If you’re a human being reading this blog post it’s a safe bet you 1) have impeccable taste with regards to the strength coaches you choose to follow 2) have a pair of shoulders and 3) are likely interested in keeping them healthy and thus performing at a high level in the weight room.
NOTE: If you happened to have come across this blog post by Googling the terms “world’s best tickle fighter” or “The Notebook spoilers”….welcome!
I’m a little biased given my years of experience working with overhead athletes and meatheads alike, but I’d garner a guess that nothing is more annoying or derails progress more than a pissed off shoulder…or shoulders.
My friends Dan Pope and Dave Tilley of Champion Physical Therapy & Performance just released a stellar resource, Peak Shoulder Performance, that’s perfect for any coach or personal trainer looking to help their clients/athletes nip their shoulder woes in the bud. AND it’s on sale for this week only at $100 off the regular price.
Guess what most people think is the cause of their shoulder woes?
The rotator cuff.
Guess what’s likely not the cause of their shoulder woes?
The rotator cuff.
It’s lost on a lot of people that the “shoulder” isn’t just the rotator cuff.
I mean, N’Sync back in the wasn’t just Justin Timberlake, right?
JC, Lance, Chris, and Joey (<— didn’t have to look up all their names) deserve our respect and admiration too. They all played key role(s) as individual entertainers to make the group more cohesive, successful, and relevant.
The phrase “the whole is greater than the sum of its parts” has never rang more true than right here and right now, reminiscing on long past their prime 90’s boy bands.
[Except, you know, we all know Justin was/is the only one with talent. He can sing, he can dance, he can act, he’s got comedic timing. He’s a delight.]
The rotator cuff is Justin Timberlake.
It gets all the credit and accolades and attention with regards to shoulder health and function. However, the shoulder consists of four articulations that comprise the entire shoulder girdle:
Glenohumeral Joint (rotator cuff) – Justin
Acromioclavicular Joint – JC
Sternoclavicular Joint – Lance
Scapulothoracic Joint – Joey and Chris
I’d make the case, and this is an arbitrary number I’m tossing out here (so don’t quote me on Twitter), that 80% of the shoulder issues most people encounter can be pin pointed to the Scapulothoracic area (shoulder blades) and what it is or isn’t doing.
The shoulder blades, since you have two of them, are Joey and Chris.
Think about it:
Justin, JC, and Lance were generally considered the heartthrobs of the group and were always taking center stage, in the forefront, and amassing Tiger Beat covers.
Conversely, who was in the shadows, taking a back seat, presumably doing all the heavy labor, regional Mall appearances, and B-list talk shows the other guys didn’t want to do?
That’s right…..Joey Fatone and motherfucking Chris Fitzpatrick, son!
Lets Give the Scaps Some Love
All of this isn’t to insinuate the rotator cuff alone is never the culprit or that pain in that area should be shrugged off, ignored, and not addressed directly.
However, when lumping shoulder pain and the rotator cuff into the same sentence we’re often referring to something called “shoulder impingement.”
Shoulder impingement is a thing – loosely defined: it’s compression of the rotator cuff (usually the supraspinatus) by the undersurface of the acromion – and it is a nuisance.
There’s even varying types of shoulder impingement – Internal vs. External Impingement. Moreover, just saying “shoulder impingement” doesn’t say anything as to it’s root cause.
Many factors come into play:
Exercise Technique
Poor Programming
Lack of T-Spine Mobility
Fatigue (rotator cuff fatigue = superior migration of humeral head)
Faulty Breathing Patterns
Wearing White Past Labor Day
And Scapular Dyskinesis…to name a few
Just saying someone has “shoulder impingement” and telling him or her to perform band external rotation drills (oftentimes poorly) till they’re blue in the face doesn’t solve WHY it may be happening in the first place.
Often, the rotator cuff hurts or isn’t functioning optimally because something nefarious is happening elsewhere.
And on that note I’d like to point your attention to the shoulder blades.
Release, Access, Train
I have a lot of people/athletes stop by CORE because their shoulder(s) don’t feel great. Many have gone to several physical therapists prior to seeing me frustrated they’re not seeing progress, and if they are it’s often fleeting.
Full Disclosure: I know my scope and am never diagnosing anyone or anything.
Actually, Things I Can Diagnose = poor deadlift technique, poor movement in general, and epic poops vs. average poops (#dadlife).
Things I Can’t Diagnose = MRIs, musculoskeletal injuries/limitations, gonorrhea.
I find it amazing, though, whenever I do work with someone with shoulder pain, how much of a rare occurrence it is anyone ever took the time to assess scapular function.
If the scapulae are in a bad position to begin with (maybe in excessive anterior tilt or downwardly rotated) and/or are unable to move in all their glory (upward/downward rotation, anterior/posterior tilt, adduction/abduction, elevation/depression), or altogether move poorly…is it any wonder then, why, possibly, maybe, the rotator cuff is pissed off?
Photo Credit: EricCressey.com
While not an exhaustive list or explanation – everyone’s their own unique special snowflake – the following approach covers most people’s bases:
Release
Scapular position is at the mercy of the thorax and T-Spine.
Those in a more kyphotic posture – think: computer guy – will tend to be (not always) more anteriorly tilted and abducted.
Those in a more extended posture – think: athletes/meatheads – will tend to be (not always) more downwardly rotated and adducted.
In both cases the congruency of the shoulder blade(s) and thorax is compromised often resulting in an ouchie.
“Releasing” the area is often beneficial:
Access
Now that the area is released we can then gain “access” to improved scapular movement by nudging the ribcage/thorax to move via some dedicated positional breathing drills.
Think of it this way: if the ribs/thorax are unable to move because they’re glued in place, how the heck are the scapulae going to move?1
A few of my favorites include:
NOTE: Which one you use will depend on an individual’s presentation. A good rule of thumb to follow would be for those in a more extended posture to include breathing drills that place them in flexion and vice versa. There are always exceptions to the rule, but for the sake of brevity it’s a decent rule to follow.
All 4s Belly Breathing
The Bear
Supine 90/90 Belly Breathing
Prone Sphinx
NOTE: I didn’t discuss it in this video but I’d also encourage people to include a full inhale/exhale with each “reach” or repetition on this exercise.
Train (and Go Lift Heavy Things)
Now that we’ve released and gained access to the area, we need to train. Specifically, almost always, we need to improve one’s ability to move their arms overhead (shoulder flexion) without any major compensations.
In order to do so, the scapulae need to do three things:
Posterior tilt
Upward rotation (which, as a whole, describes the end goal)
Protract
All three entail utilizing the force couples of the upper/lower traps and serratus anterior in concert to help move the shoulder blades into the upwardly rotated position we’re after.
There are a litany of drills and exercises that can be discussed here, and it’s important to perform a thorough screen/assessment to ascertain which ones need to be prioritized.
When it comes to neck pain, as a strength coach, I (generally) don’t touch that with a ten-foot pole. It’s case dependent of course, but more often than not, if someone I’m working with walks in with a some significant discomfort in their neck I 1) start hyperventilating into a paper bag and 2) immediately refer out to a someone who has more diagnostic and manual therapy skills.
This is not to say, however, that there aren’t any avenues to take if you’re a personal trainer or strength coach. It’s not like you can’t do anything. In today’s guest post physical therapist, Dr. Michael Infantino, goes into great detail on some things to consider if you ever find yourself in this predicament.
The Gym Is a Pain In My Neck: Two Movements To Cure Them All
Are you struggling with neck pain?
Does the gym make it worse?
Do you find yourself looking at a lot of informative websites for ways to resolve these issues, but wish it were compactly put in one place?
Does this sound like an infomercial?
Well it’s not!
But for just $29/month you can… just kidding.
This article is here to solve all of those problems. Neck pain is often blamed on poor form when exercising. This is absolutely true. Unfortunately this does not answer a crucial question, “why?” Discovering WHY your form is poor is the goal. On top of that, people often fail to recognize other human errors that are contributing to their symptoms. We will provide a guide for figuring out why you have neck pain and how to resolve it.
In most cases, pain attributed to the gym can be tied to the following:
Limitations in the necessary mobility to perform a movement
Limitations in the skill needed to perform a movement
Limitations in the capacity to perform a movement (Strength and Endurance)
Human error [Electrolyte and Fluid balance, Self-Care, Rest, Sleep, Breathing, Posture, Medication and Fear.]
Limitations in MOBILITY: 2 movements to cure them all!?
Limitations in your ability to put yourself in optimal positions during almost any upper body movement are a result of two movement limitations.
Limitations in these positions can lead to a host of different complaints. For the sake of time we are going to pick on NECK PAIN. If you are struggling with one exercise you are likely struggling with another, you just might not realize it.
Position #1: Shoulder Extension Test
Movements: Push Up, Pull Up, Row, Dip, Pull Up (top), Jump Rope, Punching someone in the nose because they have one of those weird miniature poodle mixes.
Attempt to perform the ^^THIS^^ motion
Instructions: Keep the neck retracted while extending the shoulders just beyond the trunk without the following:
Increased forward head position
Forward shoulder translation
Shoulder shrug
If you are unable to replicate the picture above you likely have a MOBILITY problem.
If you can’t perform this motion when you aren’t under load, you will definitely struggle when you are. Especially with repeated repetitions and the addition of weight.
Target Areas for Treatment
Soft Tissue Mobility
Pecs
Serratus Anterior
Upper Traps
Stretches and Joint Mobilization
Chin Retraction
Thoracic Extension (arms overhead)
Open Book Stretch
After working these bad boys out I want you to RE-CHECK the test position.
Is it better?
If not, you need to keep working on it.
Assuming you now have the necessary MOBILITY to perform this motion, we need to make sure you have the required SKILL with the particular movement you are interested in.
Skill: the necessary strength, stability and coordination to perform the most basic form of a loaded movement (pull up, push up, dip, row, etc.).
Are you able to maintain a good position in the:
Bottom of your push up
Row
Top of your pull up
Bottom of your dip
Jump roping
As you load the arm for a hay maker!
We aren’t as complex as you might think. Many of our daily activities are broken into a few movement patterns.
Follow this sequence:
Create the mobility necessary to perform the pattern in its most basic form. (In this case, Position #1 and #2).
Ensure you have the skill needed to perform your desired movement (Push Up, Pull Up, etc.)
Build capacity with that movement (Endurance and Strength).
If you don’t have the skill to perform a specific exercise or movement, you need to practice. Look at the above definition of skill to make that judgement. If you don’t have the baseline strength to perform one good push up, pull up, dip or row, see below for regressions that will allow you to maintain good form as you work your way back to mastering these moves.
Here are some ideas:
Push Up: Inclined position (Ex. against weight bench or counter), knee push ups
Pull Up: Assisted with a band, inverted row
Dip: Assisted with a band, bench dip
Row: Kind of an outlier since this move typically doesn’t require body weight. Use a weight that allows good form. TRX Row and inverted row are body weight options. Adjust the angle of your body to reduce the difficulty.
The goal here is to demonstrate the ability to maintain proper form throughout each movement with a regression that is appropriate for you.
Joe Muscles next to you may need to take 50 lbs. off his 200 lb. weighted belt during his pull-ups to maintain good form. You may need to work on getting one pull up with good form without any extra weight.
Most of us have one or two good pull ups in our bag of tricks to whip out for an “impromptu” Instagram post. Preventing injury is going to require you to build the strength and endurance to exceed Instagram’s one-minute time cap. DAMN you Instagram!
Adding repetitions and weight to the regression will help you work your way back to a standard pull up, row, dip, push up, etc.
I can’t emphasize this point enough.
We all have high expectations of ourselves. Neck pain after 10 reps is not necessarily a “push up” problem. It may be the fact that you did three other exercises before push ups that started to fatigue the neck. The push up was the breaking point. You need to have a realistic expectation of your current ability, or capacity.
Position #2: Overhead Test
Movements: Overhead Press, Pull Up (bottom position), Snatch
Instructions: Lie on your back with knees bent. Tuck chin (neck flat to ground) with arms flat to the ground in the start of a press position. Press arms overhead by sliding arms along the ground.
Common Faults:
One or both arms come off the floor at any point in time.
Compensatory forward head or extended neck position to keep arms on floor
Compensatory spine arch to keep arms on the floor
Assuming you repeatedly tried to replicate this position without success, once again we have a MOBILITY PROBLEM.
Target Areas for Treatment
Soft Tissue Mobility
Pecs
Lats
Rhomboids
Stretches and Joint Mobilization
Chin Retraction
T-Spine Drop In (or T Spine Extension)
Open Book Stretch (Add: External Rotation at Shoulder)
1st Rib and Scalene mobility
After finding the weak link, it is time to RE-CHECK. If it looks better, great let’s move on. Similar to Position #1, assuming you now have the pre-requisite MOBILITY to perform this motion we need to make sure you have the SKILL necessary.
*If you are having trouble improving your mobility or resolving pain, seek the advice of a qualified medical provider or fitness professional.
Can you maintain the same control and form during your overhead press, snatch, hang position of your pull up (or any variation- kipping pull up, toes to bar)? If not, we need to REGRESS the move. Unlike the shoulder extension position, many of the overhead exercises can be regressed by reducing the weight or working on single arm presses instead of two arms. Other regressions include:
Regressions:
Overhead press: Landmines (Tony goes into more depth in this article).
Snatch: Cleans, Single arm overhead kettlebell squat, single arm overhead lunge
Pull up (bottom): use a resistance band for support, inverted row
Human Error
Now that you have mastered Position #1 and #2, it is time to make sure that you are limiting HUMAN ERROR.
I think everyone should have someone in their life that serves as an extra pair of eyes. Even the best fitness trainers and medical providers in the world have a hard time being objective toward different areas of their own life. Barbers don’t cut their own hair, right? Not positive about that one. Either way, you can’t go wrong with some quality feedback!
Most of us are quick to blame the boulders in our life when it comes to pain, but we overlook the pebbles.
With pain we can’t overlook the pebbles.
The pebbles are diet, water intake, sleep, and self-care habits.
Patients usually tell me that they are doing “better than most” or that they are “pretty good” about optimizing these areas of their life. It isn’t until their spouse shows up to the appointment that we get the whole truth.
I love it!
Proper Fluid and Electrolyte Balance
Paying attention to what you consume pre and post workout is important. Proper fluids and electrolyte intake prior to exercise can help delay muscle fatigue and cramping.
Many people can get by with less than optimal effort when it comes to this category. However, if you are having neck pain you need to give yourself the best chance at success.
“At least 4 hours before exercise, individuals should drink approximately 5-7 mL·kg−1 body weight (~2-3 mL·lb−1) of water or a sport beverage. This would allow enough time to optimize hydration status and for excretion of any excess fluid as urine” (Sawka, 2007).
This is not always possible, I understand. Do your best. Some is better than none.
Warm Up
Proper warm up is also important.
Engaging in a warm up that gradually increases heart rate and muscle flexibility is a great way to prime the muscles. Dramatic increases in blood pressure and heart rate can lead to less than optimal muscle performance and increased risk of exertion headache during your workout.
Your warm up should be focused on getting the heart rate up; along with preparing the body for the movements you are going to perform during your workout (squat, push up, deadlift, clean, etc.).
Taking the time to stretch and do some soft tissue work after exercise will help reduce muscle soreness in the days following your workout (Gregory, 2015).
Leaving your body more prepared for the next workout. It is a great way to improve muscle extensibility and eliminate trigger points that aren’t allowing your muscles to perform effectively (Lucas, 2004).
Adequate rest is also important for recovery.
Going hard every day and not getting adequate sleep does not allow your body to grow and repair itself. Neglecting proper recovery leads to a less than optimal immune system and central nervous system.
Sleep deficits can also lead to an increase in the intensity of pain and alterations in mood. This is some serious shiznit. Can’t express enough how important this category is. I am a huge fan of the “grind.” It just sounds cool. You aren’t meant to grind everyday though, so please take some time to recover.
Breathing and Posture
Proper breathing is something that is often overlooked, but may be contributing to neck pain.
Gritting it out is cool, I highly recommend it. It builds character.
However, regularly holding your breath or clinching of your teeth when exercising can lead to increased tension around the neck. This could end up resulting in tension headaches as well.
Many of us without realizing it spend most of our day performing shallow breaths. We often over utilize the neck musculature. Shallow breathing into the chest can increase tension in these muscles and even increase feelings of anxiety.
It is recommended that people learn how to perform relaxed diaphragmatic breathing to reduce tension in the neck muscles. Staying in sustained postures throughout the day can also be contributing to your neck pain.
Many studies continue to show that sustained postures throughout the day (typically with office workers), especially with a forward head position, can increase neck pain and headaches (Ariëns, 2001).
Symptoms are also more common in people that hate their job.
Really off topic, but it is true …
Consider how stress in your life (emotional or physical) is amplifying your feelings of pain. Emotional pain and physical pain are HEAVILY connected. Check out this video by Tony to learn a little more about proper breathing strategies.
The Advil Fix
This may not seem to fit with the other categories.
Nonetheless, it is super important.
Side effects related to over the counter anti-inflammatory use are becoming common knowledge. Every now and then I run into someone that isn’t aware of the potential risks of regular use.
Popping over the counter anti-inflammatories (i.e. advil) before or after your workouts IS NOT recommended.
It’s like sweeping the dirt under the rug.
“The most common side effect from all NSAIDs is damage to the gastrointestinal tract, which includes your esophagus, stomach, and small intestine. More than half of all bleeding ulcers are caused by NSAIDs, says gastroenterologist Byron Cryer, MD, a spokesperson for the American Gastroenterological Association.”
Fear
One of the reasons that I started RehabRenegade.com was to help share information like this with as many people as possible. Many of the complaints I get in clinic can be fixed SUPER QUICK. Having a basic understanding of how to care for yourself and knowledge of the body can remove the “threat” of pain.
Red flags (serious pathology) represent less than 2% of the cases that are seen in a clinical setting (Medbridge, Chad Cook: Cervical Examination).
The Internet can be a blessing and a curse.
It can either lead you down the right road or scare the living crap out of you. We all know that any injury or illness is usually presumed to be cancer after a late night search on WebMD. Here are some discussions and advice I found on the inter-web related to neck pain in the gym.
Great intentions, but poor advice.
We tend to blame everything on a “pulled muscle,” whatever that means.
Rest?
What year is it?
We stopped recommending straight rest in like 1902.
By all means, take time off from the gym.
This doesn’t give you free rain to lie in bed all day watching re-runs of Game of Thrones.
It’s true… you may have over done it. Your muscles were overworked. Likely leading to a nice amount of local inflammation and some trigger points. The more constructive advice would be to perform some soft tissue work, light stretching and low intensity non-painful exercise to keep that area mobile.
Resorting to pain medication is not a healthy option. Last but not least, mentioning damaged discs and compressed nerves never makes someone feel at ease. Trauma to the neck may be a reason for disc injury. Overdoing your push ups and pull ups is NOT.
Fun Fact: The prevalence of disk degeneration in asymptomatic (without symptoms) individuals increased from “37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age” (Brinjikji, 2015).
Positive findings on MRI are common in people without pain. Don’t get too caught up in images and diagnoses. Do the things we know are healthy. If you hit the gym hard this morning and then followed that up with a CROISSAN’WICH from Burger King, and a cigarette at lunch we have bigger fish to fry.
First and foremost, muscle and joint strain at the neck commonly refers pain to the head. We call this a cervicogenic headache. Rest assured that it is very rare that you have a more serious pathology requiring immediate medical attention. Give the tips in this post a shot, if it doesn’t help by all means see a medical professional. The worst thing you can do is show up to your medical provider without attempting to improve your flexibility, tweak your form or get adequate rest.
If I had a dollar for every time a therapist told someone they had the tightest (fill in the blank) they have ever seen I would be a little better off.
If this poor girl wasn’t worried enough… Now she has the tightest back he has ever seen… really?
As providers we need to be very careful with our words. It is really easy for us to turn neck pain into chronic neck pain.
It is called an iatrogenic vortex.
When people get tied up in the medical system too long they often see symptoms worsen or develop other unexplained diagnoses.
Overview
In most cases, pain attributed to the gym can be tied to the following:
Limitations in the necessary mobility to perform a movement
Limitations in the Skill needed to perform a movement
Limitations in the Capacity to perform a movement (Strength and Endurance)
Human Error [Electrolyte and fluid balance, Self-Care, Rest, Sleep, Breathing, Posture, Medication and Fear]
You could be one small modification away from eliminating your neck pain.
The big takeaway here is to make sure you have the ability to perform various exercises with good skill.
From there, you need the knowledge and self-awareness to know when you have exceeded you capacity.
You also need to look at the big picture to ensure that you are checking the boxes when it comes to living a healthy life. If you are someone that often finds yourself worried or anxious when injury sets in please take a step back and look at the big picture. Use this article to see where your gaps are. If you still can’t get relief please see a medical provider. Nothing makes medical providers happier than working with patients who demonstrate a willingness to learn and grow.
About the Author
Dr. Michael Infantino is a physical therapist. He works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.
References
Ariëns GAM, Bongers PM, Douwes M, et al
Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study. Occupational and Environmental Medicine 2001;58:200-207.
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A.,Jarvik, J. G. (2015). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR. American Journal of Neuroradiology, 36(4), 811–816. http://doi.org/10.3174/ajnr.A4173
Gregory E. P. Pearcey, David J. Bradbury-Squires, Jon-Erik Kawamoto, Eric J. Drinkwater, David G. Behm, and Duane C. Button (2015) Foam Rolling for Delayed-Onset Muscle Soreness and Recovery of Dynamic Performance Measures. Journal of Athletic Training: January 2015, Vol. 50, No. 1, pp. 5-13.
Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166
Sawka MN, Burke LM, Eichner ER, Maughan RJ, Montain SJ, Stachenfeld NS. American College of Sports Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39:377-90.
I’m currently with my family taking a little vacation down in Florida.2 I’ll be checking in at some point this week with some content, but on the meantime I’ve got some awesome people pinch-writing for me this week.
Today’s post is written by physical therapist Dr. Michael Infantino on a topic that’s a pain in the ass foot for a lot of people: plantar fasciitis.
The 411 On Plantar Fasciitis & How to Make It Vanish
Lets set the scene: It’s a little after 5:00 am. As you open your eyes the sun is just starting to peak through your window. To your right, your husband; to your left, the band Maroon 5 casually playing an old hit. “Sunday morning rain is falling, steal some covers share some skin….”.
Just kidding it’s Sunday morning, rain is falling and you are dead set on getting that five-mile run in.
As you take the first step out of bed, the pain in your heel makes you rethink this whole running idea.
Unknowingly to your heel, your mind knows your day is going to drag if you don’t accomplish this feat.
I know the “drive” that runners possess.
The word “drive” and addictive personality disorder can sometimes be inter-changed, but that’s neither here nor there. This post is going to give you the 411 on everything plantar fasciitis is in as concise of a fashion as possible.
To make life easier we will just say heel pain.
Quick Rundown Of Todays Topics:
WHO is more susceptible to developing plantar fasciitis?
WHAT is plantar fasciitis? [Sounds like a skin eating disease.]
WHAT can I do to treat this damn pain? [I know, I put “WHAT” twice. I wasn’t an English Major.]
WHY am I not seeing progress?
WHO Is More Susceptible To Plantar Fasciitis?
Straight from the Journal of Orthopaedic & Sports Physical Therapy Guidelines for Plantar Fasciitis.
Overweight & Un-Athletic
I know, I know. This sounds awful. No one wants to be called overweight. More than that they don’t want to believe they fall into the un-athletic category.
Prime example: My dad (I love you dad). He has gained some lbs. over the years, and I wouldn’t classify him as an athlete by any means at this stage in his life. Despite my opinion, he still thinks he is SUPER.
His workouts usually come few and far in between. To my surprise, he can never quite understand why his body hurts after his impromptu 3-mile sprint (he calls it a jog) once every 3 months.
Runners
Yay runners! You made it into the JOSPT Guidelines. Victory! Wear this as a badge of honor… I think?
Workers That Spend Increased Time On Their Feet (i.e. factory workers)
Fearful Avoiders
No one wants to admit this characteristic. Regardless, it exists. Many people who actually develop chronic pain fall into this category. Your worries about causing more “damage” to your body often make you think bed rest is still a reasonable option.
I am sorry to say that it is not.
Runners, don’t smirk. You fall into the “overboard” category where your “driven” personality encourages you to push through pain. Because it is weakness leaving the body! Sometimes… not always.
The big takeaway here is to accept the fact that your job, your hobby or your current weight just makes this injury more likely. Knowing that this injury comes with the territory allows you to switch your focus to PREVENTION.
Give Me The Low Down On Plantar Fasciitis.
Research has continuously stated that your heel pain isn’t typically an “iitis,” or inflammation.
Ultrasound actually reveals increased thickening of the fascia near the insertion on the heel (Fabrikant, 2011). This sort of debunks the old “RICE” concept when trying to manage this injury.
It is safer to say plantar fasciopathy.
This could mean either an inflammatory or a degenerative process. Degenerative sounds scary. It isn’t. Changes in tissue quality are normal, not everyone has pain with these changes. [This one’s for you Fear Avoiders].
Diagnosing TRUE Plantar Fasciitis, Or “Fasciopathy.”
1st step in the morning reproduces heel pain
Tenderness to touch at the insertion of the fascia on the heel
“Both were positive! Am I sentenced to months of night splints, orthotics and stretching?”
Not necessarily. If it is a true plantar fasciitis the research shows that these things can help. They may diminish symptoms, but it’s a Band-Aid.
JOSPT Guidelines
We need to be careful here. Some studies also showed that increased arch height was a predictive factor for pain. Your best bet is to have someone perform a running analysis to see what your foot is doing during the loading phase of running (preferably someone with a ton of knowledge about the human body).
If you don’t display “excessive pronation” or actually lack adequate pronation, an orthotic may not be a good fit. Excessive supination (opposite of pronation) while the foot is in contact with the ground during running or walking could actually be exaggerated with an orthotic.
Leading to ankle sprains.
JOSPT Guidelines
In my experience, night splints are hit or miss. With a true plantar fasciitis it could be a big hit. As I mentioned earlier, it is not actually fixing the source of the problem (the way you move, strength deficits, poor pacing etc). Before you sentence yourself to months of night splinting try to push the RESET button first.
Lets Get Started! Address Limitations In Ankle Mobility First.
1. Trigger Points
Work out those nasty tender points in your calves and the bottom of your feet. Calf trigger points can cause referral pain to the heel and bottom of the foot. Mimicking plantar fasciitis. Trigger points are responsible for reduced mobility, strength and timing of muscles! (Lucas, 2004)
BONUS: Self Instrument Assisted Soft Tissue Treatment (better than the roller stick… in my opinion.)
This is more of a soft tissue mobilization than trigger point treatment. It can actually be a great lead in to trigger point treatment. It helps reduce tone in the muscles. It is also a quick way to scan for areas that are more “stiff” and more irritated (increased trigger points local to that tissue). This is why I prefer it to the roller stick.
2. Stretch The Calves and Foot Musculature
Stretching feels good and it can help restore motion. BUT do not neglect the importance of strength and endurance at the shin musculature when looking to maintain that new length.
Performing strengthening drills, like the Shuffle Walk (courtesy of The Gait Guys) demonstrated in the video below will prevent increased tone in the calves from returning.
Prescription:
To make this more effective, actively pull the forefoot and toes up as you are stretching.
Pull the toes and forefoot up for 10 seconds (keep the heel down) followed by a 30 second stretch (work into it slow to get the desired effect). Repeat for 3 minutes.
Renan-Ordine R, 2011
3. Attack The Joints
Get the joints in your ankles and feet moving more freely. Don’t forget about motion at that BIG TOE. Without proper extension at the big toe you can forget about actually accessing that new ankle motion.
This means you can’t access that hip extension while running. This equals poor gluteal function. It all goes down hill after that…
1st Toe Mobilization + Shuffle Walks
Banded Ankle Mobilization With Active Dorsiflexion
This one is all over the Internet. From personal experience, having someone mobilize the ankle for you ends up being way more effective. But better than nothing!
Self Ankle Manipulation
Great way to get some quick improvements. Combine with the other techniques!
Gave It A Go For A Couple Weeks And Still No Change?
The loss of considerable amounts of body fat obviously doesn’t occur overnight. Stick with a guided nutrition plan and exercise routine to work on weight loss without further aggravating any painful regions. This may require modifications in exercise choices for the time being.
If You Are An Avid Runner Or Stand A Lot For Your Job Consider The Following:
Regular Shoe Rotation was found to be helpful in workers that spent more time on their feet. (Werner, 2010)
Your shoes really tell a story. Excessive pronation and supination start to wear down parts of the shoe. This exaggerates pronation and supination at the foot leading to increases in the speed at which these motions occur. Potentially leading to increased risk of injury.
Orthotics/Taping
We discussed this earlier. Orthotics don’t always fix the problem, sometimes they can worsen it. Taping to support the foot or promote increase stability at the foot could be a safer and cheaper 1st step.
Strengthening
The focus is typically on reducing “pronatory tendencies” at the foot. Sounds promiscuous, grrrrr! Tony can help you with that one.
Your ability to land in a good position during the loading phase of running, and continually do that over the course of a run is the primary goal; despite the addition of weight (maybe a ruck sack), speed or exertion.
Strangely, I find joy in watching people run. It is easy to tell which people skipped some developmental milestones growing up or didn’t take part in too many athletic events. If you fall into one of those categories I would definitely recommend some training to improve your running mechanics.
Leg Length Discrepancy (LLD)
I was hesitant to mention this because of how common LLD is in symptomatic and asymptomatic populations. However, it is mentioned in one study in the Plantar Fasciitis Guidelines (Mahmood, 2010). In various studies, a LLD of as little as 4-6 mm is considered clinically significant. In rehabilitation and the fitness world neuroscience is getting a lot attention; often disregarding biomechanics. It is probably in our best interest not to sweep this under the rug if we aren’t seeing progress. LLD will have an impact on your mechanics when walking and running.
Lets Wrap This Up!
The important thing to remember is that the recommendations made today are just guidelines based on an overwhelming amount of research. If you are in pain let these tips guide you. Don’t grasp on to them like they are the word of God, Buddha or The Dos Equis Guy. Accept the fact that your job, hobby, weight or lack of athletic ability make you more susceptible to this injury.
Fix the things you can, accept the things you can’t. There is no harm in trying out a cheap orthotic or heel pad for a little relief. If you want to take it a step further see a professional trained in running evaluations to determine needed changes in running mechanics, programming, proper shoe fit and/or orthotic fit. Knowledge is potential power. Go forth and conquer!
About the Author
Dr. Michael Infantino is a physical therapist who works with active military members in the DMV region. You can find more articles by Michael HERE.
References
Cotchett MP, Landorf KB, Munteanu SE. Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review. J Foot Ankle Res. 2010;3:18. http:// dx.doi.org/10.1186/1757-1146-3-18
Eftekharsadat, B., Babaei-Ghazani, A., & Zeinolabedinzadeh, V. (2016). Dry needling in patients with chronic heel pain due to plantar fasciitis: A single-blinded randomized clinical trial. Medical Journal Of The Islamic Republic Of Iran, 30401.
Fabrikant JM, Park TS. Plantar fasciitis (fasciosis) treatment outcome study: Plantar fascia thickness measured by ultrasound and correlated with patient self-reported improvement. Foot (Edinb) 2011;21:79–83. [PubMed]
Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93:234-237.
Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166
Martin, R. L., Davenport, T. E., Reischl, S. F., McPoil, T. G., Matheson, J. W., Wukich, D. K., & McDonough, C. M. (2014). Heel pain-plantar fasciitis: revision 2014. The Journal Of Orthopaedic And Sports Physical Therapy, 44(11), A1-A33. doi:10.2519/jospt.2014.0303
Mahmood S, Huffman LK, Harris JG. Limb-length discrepancy as a cause of plantar fasciitis. J Am Podiatr Med Assoc. 2010;100:452-455. http:// dx.doi.org/10.7547/1000452
Renan-Ordine R, Alburquerque-Sendín F, de Souza DP, Cleland JA, Fernán- dez-de-las-Peñas C. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41:43-50. http://dx.doi.org/10.2519/jospt.2011.3504
Werner RA, Gell N, Hartigan A, Wiggerman N, Keyserling WM. Risk factors for plantar fasciitis among assembly plant workers. PM R. 2010;2:110-116. http://dx.doi.org/10.1016/j.pmrj.2009.11.012
Forgive the aloof and standoffish tone. I recognize the term “scapular winging” is a thing and that it can be an actual, real-live, medical diagnosis with dastardly consequences.3
But more on that in a minute.
It’s just that, in some ways, I find a lot of fitness pros – personal trainers, strength coaches, and even physical therapists – can often be a little too liberal with use of the term. They toss it around with little understanding of what it actually means and with little “feel” on how it’s interpreted by their clients and athletes.
I’ve long championed the sentiment that most (not all) fitness pros use the initial assessment as an opportunity to showcase how much people suck at doing things and how broken they are, and that, for the mere cost of a 215 pack of training sessions (the equivalent of a really, really nice Audi), they’ll fix you.
Pffffft, who wants an Audi anyways?
Here’s how a typical conversation goes:
Client: “Hey, I’m thinking about hiring someone to train me.”
Douchy Trainer: “Great, I’d be glad to help. We need to start with an assessment so I have ample opportunity to showcase how much of walking ball of fail you are and how I alone can fix you.”
Client: “Uh, okay. When do we start?
Douchy Trainer: “Right now, take off your shirt.”
Client: “Not going to buy me dinner first, huh? Kidding, okay, BAM.”
[takes off shirt]
Douchy Trainer: “Oh……….MY………..GOD.”
Client: “What? What’s wrong?”
Douchy Trainer: “I’m sorry to have to tell you this, but, you may want to sit down for this.”
Client: “Okay. What is it?
Douchy Trainer: “I’m sorry to have to tell you, but, but…..you have scapular winging.”
Client: “Is….that bad?”
Douchy Trainer: “I honestly have no idea how you’re able to walk, let alone speak complete sentences. We need to fix this ASAP.”
And this is where the trainer turns into that a-hole nun from Game of Thrones walking the client, Cersei style, down to the training floor to take them through a bevy of corrective exercise drills.
Now, admittedly, the key words used to find this picture were “most fucked up, dumpster fire of a case of scapular winging on the internet,” so don’t get too alarmed.
This is a legit, medically diagnosedcase, and not at all normal.
In a general sense, when we say “scapular winging” all we’re saying is that the shoulder blade comes or “wings” off the ribcage.
It’s sorta tricky because this pretty much describes everyone. You, me, George Clooney, your second cousin’s brother-in-law’s nephew’s Little League coach, literally, everyone, has some form of scapular winging.
So, what is it then? How much is too much? And, more importantly, what, if anything, should we do to fix it? Do we even need to fix it?
Dr. Quinn Henoch of Juggernaut Training Systems described this beautifully not too long ago. In short: a true case of scapular winging, like what’s pictured above, is a neurological condition where the Long Thoracic Nerve isn’t doing it’s job of innervating the Serratus Anterior (who’s job it is to adhere the shoulder blade to the ribcage).
The approach or fix in this case hasn’t anything to do with turning on “x” muscle or performing x, y, and z corrective exercises.
It’s not quite that simple.
Scapular Winging: What It Isn’t
I’ll tell you this much: we don’t have a pandemic of people walking around with true scapular winging. The vast majority of people you’ll encounter are owner’s of a completely healthy Long Thoracic Nerve.
They’re not broken. There’s nothing super duper nefarious happening.
What’s likely the culprit is a lack of tension and motor control.
The fix, then, is……..Drum roll…..
LOAD
If we can figure out ways to introduce load and subsequently, tension, this will not only help to turn shit on (without having to go down the 19-part corrective exercise rabbit hole) but also help people get into better positions via a little introduction to protraction.
Want to “cure” someone’s scapular winging in a matter of seconds?
Watch this. Closed-chain movements, protraction in general, is kind of magical.
Wall Press & Push-Ups That Don’t Suck
Pretty cool, right? That’s some Gandalf shit right there.
Quadruped Rockback w/ Floor Press
Typically the Quadruped Rockback is a a screen used to gauge active hip flexion ROM and to ascertain someone’s appropriate squat depth based of his or her’s anatomy. However, after listening to Mike Reinold speak on the topic it’s also a great drill to cue people into more protraction and upward rotation
Floor Press w/ Upward Rotation
Taking the floor press a step further, we can take away a base of support (and force the stabilizing arm to work that much harder in order to maintain position) and then incorporate some upward rotation.
Wrap Up
The umbrella theme here is not to dismiss scapular winging as an actual diagnosis. It is a diagnosis. It’s just not as common as people think, and I wish more fitness pros would stop jumping to conclusions so fast.
Oftentimes the fix is just to coach people up, introduce some load, and get them into better positions.
Last Chance to Save $100 off Complete Shoulder & Hip Blueprint
Foam rolling was never a “thing,” at least in mainstream fitness circles, until the early 2000’s. Since then it seems you can’t lift a weight or make a tuna salad without first taking yourself through a myriad of foam rolling drills to ensure “safety.”
Do I have my clients foam roll? Yes. Do I feel it’s imperative? It depends. In today’s guest post by Dr. Nicholas Licameli, he sets the record straight on what foam rolling is and what it isn’t
In the fitness world, foam rolling has become just about as popular as yoga pants, bright stretchy shirts with motivational and quirky quotes, and transformation pictures on Instagram. That being said, a foam roller can be an effective tool, if used correctly.
Some buzz terms you may have heard when it comes to foam rolling are muscle lengthening, breaking down scar tissue, freeing up adhesions, remodeling of collagen, curing cancer, etc., however recent research does not support these claims as the mechanism by which foam rolling works.
In reality, we as humans cannot produce the amount of force necessary to remodel our tissues. Our tissues are much more resilient than that. It actually takes thousands of pounds of force to accomplish this, which is probably a good thing because we don’t want our tissues breaking up or remodeling when we’re carrying groceries, sitting on a park bench, squatting with 500lbs on our backs, or anytime we put weight into them.4,5,8
Last time I checked, no one is foam rolling with that much force!
But…We Feel Better and “Looser” After We Foam Roll. Why????
The mechanism by which foam rolling works seems to be neurophysiological rather than physical.
Neurophysio what? Neurophysiological.
This means that foam rolling induces a global decrease in muscle tone. Muscle tone is the continuous passive contraction of a muscle controlled subconsciously by the brain. In other words, it’s a muscle’s resistance to passive stretch. Tone is created by a constant subconscious message from the brain telling a muscle to contract. Many times the sensation of muscle “tightness” has more to do with tone and less to do with actual muscle length.
This is similar to how pain is perceived. Pain is a sensory input. Foam rolling adds a sensory input (the pressure) to override another sensory input (tightness or pain) to disrupt that subconscious message between the brain and the muscle to contract or perceive pain.1,6,8 This is why we feel better, looser, and less pain after foam rolling.
A Word (Or two. Or three.) On the Iliotibial Band (IT-Band)
By understanding the neurophysiological mechanism by which foam rolling works, it is now clear why you should NEVER FOAM ROLL THE IT-BAND.
The IT-band is a long tendon that has connections to the hip musculature, lateral quads, and lateral hamstrings…but it is only a tendon, not a muscle.
It is not made up of contractile tissue and therefore cannot have tone. The IT-band becomes tight as a result of increased muscle tone of its muscular attachments.
Think of it like this…imagine attaching the rear bumpers of two tractor-trailers with a chain. Both drivers hit the gas and the trucks try to move away from each other, increasing tension on the chain. In order to lessen the tension on the chain, it’s obvious that you would have the drivers ease off the gas. The chain itself does not cause the tension. The force of the trucks causes the tension.
The same goes for the IT-band. To improve IT-band tightness with a foam roller, focus on the hip musculature, lateral quads, and lateral hamstrings. By rolling directly over the IT-band, you are only causing yourself pain, which is most likely causing a global increase in muscle tone throughout the body.
Great Let’s Get Rolling! I’m Going to Foam Roll Every Muscle of My Body 3x/day For the Rest of My Life!
Not so fast.
The above-mentioned benefits of foam rolling seem to be very short lived. If you spend 10, 20, or 30 minutes foam rolling different muscle groups, by the time you’re done, you’ve likely lost the benefits of the first 5-10 min.
Although the research has not shown an optimal dosage for foam rolling, it has been shown that short bouts of 10-60 seconds is effective.7,8,9 That being said, do not focus on time. Focus on “feel.” Feel that muscle release!
Don’t just roll and roll and roll.
Note From TG: ^^^ Sorry, I couldn’t resist. And, you’re welcome.
Start off with a slow, steady roll covering the entire muscle group scanning the area for tender spots. Think of scanning the area as a blind person would scan a new environment.
Once you find a tender spot, pause and hold on that spot until a release is felt and the tenderness lessens. Follow this up with another slow, steady roll over the entire muscle just like you started. It is true that foam rolling should be a bit painful, but too much pain will cause an increase in muscle tone, which, as previously mentioned, is exactly the opposite of what we want to do.
More pain is not better. Better quality is better.
Foam rolling should be done with a specific purpose targeting specific muscles (see a qualified healthcare practitioner to pinpoint target areas specific to you). Stop mindlessly flailing around on the dirty gym floor rolling every muscle of your body. Foam rolling should address a specific movement that is limited.
Test/retest means you test a movement (like a squat) before and after performing soft tissue work to determine if there was any significant change. A useful way to do this is between warm up sets.
So I Understand That the Benefits of Foam Rolling Are Relatively Short Lived, but Can Foam Rolling Help Achieve Long-Term Improvements in Tissue and Movement Quality?
Yes!
That is where loaded movements come in. During the window following foam rolling, it is important to load the movement that you are trying to improve. This is why I recommend performing soft tissue work between your warm up sets.
It will allow you to test/retest as well as gradually load the movement, given you are gradually increasing load with each warm up set.
Take a squat for example.
You feel tightness and restriction in your hips halfway into the descent of your squat. You test and retest your squat and notice you are able to squat deeper and with less tightness. As you load the squat and work up to your working/heavier sets, this newly achieved movement pattern will be trained.
Training this movement with loads will, over time, lead to long term improvements in tissue and movement quality.2,8 Foam rolling can also be a great way to kick-start the recovery process by tapping into the parasympathetic nervous system, but that’s for a different article.
So do not fall victim to the latest trend or claims from gurus. I hope this helps shed some light on what foam rolling is, what it isn’t, how it works, and how to implement it into your training routine.
Let’s roll!
Author’s Bio
Dr. Nicholas M. Licameli, PT, DPT
Nick’s passion lies between his love for the journey of bodybuilding, education, spreading happiness, and helping others. He views bodybuilding through the eyes of a physical therapist and physical therapy through the eyes of a bodybuilder. Nick is a doctor of physical therapy and professional natural bodybuilder. He graduated summa cum laude from Ramapo College of New Jersey with his bachelor’s degree in biology, then furthered his education by completing his doctoral degree in physical therapy from Rutgers School of Biomedical and Health Sciences (previously the University of Medicine and Dentistry of New Jersey) at the age of 24. His knowledge of sport and exercise biomechanics, movement quality, and the practical application of research combined with personal experience in bodybuilding and nutrition allows him to help people in truly unique ways. Passion. Respect. Humility.
References
Andersen, L. L., Jay, K., Andersen, C. H., Jakobsen, M. D., Sundstrup, E., Topp, R., & Behm, D. G. (2013). Acute effects of massage or active exercise in relieving muscle soreness: Randomized controlled trial. The Journal of Strength & Conditioning Research, 27(12), 3352-3359.[PubMed]
Beardsley, Chris, and Andrew Vigotsky. “Foam rolling and self-myofascial release. “www.strengthandconditioningresearch.com. N.p., n.d. Web 19 Sept. 2016. https://www.strengthandconditioningresearch.com/foam-rolling-self-myofascial-release/
Chaudhry, H., Schleip, R., Ji, Z., Bukiet, B., Maney, M., & Findley, T. (2008). Three-dimensional mathematical model for deformation of human fasciae in manual therapy. JAOA: Journal of the American Osteopathic Association, 108(8), 379-390.[PubMed]
Chaudhry, H., Bukiet, B., Ji, Z., Stecco, A., & Findley, T. W. (2014). Deformations experienced in the human skin, adipose tissue, and fascia in osteopathic manipulative medicine. Journal of the American Osteopathic Association, 114(10), 780-787.[PubMed]
Goats, G. C. (1994). Massage–the scientific basis of an ancient art: Part 2. Physiological and therapeutic effects. British Journal of Sports Medicine, 28(3), 153-156.[PubMed]
MacDonald G., Penney M., Mullaley M., Cuconato A., Drake C., Behm D.G., Button D.C. An acute bout of self myofascial release increases range of motion without a subsequent decrease in neuromuscular performance. J of Strength Cond Res. 2012. (published ahead of print).
“Mobility Myths With Dr. Quinn Henoch- Foam Rolling”. JTSstrength.com. N.p., 2016. Web Sept. 2016.
Sullivan, K. M., Silvey, D. B., Button, D. C., & Behm, D. G. (2013). Roller-massager application to the hamstrings increases sit-and-reach range of motion within five to ten seconds without performance impairments.International Journal of Sports Physical Therapy, 8(3), 228.[PubMed]
I hate the term “girl push-up.” I hate the connotation it breeds; that girls are weak and that they should do these kind of push-ups instead (performed from the knees). Coaches who use it are 1) lazy and 2) are definitely worthy of the stink eye.
But what about squats? Is there such a thing as “squatting like a girl?” Does the term equally make me want to toss an ax into my face? Well, not exactly. In today’s excellent guest post, NY based coach, Meg Julian, provides some insight on why, sometimes, there is such a thing as squatting like a girl.
I’d like to start off by saying that I’m truly honored Tony named his firstborn child, Julian, after me. I hope to inspire the masses as much as I’ve affected Tony. But I’m not here to talk about Baby Julian; I am here because of Baby Julian (yay!).
We are here to talk about why “squatting like a girl” can be different than squatting like a boy.
After working in a female-only gym for five years and training many females clients during the past seven years (not to mention being a woman myself), I’ve found that we often don’t hear about how tips for men might not work perfectly for women, because our bodies (shocker!) are different.
This is one major reason why when I ask new clients to squat, they often struggle to squat, or even look back blankly (really!) Why? Because squats can be complicated, and most exercise science was developed for men by men.
Photo Credit: T-Nation.com
And that’s no way to live, as a great squat can help women with overall strength and weight-loss, which are frequently among the goals I hear from clients.
So, whether you want to put an Olympic barbell on your back or just get in and out of a chair, you’ll want learn how to properly squat. Here are four important ways that women can improve their squat:
#1: Use Your Butt
Squatting is widely considered a phenomenal exercise for building your butt, but many women don’t effectively engage their glutes when they squat. Counter-intuitive, right?
That’s partly because most people sit for much of the day and thus over-stretch their posterior chain, which is the butt and hamstrings; we also tend to over-work the front of our bodies, rather than the posterior.
It’s no surprise, then, that the little elves in your muscles don’t stand a chance.
This condition is called “glute amnesia,” and it’s a term coined by back specialist Stuart McGill — I’m not kidding! If you don’t engage your glutes when you squat, the connection between your muscles and brain will fade, which will make it even harder to use your bum when you want to. In other words, if you don’t use it, you lose it.
To remedy this, the cue we often hear when squatting is to “sit back.”
But this often turns into a balancing act of:
Gripping the ground with your toes and hanging on for dear life;
Sticking your butt back;
Leaning forward and hoping to not fall over; AND
Doing nothing positive for your body.
Instead, I tell clients to pick their toes up off the ground.
Picking your toes off the ground, and putting the weight in your heels, makes the connection between the brain and posterior chain stronger. This is often what is meant by “sit back,” but our bodies tend to take the path of least resistance, so instead of truly using your glutes, it’s common to become a bit of a surfing expert.
Note from TG: Nice cue to get people to “feel” their glutes work and to understand their role in squatting. While I don’t want to speak for Meg, it’s not one I’d use long-term, especially if the goal is to lift more weight.
If this seems weird and awful, or you topple over, you’re probably not doing it incorrectly; you just haven’t built the strength yet. Keep trying. And you might want to practice over a bench until you get the hang of it.
#2: Redefine the Relationship Between Your Knees and Your Toes.
The misinformed cue we often hear is “Don’t let your knees come past your toes.”
The idea, again, is that your weight should be in your heels and mid-foot instead of being perched up on your toes. The cue has it’s heart in the right place, but it’s just misdirected, much like this meme:
But I love home; that’s where I keep my bed, food and dog.
The problem? Again, everyone is built differently. For example, if you have long femurs (thigh bones), it’s going to be better for your squat to let your knees come past your toes.
The focus, instead, should be on having your shoulders go straight up and down as you squat.
So instead of focusing on your knee placement, double-down on your efforts to keep your weight back, barbell over mid-foot, and your back upright.
#3 And One More Thing About Your Feet.
It’s common to be told “Squat with your toes facing forward,” but most women will feel more comfortable turning their toes out a bit when they squat. The female hips and the way the leg bones fit into them are built to be a little wider; you know, “birthing hips” and all.
So instead of focusing on your feet facing forward, focus on aligning your knees above your toes, and for women, this likely means turning your feet slightly outward — and your knees along with it.
Trying to force a more narrow stance or twist the toes in a direction they don’t naturally want to go will cause a lot of tension in the knees. It’s like trying to jam a drawer shut that’s off its runners — not pleasant.
This may be perfectly fine for some and even how most assessments are done, but it’s possible that this is not the ideal form during every workout. Just look at the way a little kid naturally sits in a sandbox (do they still have those?): knees are wide and toes are turned out.
Not sure how wide to point your toes? I recommend standing barefoot with your heels together on a smooth surface like wood, and squeeze your glutes. Then, separate your feet until your heels are under your shoulders. This is likely the most comfortable position for a squat for your body. Play around and see what feels best.
#4: Show Your Ankles Some Love.
Tight calves can lead to a lack of dorsiflexion, which is the ability to flex the toes up toward the shins. It’s a problem I often see in women who wear high heels or flip flops and never stretch.
Lacking range of motion in your ankles is terrible for nailing a squat. By limiting the bend, your body will find a way to compensate by flattening arches, caving knees in toward each other or leaning too far forward.
Here’s a simple test of ankle mobility: Place your toes four inches from a wall. Without lifting your heel, can you bend your knee until it taps the wall. If yes, you’re good! If no, keep practicing twice a day until you can. Keep it up until you can consistently hit a wall. In a good way.
Wrapping It Up
Most women have goals of losing weight, improving their backsides and getting stronger. While these goals are a bit vague, I do have a specific answer: Squat as much as you can handle — after you master squatting like a girl.
Author’s Bio
If you enjoyed what you read, want to learn more or just need to know where to send the hate mail, visit me HERE, where you can subscribe to my weekly email dedicated to tips like these and improving technique and strength for obstacle course racing. You can also follow me on Instagram HERE.
Megan Julian is a New York-based NASM Certified Personal Trainer, with additional certifications such as, FMS L2, NASM-CES and CFSC. She specializes in preparing brides for the big day, helping obstacle course racers improve their times and working with clients of all ages overcome injuries. In her free time, she enjoys running through the woods, jumping over walls and crawling under barbed wire — sometimes at events such as the World Championship Obstacle Course Race in Canada.
It was 1:30 AM, maybe even 2:17 (it’s always a blur, sucky, and when it’s that late doesn’t it even matter?) as my wife nudged me to see if the baby was alright. I turned over to my left, peeled my eye open just enough to press the button to turn the screen to the monitor on, and indeed it was our newborn, Julian, making his case for one of the two of us to get our asses out of bed and ascertain the situation.
Julian, during one of his non-Gremlin moments
Our little guy passed the 4-week old mark earlier this week and in that time Lisa and I have had a crash course in sleep deprivation training (I’m basically a Navy SEAL by now) in addition to learning baby-speak, or what I like to call “What are you trying to tell me? Please stop crying. I’ll do anything. No, really, anything………”
[Jumps off roof]
We don’t have much to complain about in the grand scheme of things. Julian has been awesome. Much like any baby in the history of ever, and as any parent in the history of ever knows, when your newborn starts crying it’s indicative of one or two factors to get them to (hopefully) settle back down:
They need a diaper change.
They need to be fed.
They need to be swaddled,
They need their binkie.
They need to be swung or need movement (or maybe they’re overstimulated).
WILDCARD: They need more cowbell.
As time passes you learn to not panic, run through the checklist, and before long you’re a first class baby-calmer-downer.
It’s funny, though.
Since I’ve been neck deep in baby shenanigans the past few weeks it’s been a trip to see how I make connections and correlations between that and stuff I see and come across in my professional life… training and coaching athletes/clients. One of the purest examples is something I witness on an almost weekly basis.
Many of the new people who start with me are beginner or intermediate level meatheads (male and female) who, for whatever reason(s), have been dealing with a pissed off shoulder that inhibits their ability to train at the level or intensity they’d like. It’s frustrating on their end and it’s my job as the coach to try to peel back the onion and see what may or may not be the root cause or causes.
Most commonly people will note how bench pressing bothers their shoulder(s). Working on their technique is the baby check list equivalent of blow out explosive diarrhea.
I.e., It’s code mother-fucking red.
Following the mantra “if it causes pain, stop doing it” is never a bad call, and I am all for nixing any exercise or drill that does such a thing. However, I don’t like to jump to conclusions too too quickly. Sometimes making a few minor adjustments to someone’s technique or setup can make all the difference in the world.
Almost always I’ll have to spend some time on their set-up. I like to cue people to start in a bridge position to drive their upper traps into the bench and to set their scapulae (together AND down).
We can make arguments as to what this is actually doing. Some will gravitate towards it improving joint centration. Cool (and not wrong). I like to keep a little simpler and note that all it really does is improve stability.
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Another thing to note is many people tend to flare their elbows out too much when they bench which leaves the shoulders out to dry and in a vulnerable position.
MINOR NOTE: Since recording that video above (two years ago), I have since changed my views slightly thanks to some cueing from Cressey Sports Performance coach Tony Bonvechio. Elbows tucked on the way down is still something I’m after (albeit some are too aggressive at the expense of placing too much valgus stress on the elbows). However, when initiating the press motion, in concert with leg drive, allowing the elbows to flare out a teeny tiny bit (in an effort to keep the joints stacked and to place the triceps in a more mechanical advantage) will often play huge dividends in performance.
In the end, much of the time it comes down to people not paying any attention to how crucial their set-up is. It’s amazing how often shoulder pain dissipates or disappears altogether with just a few minor adjustments.
2) What People Don’t Want to Hear: Stop Benching, Bro
This is where the Apocalypse begins. Telling a guy (usually not women, they could care less) that he should probably stop benching for the foreseeable future is analogous to telling Donald Trump he can’t Tweet.
The thing about holding a barbell is that it “locks” the glenohumeral joint into internal rotation which can be problematic for a lot of people and often feeds into impingement syndrome.
[The rotator cuff muscles become “impinged” due to a narrowing of the acromion space.]
NOTE: I hate the term “shoulder impingement” because it doesn’t really tell you anything. There are any number of reasons why someone may be impinged. Not to mention there are vast differences between External Impingement and Internal Impingement….which you can read about in more detail HERE.
If bench pressing hurts, and we’ve tried to address technique, I’ll often tell them to OMIT barbell pressing in lieu of using dumbbells instead. With DBs we can utilize a neutral grip, externally rotate the shoulders a bit more, and open up the acromion space.
Or, maybe they can still barbell press, albeit at a decline. When you place the torso at a decline the arms can’t go into as much shoulder flexion and you’re then able to avoid the “danger zone.”
Something else to consider is maybe pressing off a foam roller. Sure, you won’t be able to use as much weight, but as Dr. Joel Seedman explains in the video below you’ll be able to work on better joint centration AND the scapulae can actually move (an important variable discussed more below).
If all else fails, sadly, you may have to be the bearer of bad news and tell someone that (s)he needs to stop benching for a few weeks to allow things to settle down.
3) Let the Scaps Move, Yo
Above I mentioned the importance to bringing the shoulder blades together and down in an effort to improve stability.
If you want to lift heavy shit, you need to learn to appreciate the importance of getting and maintaining tension. That said, if lifting heavy shit hurts your shit, we may need to take the opposite approach. Meaning: maybe we just need to get your shoulder blades moving.
When the scaps are “glued” together and unable to go through their normal ROM it can have ramifications with shoulder health. Push-ups are a wonderful anecdote here.
Unlike the bench press – an open-chain exercise – the push-up is a closed-chain exercise (hands don’t move) which lends itself to several advantages – namely scapular movement.
4) More Rows
This one will be short and sweet. Perform more rows. Many trainees tend to be very anterior dominant and spend an inordinate amount of time training their “mirror muscles” at the expense of ignoring their backside. This can lead to muscular imbalances and postural issues.
This makes me sad. And, when it happens, a kitten becomes homeless.
You sick bastard.
The easy fix is to follow this simple rule: For every pressing motion you put into your program, perform 2-3 ROWING movements. Any row, I don’t care.4
5) Address Scapular Positioning
I’m going to toss out an arbitrary number and I have no research to back this up, but 99% of the time when someone comes in complaining of rotator cuff or shoulder issues the culprit is usually faulty scapular mechanics. Sometimes people DO need a little more TLC and we may need to go down the “corrective exercise” rabbit hole.
The scapulae perform many tasks:
Upwardly and downwardly rotate
Externally and internally rotate
Anteriorly and posteriorly tilt.
AB and ADDuct (retract and protract).
Will clean and fold your laundry too!
They do a lot. And for a plethora of reasons, if they’re not moving optimally it can cause a shoulder ouchie. Sometimes people are too “shruggy” (upper trap dominant) with overhead movements, or maybe they’re stuck in downward rotation? Maybe they can’t protract enough and need more serratus work? Maybe they lack eccentric control and need a heavy dose of low trap correctives?
It dumbfounds me the number of times I have had people come in to see me explaining how they had been to this person and that person and NO ONE took the time to look at how their shoulder blades move.
I don’t like to get too corrective too soon (as I prefer to not make my clients feel like a patient), but if I’ve exhausted all of the above and stuff still hurts….it’s time to dig deeper.
If only there were a resource that dives into this topic in a more thorough fashion.
NOTE: the term “Porcelain Post” first came to fruition last year between Brian Patrick Murphy and Pete Dupuis. Without getting into the specifics, it describes a post that can be read in the same time it takes you to go #2.
Huh, I guess that was more specific than I thought.
The Birddog Exercise: Please, Start Coaching It Right
The birddog exercise is a common drill used in many components of health/fitness. It’s most commonly utilized within yoga/pilates circles and referred to as either the donkey kick or chakaravakasana. Which, as we all know, is Elvish for, “doing something poorly and making my corneas jump out of their sockets into a fiery volcano.”
Okay, that’s not true.
But we all know that the bulk of people performing this exercise, whether they’re in a yoga class, performing it on their own, or following the tutelage of a strength coach or personal trainer, end up looking like this (not always, but enough to warrant an intervention in the form of this brief post):
The birddog exercise not only targets the back, but also the hip extensors. It also, and more importantly, teaches the discipline of using proper hip and shoulder motion while maintaining a stable spine.
The picture shown above is the complete opposite of that. What we see instead is a gross exaggeration of lumbar (lower back) extension and a lengthening of the rectus abdominus compounded with excessive rib flare and cervical extension.
Essentially this person is tossing up a ginormous middle finger to any semblance of spinal stability.
Now, in fairness, maybe the woman pictured above was coached into that position for a specific reason:
Prepping for the World “How to Eff Up Your Back” Championships?
Because it’s Wednesday?
I don’t know the true details. Maybe I should lighten up.5 But what I do know is that I find little benefit in performing the birddog, and it’s likely doing more harm than good.
And when I see it performed this way it makes me do this:
What’s most frustrating is the reactions I get from some people when I ask them to perform the birddog. I’ll get someone coming in with a history of low-back pain, and after taking them through a series of screens to see what exacerbates their symptoms I’ll then have them demonstrate this exercise.
What follows is typically a few eye-rolls and a seemingly crescendo of “come on Tony, really? I’ve been doing this exercise all along, can we please turn the page?”
Low and behold 9/10 (if not 10/10), the same person who has been complaining of weeks/months/years of low back pain in addition to a bevy of other fitness professionals espousing the merits of the birddog, when asked to demonstrate it, ends up looking exactly like the second picture above.
Case in point. I had an eval with a new female client last week. She was a referral from another trainer located here in the Boston area and she informed me that this client had been battling some chronic low-back shenanigans for the past few years. To the other trainer’s credit: much of what she had been doing with this client was spot on (and I have zero doubts this client was coached very well). However, the birddog lends itself to be one of those “hum-drum, don’t worry, I got this” exercises where people (I.e., the client), when left to their own devices, becomes complacent and lackadaisical in its execution.
Play close attention to the before and after videos below:
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Before = her execution of the exercise was “feeding” into her symptoms and most likely resulted in a kitten dying.
After = ticker tape parade for coaching!
With a just a few subtle cues and a “molding” of the exercise to better fit her current ability level, we were able to significantly clean up her technique and the exercise not only felt more challenging, but she felt better.
The difference maker was placing a ValSlide underneath her moving leg so that she’d be less likely to fall into extension.
From there, with the leg fully straight, I then had her lift her foot off the ground an inch or two and then “OWN” the movement/position.
She then held for a 3-5s count, performed 3-5 repetitions per side, and we then fist pumped to some Tiesto.
Coaching oftentimes involves paying closer attention to the details, even with the more mundane exercise that we often take for granted. With the birddog it often behooves us to slow people down, get a little more hands on with them (provide more kinesthetic awareness), and hold then accountable to be SPOT ON with their technique each and every rep.
This is what separates correctives and programs that work (and serve a purpose) and those that lead to less than exemplary results due to haphazard execution.
Teaching a beginner how to squat well can be challenging. There’s no denying there are a lot of moving parts that can derail our best efforts to do so.
My intention of this quick-n-dirty post isn’t to break down the squat in its entirety. For that I’d encourage you to check out Greg Nuckols’ How to Squat: The Definitive Guide.
It’s basically the War and Peace of squat biomechanics and technique. Except, you know, not written by a Russian.
Instead, my goal today is to hammer home a few candid points when working with beginners on their squatting technique.
1. “Beginners” in this sense could mean a 13 year old who’s never touched a weight or a 57 year old who’s had a few decade hiatus. And everything in between. Male, female, athletes, non-athletes, centaurs, you name it.
2. The squat is a basic human movement pattern. Unfortunately, in today’s world, we don’t move as much as we used to, and subsequently many struggle with the movement. Oftentimes one’s only source of physical activity is if or when they get their butts to the gym.
And even if they do that, there’s no guarantee they exercise in a range of motion below a certain degree of hip flexion.
There’s truth to the common phrase “if you don’t use it, you lose it.”
This isn’t to insinuate that everyone has to squat to a certain level or that you’ll lose some street cred if you happen to not squat ass-to-grass. As I’ve repeatedly stated on this blog everyone is different (leverages, anthropometry) and it’s silly, nay, fucking moronic to think everyone has to squat deep.
So whenever I work with a beginner or someone coming off a significant injury it’s on me – the coach – to take the time to groove a solid squat pattern.
This rarely (if ever) involves placing a barbell on someone’s back on Day #1.
Why?
Because I said so….;o)
Many people lack the requisite t-spine (extension) and shoulder mobility (abduction/external rotation) to hold a barbell in that position without it feeling weird of wonky.
Many lack the kinesthetic awareness to sit back (and down) in a fashion that emulates a squat.
There’s no Golden Rule that we have to load people right away.
I’m more concerned with teaching proper position.
It’s that last point – teaching proper position – that’s a game changer in my eyes. You see, many people tend to “sit” in a state of perpetual (excessive) extension where their pelvis tilts forward, otherwise known as anterior pelvic tilt (APT)
To be clear: APT is not bad or wrong or needs to be fixed. It’s normal. However, when it’s excessive it not only places more strain on the spine (particularly the facet joints), but it also leads to poor alignment where the diaphragm and pelvic floor point in different directions.
Within PRI (Postural Restoration Institute) circles (<— total nerd fest) this is called the “Scissor Position.” What we’d like to strive for is what’s known as the “Canister Position,” where the diaphragm and pelvic floor are aligned or stacked on top of another.
Another way to think of it, is something I stole from Dr. Evan Osar.
“Think of your pelvis as one ring and your rib cage as a bunch of more rings. What you want is to stack those rings on top of one another.”
Mike Robertson is also a fan of this approach and even goes a step further and notes the importance of reaching, and how that can have a positive effect on one’s overall positioning. When we “reach” we nudge ourselves into a little more posterior pelvic tilt (back to “neutral”) and we then achieve proper diaphragm/pelvic floor alignment. Bada bing, bada boom.
If all of that comes across as me speaking Elvish, watch this video.
Plate Loaded Front Squat
The plate loaded front squat is now my “go to” squat progression when working with beginners. It’s something I’ve used for years for a few reasons:
1. The plate serves a counterbalance as one squats down towards the floor helping them to learn proper torso positioning and balance. It’s makes things infinitely easier with regards to sitting back & down into a squat.
2. Pressing the plate out front also helps to better engage the anterior core musculature. This is so crucial. I can’t tell you how many times people have come in for an assessment telling me stories of trainer upon trainer telling them how “tight” they are because they couldn’t squat past parallel. Prior to coming to me they had spent years, years stretching and working on any number of hip mobility drills.
Thing is: they weren’t tight. People rarely are. Or, at least it’s rarely ever that cut and dry (tight vs. not tight). In reality most are weak and unstable. For many, their nervous system is putting on the brakes because it perceives a lack stability. By having trainees press the plate out front it automatically forces the core to fire – thus providing more stability. And miraculously they’re able to squat deeper.
And I come across as the next Professor Dumbledore.
Moreover, it was Mike Robertson who pointed out to me the added benefit of the plate loaded front squat. The “reach” results in better diaphragm and pelvic floor alignment.
It teaches people context, and to own the “canister” position (preventing the ribs from flaring out). That way, when they progress to barbell variations, they’ll have a better understanding of what we’re after and what will (in all likelihood) allow them to perform at a higher level for longer periods of time reducing the risk of injury.
Want More Mike Robertson Nuggets of Programming Badassery?
I owe much of my programming savvy to Mike Robertson. It’s little nuggets of wisdom (as demonstrated above) that helps to separate him from the masses. I’ve always enjoyed his approach and way of explaining things. There aren’t many coaches who have the innate ability to take complex topics and “dumb them down” for the masses (like myself).
His excellent resource, Physical Preparation 101 is currently on sale at $100 off the regular price from now through this Friday (2/10).
It’s basically his entire philosophy on program design. 12 DVDs of Mike Robertson knowledge bombs. I have zero doubts the money you invest in this will pay for itself tenfold in client retention.
Back pain can be tricky. First off, anyone who’s ever dealt with it (pretty much everyone) knows it’s no fun. Second, there’s no overwhelming agreement as to what actually causes it. One person says weak glutes, another says tight hip flexors or hamstrings, and yet another may point to a bad hair day (NOTE: read this footnote, it’s a doozy —>).6
Third, if the stock photo I chose below is any indication, back pain can also put a real damper on what can only be described as an Old Spice or Abercrombie & Fitch ad shoot.
In my career as a personal trainer and strength coach I’ve worked with dozens and dozens of athletes and clients battling low back pain. It comes with a territory as a fitness professional. I’ve tried my best to arm myself with the best skill-sets possible (within my scope of practice) to help my clients work through their low back shenanigans. I can assess – not diagnose – and try to come up with the best game plan possible to address things.
And, to be honest, addressing one’s lower back issues can be mind-numbingly simple.
In short:
“Find what movements hurt or exacerbate symptoms, don’t do those movements, and then find movements that allow for a degree of success or pain free training.”
I’d be remiss not to mention Dr. Stuart McGill’s work here. Not only is he one of the world’s Godfathers of spine research, but he’s also one of the world’s best mustache havers.
He’s co-authored hundreds of studies and written several books on the topic of low-back pain – with Ultimate Back Fitness & Performance (now in it’s 6th Edition) and Low Back Disorders being his flagship pieces of work.
Speaking of Ultimate Back Fitness & Performance, look who makes a cameo appearance on pg. 289 in the latest edition:
BOOM
For the Record: TG Life Bucket List
Get to a point in my career where Dr. Stuart McGill not only knows who I am, but emails me out of the blue and asks permission to use a picture of me in his latest book update.
Appear in a Star Wars movie.
Become BFFs with Matt Damon
Own a cat.
I’d have to say, however, that his most “user friendly” book is Back Mechanic. In it, he breaks down his entire method for “fixing” low back pain covering everything from spinal hygiene, assessment, corrective exercise, and strength training.
I’m not going to belabor anything, you can purchase the book and peel back the onion on his protocols (seriously, the assessment portion is gold).
I’ve noticed a trend in recent years, though. Dr. McGill has done so much for the industry and his work is so ingrained in our thoughts as fitness professionals that I feel the whole idea of “avoiding spinal flexion (sometimes at all costs)” has bitten us in the ass.
Yes, avoiding spinal flexion is a thing, especially if someone is symptomatic and flexion intolerant.7. It’s that point, though, “avoiding spinal flexion” that has gotten the best of us for the past decade or so.
We’ve done such an immaculate job at coaching people to know what “spinal neutral is” via prone planks, side planks, and birddogs, and then used strength training to engrain that motor pattern, that (some, not all) people transitioned into more extension-based back pain because they lost their ability to move their spine into (pain free) flexion.
Dr. Ryan DeBell discussed this phenomenon recently where he discussed his own back pain history. He started as flexion intolerant, trained himself into “spinal neutral,” (which is what you should do), started to avoid all flexion like the plague, and after awhile, extension-based movements & positions started to hurt…because he was locked into extension.
As a corollary, I see this quite often myself: someone comes in to see me and both flexion and extension based movements hurt. It’s so frustrating for the person and I can understand why.
My job, then, as the coach is to garner confidence and self-efficacy with my client/athlete and work with him/her on what I know tends to work….find movements that do not hurt and work from there.
Dr. McGill has his own version of the “Big 3,” or his go to exercises when first starting with a low-back person:
The Curl-Up (I.e., not a sit-up)
Side Bridge or Plank
Birddog
Even when we master those movements, which are often very challenging for people when performed right, I’ll stick with them for a couple of months and just up the ante with appropriate progressions. Lets take the birddog for example.
Birddog w/ RNT
The band adds an additional kinesthetic component where increased stiffness or engagement occurs in the anterior core and glutes. Truthfully, it’s not uncommon for me to START with this variation so the person can feel what their limbs are doing in space.
Birddog – Off Bench
I “stole” this one from Dr. Joel Seedman and feel it’s an ingenious progression. Doing the birddog off the bench takes away a component of stability (feet off the floor) and forces people to slow the eff down and learn to control the movement. If they don’t, they fall of the bench. And I laugh.
Your Spine, Move It!
Going back to the assessment for a quick second, it’s not uncommon for me to assess someone and to find that their spine doesn’t move. Whether it’s because of a faulty pattern or they were coached to avoid flexion at all costs (even when asymptomatic) it’s as if their spine is Han Solo frozen in carbonite.
One screen I like to use is a the toe touch drill. When someone bends over to touch their toes there should be a consistent curvature/roundness of the spine. Often, what I’ll see is more of a “V” pattern where they’ll bend over, but instead of seeing a nice curve I’ll see their lower back stay flat throughout the movement; as in zero movement.
This can be just as detrimental as anything else. It may or may not be a root cause of their low-back pain, but I know it’s a red flag I’d like to address.
Segmental Cat-Cow
Below is a drill I’ve been using more and more with my low-back clients. We’re all familiar with the Cat-Cow exercise, where you round and arch your spine moving through a full-ROM.
Cool, great. The human body is great a compensating, and unless you have a keen eye for detail it’s easy to assume that if someone can round and arch their back they’re good to go. But
But are they? Often, if you SLOW PEOPLE DOWN it’ll become abundantly clear that they may move well in certain areas of their spine (thoracic), but not in others (often lumbar).
Coaching them through the movement – point by point, segmentally – is a fantastic way to hammer this point home and to help nudge them to move their spine in a slow and controlled fashion.
Give this one a try with some of your clients. COACH THEM. This drill doesn’t require more than two passes (up and down) per set, for a total of 3-4 sets. Helping them understand that they are allowed to move their spine – assuming it’s pain free – is a sure fire way to set them up for long-term healthy spine success.
Dr. Michael Infantino is a physical therapist. He works with active military members in the DMV region. You can find more articles by Michael at 
Dr. Nicholas M. Licameli, PT, DPT
