at the base of the kneecap
- pain aggravated by decline board squats
- tenderness of patellar tendon
- associated tightness of quads, hamstrings, possible pelvic biomechanical issues
- calf weakness commonly found

Treatment of each of these conditions varies so it's always best if you get a Physio to do an assessment. Self diagnosis via "Dr Google" can be misleading, not to mention you could be wasting your time barking up the wrong tree. In any case, addressing the tissues around the knee can be a good place to start.

Try rolling out/trigger pointing the quads, hammies, calves, adductors and glutes and see if it changes your knee pain. Make sure to test first (whatever movement causes the pain) and re-test post rollout to see if you have made change. No change = see a professional. Change = keep it up!

Shoulder rotation - do you have enough?

The shoulder is an amazing joint, capable of great things...when it is all functioning properly!

The shoulder is comprised of 4 joints - the sternoclavicular, the acromioclavicular, the scapulothoracic(ScTJ) and the glenohumeral (GHJ). The GHJ is quite unstable due to its lack of bony stability but is held in place by numerous ligaments, the joint capsule and rotator cuff  and scapular muscles.

Normal shoulder ROM is as follows:
Flexion 180 degrees (the top of a push press)
Extension 40-60 degrees (lifting your arm straight behind you)
Abduction 180 degrees (lifting your arm out to the side)
Internal rotation 60-70 degrees (rotating the arm in towards the middle)*
External rotation 80-100 degrees (rotating the arm outwards)*
* tested with the arm abducted and elbow flexed to 90 degrees

In Crossfit (and in normal day to day life) our shoulders also need to be able to hit combined ROM - for example reaching for a seat belt involves shoulder abduction and external rotation, putting your wallet in your back pocket involves shoulder extension and internal rotation.

Lets take a look at the shoulder position in an overhead squat - full shoulder flexion, abduction and external rotation. The overhead squat is a demanding movement that requires not only good mobility and stability at the shoulder joint, but a mobile thoracic spine and hips, plus great core control. Take a look at the two photos below, one of which demonstrates a good overhead position.


   Which one would you rather look like?

 

I often see people complaining of shoulder pain and they are usually missing some degree of shoulder internal and/or external rotation. Lack of external rotation at the shoulders causes you to look like the guy on the right (he's probably also missing full range shoulder flexion and some degree of thoracic extension. I won't get started on the hips...)

Try the Apley Scratch test to see if you have adequate shoulder rotation:

---

Apley scratch test. The patient attempts to touch the opposite scapula to test range of motion of the shoulder. (Left) Testing abduction and external rotation. (Right) Testing adduction and internal rotation.

If you can't achieve full shoulder external rotation due to tight lats, pecs and teres major, your overhead movements are going to suffer. Try mobilizing your lats (foam roller or band), pecs (lacrosse ball) and teres major (lacrosse ball) for 3-4 minutes each side before your next WOD that includes an overhead squat/snatch component and see if you notice a difference.



Hip mobility in Crossfit

So I put out the call yesterday on our MobilizeMe Facebook page to find out what you wanted me to discuss in my next blog posts - and a lot of you asked for hips. So here goes.

Hip mobility is essential for developing a good squat. If you read that article I posted yesterday by Spencer Arnold, you'll see that he mentions mobility a lot. I think a good deal of problems with LACK of hip mobility in the population stems from the fact that we spend most of our day in sitting. Sitting requires about 90 degrees of hip flexion. Squatting requires at least 100 degrees of hip flexion (just breaking parallel), not to mention hip abduction and external rotation.

Sitting is also a PASSIVE activity, meaning that it requires little to no activation of any of the muscles in your lower limbs - you are being held up by the chair (I'm not going to get into a Physics discussion with this statement so don't get all science-y on me :-) Sitting for long periods causes our hip flexors to become short, and our hip extensors to lengthen and become weaker. In essence, we become the shape of a chair.

The Thomas test is a measure of hip flexor length and is shown in the two photos below:

Tight hip flexors - Positive Thomas Test - the knee is higher than the hip




Normal hip flexors - Negative Thomas Test - the knee is lower than the hip with knee flexed to near 90 degrees
 
 
Which of these two do you think would have issues attaining depth in a squat? I'll give you a hint, it's not the second photo....
 

Good hip mobility also includes rotational components; with a squat we are more concerned with the ability to externally rotate the hip/thigh. This puts our hip into a stable position and engages the gluteus maximus. Have you ever seen someone squat and let their knees cave in, then miss the rep or look like they're about to give birth trying to squeeze that rep out? Poor hip external rotation. Now, that can be due to poor mobility or poor hip stability/strength. It's up to your Physio (or really good coach) to figure that one out. But here's a tip: if you honestly, truly, consistently work your mobility and you are getting nowhere, it's a stability problem. All the mobility in the universe won't cure poor stability.

 

So where is this all going - I would have to reiterate what was said in the Spencer Arnold blog post - learn to squat properly from the start and don't add weight until you are proficient. Load is NOT going to help you squat properly. Do your mobility - sit on the lacrosse ball until it no longer hurts (not all at once), get out the band and do hip mobility with the band (it's in the MobilizeMe app and about a kazillion K-starr MWOD's), get up off your ass at work at least every hour. Like I said before, if none of this is working, you need a professional to look at it. Pony up and book into a Physio for an assessment. You can't assess yourself (believe me I have tried and I AM a physio!!).