Rehab/Prehab – Tony Gentilcore

Everything and Nothing Causes Low Back Pain

The topic of low back pain (LBP) – how to assess it, diagnose it, and how to treat it – can be a controversial one. I italicized the word “can” because I don’t feel it’s all that controversial.

Cauliflower as an option for pizza crust or Zach being chosen as the bachelor on the current season of The Bachelor (when it’s 100% clear that a ham sandwich has more charisma) = controversial.

Simple stuff to consider to help with one’s LBP = not so much.

Copyright: olegdudko / 123RF Stock Photo

Everything and Nothing Causes Low Back Pain

The topic of low back pain and how to address it is controversial because there’s no one clear approach or answer to solve it.

(And if the last 3+ years of this pandemic dumpster fire has taught us anything it’s that we looooooove to argue over what’s best and what works).

SPOILER ALERT: Everything and nothing causes LBP.

Have ten different doctors or physical therapists work with the same patient and it’s likely you’ll get ten different opinions as to what the root cause is and what tactics need to be implemented to resolve it.

One person says it’s due to delayed firing of the Transverse Abdominus (TA), while someone else states it’s due to someone’s less than great posture or tight hamstrings.

For the record, all are weak excuses at best.

The culprit can rarely be attributed to any ONE thing.

But it’s amazing how often “tight hamstrings” is the fall guy.

Low back pain? Tight hamstrings.
Knee hurts? Tight hamstrings.
Have Type II Diabetes? Tight hamstrings.
Brown patches on your front lawn? Hamstrings.

It’s uncanny.

I mean, I could just as easily sit here and say in worse case scenarios LBP results from drinking too much coffee. I have zero evidence to back that up, but whatever.

…neither do most of the other “culprits” people tend to use as scapegoats.

So, why not coffee?

Or Care Bears for that matter, those sadistic fucks.

What works for one person, may exacerbate symptoms for someone else. And as my good friend, Dr. John Rusin notes:

“Fact of the matter is: there is NO one right way. it’s a big mistake to lump all LBP into the same category and even a bigger mistake to assume all of it presents the same or should be treated the same.”

There’s no way for me to write a thorough blog post on such a loaded topic; especially one that will make everyone happy.

It’s impossible.

I have better odds at surviving a cage match with an Uruk-hai.

Part of me feels like the proper response to the question “what causes low back pain and what’s the best way to address it?” is this:

via GIPHY

But that would be woefully uncouth of me.¹

Most people reading aren’t clinicians or physical therapists. There’s very little (if any) diagnosing going on in the hands of a personal trainer or strength coach. And, truth be told, if you are a personal trainer or strength coach and you are diagnosing, YOU……NEED…….TO…….STOP.

Just stop.

It’s imperative to defer to your network of more qualified (and vetted) fitness/health professionals whom you trust to do that.

However, it’s important to also consider we (as in personal trainers and strength coaches) are often the “first line of entry” into the medical model. We’re the first to recognize faulty movement patterns, weakness, imbalances, and bear the brunt of questioning from our clients and athletes when they come to us with low back pain.

There’s quite a bit we can do to help people.

What follows is a brief look into my mind and what has worked for me in the past with regards to LBP; a Cliff Notes “big rock” brain dump if you will.

Sorry if I offended anyone who likes Care Bears.

1) Rest Is Lame

My #1 pet peeve (and many agree with me) is that “rest” is the worst piece of advice ever.

“Go stick your finger in that electrical socket over there” would be better.

This isn’t to say there aren’t extenuating circumstances where taking a chill pill is absolutely the right choice; sometimes we do need to back off and allow the body a window of time to heal or reduce pain/swelling/symptoms.

That said, I think it’s lame when a medical professional tells someone to “rest,” or worse, informs them that they’ll need to learn to “live with low back pain.”

It’s a defeatist attitude and will spell game over for many people. Before you know it they’re living on a foam roller and thinking about a “neutral spine” while washing their hands.

(NOTE: I am not anti-teaching neutral spine to people. It’s a lovely starting point for most people, but at some stage people need to learn to move in (and out) of precarious positions…because that’s life).

A common theme reverberated in the S&C community is to say “strength is corrective.” I wholeheartedly agree with this sentiment. In fact, why the hell has this not been made into a t-shirt yet?

However, I think a slightly better moniker may be to say:

“Movement is corrective.“

We can use movement (and yes, strength) to help people get out of pain. Rest has its time and place, but I find stagnation to be more of a problem.

The body is meant to move and is wonderfully adaptive. And that’s the thing: adaptation and forcing the body to react to (appropriate levels of) change and stress is paramount to long-term success with LBP.

Sitting on a couch watching Divorce Court in the middle of the day isn’t going to help.

2) Move, But Move Well

I was watching Optimizing Movement with Mike Reinold recently and he noted there are three key elements to movement and why someone may not do it well:

Structural Issues
Coaching/Technique
Programming

It’s important to understand that, in this case, everyone is a unique snowflake.

Structure: Anatomically speaking there is huge variance amongst the population. Hip structure, for example, can have a large effect on someone’s ability to squat to a certain depth or get into certain positions. Likewise, who’s to say the hips are always the culprit? Even upper extremity considerations – like one’s ability to bring their arms overhead (lack of shoulder flexion) – can have dire consequences on back health.

The body likes to use the path of least resistance (also the most efficient) to accomplish any task. However in this case, “most efficient” doesn’t mean best. As Reinold notes:

“Efficient in this case refers to energy, not movement.”

Lack of shoulder flexion will often lead to compensation via more extension through the lumbar spine. It’s efficient movement, but it’s not better movement.

Coaching/Technique: I’m a firm believer that everyone should deadlift (it’s a hip hinge, learning to dissociate hip movement from lumbar movement, doesn’t mean we have to load it), but I don’t feel everyone should do it from the floor or with a straight bar.

Cater the exercise to the lifter, not the lifter to the exercise.

3) Finding Spinal Neutral (Pain Free ROM) is Kinda Important

In light of a past gem by Dean Somerset on what the term “spinal neutral” even means, I realize this comes with a bit of grain of salt.

I just want to find a pain-free ROM and to help people with low back pain to own that ROM.

It’s the McGill Method 101.

Find what actions hurt or exacerbate symptoms, and stop doing it.

I know I just blew your mind right there.

For example:

1. Client says “x” hurts, and then places their body into some pretzel like contortionist position that would make a Cirque du Soliel performer give them a high-five.

Me: “Um, stop doing that.”

2. But that could also mean addressing how they walk or how they sit in a chair. Someone with flexion-based back pain, will like to be in flexion, a lot.

Maybe taking them through a slump test will offer some pertinent info.

Have them start in a “good” position:

Then, have them purposely “slump” into excessive flexion:

Someone who is flexion intolerant – despite preferring to be in that position – will often say this causes pain.

Ding, ding, ding.

So, the “fix” is to coach them up and try to keep them out of excessive spinal flexion. Cueing them how to sit in their chair and to get up (wider base of support, brace abs, chest up), building spinal endurance (and strength) via planks, and having them hang out in more extension may be the right path to take.

3. On the opposite side of the spectrum is extension, which is often a problem in more athletic populations and in those occupations requiring more standing (ahem: personal trainers/coaches).

Here you might put them into extension and see what happens.

Much like people who are flexion intolerant “liking” flexion, those in excessive extension will like to live in extension.

This will likely hurt.

Finding their spinal neutral is key too.

Hammering spinal endurance/strength via planks (done well) still hits the nail on the head, as does nudging them towards exercises that emphasize posterior pelvic tilt (much of time cuing people NOT to excessively arch during their set up on squats and deadlifts), and even drills that promote spinal flexion…albeit unloaded.

Spinal flexion doesn’t always have to be avoided. In fact, it’s sometimes needed.

Either way, meticulous attention to detail on finding spinal neutral – or pain from ROM – is huge. Once that is addressed, and symptoms has subsided, we can then encourage them to marinate in more amplitude of movement, taking them OUT of spine neutral (cause, it’s gonna happen in everyday life) and use the weight-room to help strengthen those new ROMs.

But I digress.

4) Don’t Treat People Like a Patient

I know this will rub some people the wrong way, but I still use the deadlift for the bulk of people I work with you have LBP.

Nothing sounds so absurd to me than when I hear someone say how the deadlift is ruining everyone’s spines.

To recap:

Deadlift = hip hinge.

Hip Hinge = learning to dissociate hip movement from lumbar movement.

Mic drop.

Resiliency is key in my book. And not many movements make the body more resilient than the deadlift or any properly progressed hip hinge exercise catered to the individual’s goals, injury history, and ability level:

Assuming I have coached someone up enough to understand spinal neutral and they’re able to maintain it, why not poke the bear and challenge them?

A deadlift doesn’t always mean using a straight bar and pulling heavy from the floor until someone shit’s their spleen.

I can use a kettlebell and band to groove the movement:

I can also use a trap bar, which is a more user-friendly way of deadlifting as it allows those with mobility restrictions to get into a better position compared to a straight bar.

https://www.youtube.com/watch?v=p-sA3PG1kGY

Too, I have found great success with various other exercises:

Farmer and Suitcase carries
Shovel Holds

“Offset” loaded exercises like 1-arm DB presses or 1-arm rows, lunges or RDLs (where you hold ONE DB to the side and perform the exercise). It’s a great way to increase the challenge to the core musculature.
Or even outside-the-box exercises like Slideboard Miyagi’s

So long as we’re staying out of precarious positions or those positions which feed into the issue(s) at hand, we’re good.

Find a training effect with your clients/athletes.

Help them find their TRAINABLE MENU.

And That’s That

People have low back pain for a variety of reasons: They’re too tight, too loose, too weak, have poor kinesthetic awareness, or they’re left handed.

The umbrella theme to remember is that there is never ONE root cause or ONE definitive approach to address it across the board. However, that doesn’t mean there aren’t some “big rock” things to consider that will vastly improve your’s and their chances of success.

I hope this helped.

And, again, sorry about the Care Bear comment.

February 23, 2023 Tony

Program Design Rehab/Prehab Strength Training

Knee Pain When Squatting? A Simple, Practical Guide to Resolving It

To mirror yesterday’s conversation on training around pain, today’s post delves a little deeper into a specific area that many lifters tend to have issues with:

~~Not enough bicep curl variations in their program~~
~~Forgetting to remove their shaker bottle from their gym bag for week~~
Knees.

The knees are a vulnerable joint and there are myriad of reasons why they can become achy, sore, cranky, or any other similar adjective you want to put here.

Sydney, Australia based physical therapist and trainer, Dane Ford, was kind enough to write this straight-forward article on some of the root causes of knee pain and ways to address them on your own.

Enjoy!

Knee Pain When Squatting?

Squatting is an essential part of most people’s fitness routine, and it can be extremely frustrating when you experience sore hips or knees when you squat.

Today I’m going to share four killer exercise variations that will help take some pressure off your knee joints!

No matter what level your fitness is at – whether strength training or just getting healthy again after injury – these tips should work their magic in no time flat.

Let’s get started.

The Goods

Box squat.

The first variation for those who experience knee pain when squatting is the box squat. A box squat will strengthen your quads, glutes, and hamstrings. It’s also a great way to improve your squatting technique.

You’ll need a box squat or a bench around knee height to do a box squat.

Start by placing the box behind you.
Then, position your feet shoulder-width apart and push your hips back.
Next, bend your knees and lower yourself until your bottom touches the box. Pause for a second, then stand back up.

Step-Ups

Step-ups are another great variation for people who have knee pain when squatting. This exercise works your quads, hamstrings, and glutes and is a great way to build lower body strength.

To do a step up, start by placing your right foot on a box or bench.
Then, push off with your right foot and raise your body up until your leg is straight.
Pause for a second, then lower yourself back down.
Focus on keeping the hips level.
Start with a smaller step, and increase the step height as your body allows.

Hip Thrusts

Hip thrusts are a great exercise for people who want to build stronger glutes. This exercise can also help relieve knee pain when squatting by taking the pressure off your knees.

To do a hip thrust, start by sitting on the ground with your back against a box or bench.
Place your feet flat on the ground and raise your hips until your thighs and torso are in line with each other.
Pause for a second, then lower your hips to the starting position.
Progress this exercise by adding weight at your hips, like a barbell or plate.

Banded Crab Walks

Banded crab walks are an excellent exercise for people who want to build stronger glutes and legs. This exercise can also help improve your squatting technique by making it easier to push your knees out over your toes. This is a golden exercise for dealing with knee pain when squatting.

To do a banded crab walk, start by placing a resistance band around your feet. (You could place it around your knees or ankles, but the further down your legs, the harder the exercise will be).
Then, step one leg out to the side as far as the band will allow.
Keep the hips level, and the shoulders stacked over the hips.
Next, step in with the other leg.
Repeat.

Causes of Knee Pain

When addressing knee pain during squats, it’s important to understand some of the common causes. This way, you can be sure that you’re taking the right approach to fix the underlying issue. Here are three common factors which can contribute to knee pain when squatting:

Improper Form

Whilst there is no such thing as textbook technique, using ‘adequate’ form allows you to engage the right muscles when you lift and minimize injury risk. If you don’t utilize adequate form when you squat, the load in certain areas like your knee joints will be increased, instead of having the load evenly distributed through your entire body.

Your ideal squat stance will be determined by the bony alignment of your joints and other anatomical factors.

Overuse

Our body’s tissues all have a maximum tolerable capacity. This means that we need to be able to go hard enough in the gym to stimulate adaptation and promote strength, whilst not overloading ourselves to the point of tissue injury.

Giving your body time to recover with rest or a de-load week every now and then is a great start, to allow proper cell regeneration, repair and adaptation to occur.

Adding variety into our movements is another great option to avoid overuse. Beyond the exercises we’ve covered above, mixing back squats with front squats, goblet squats, or other squatting variations will help to strengthen the squatting movement whilst providing a slightly different stimulus to our tissues, and reducing the overload injury risk.

Bad Shoes

If you’re wearing shoes that don’t provide adequate stability when you squat, then this can put unnecessary strain on your knees.

Be sure to wear shoes that provide you with a solid foundation from which to lift.

Health Conditions Related to Knee Pain

So now that we understand some of the mechanisms that can contribute to knee pain during squats, how do we know which structure in the knee is causing pain?

Knee pain can present as a number of different conditions depending on the injured structure. This can include:

Patellofemoral Pain Syndrome

PFPS or patellofemoral pain syndrome is a condition that affects the knee joint. It’s characterized by pain in the front of the knee and around the patella or kneecap, and is common in those who love to squat.

If you have PFPS, you might experience pain when climbing stairs, squatting, or sitting for long periods.

IT-Band Syndrome

ITBS is a condition that affects the iliotibial band, which is a long strip of connective tissue that runs down the outside of the thigh from the hip to the knee, and normally presents as pain on the outside part of the knee. But squatters need not worry too much about this – ITBS is much more common in runners rather than lifters.

Patellar Tendinopathy

Tendonitis is the inflammation of a tendon, which can occur in any tendon in the body. However, Patella tendonitis presents as pain just below the knee cap. If you perform a lot of explosive movements like box jumps, or fast tempo squats, you should be aware of patella tendinopathy.

Arthritis

Arthritis is a condition that causes inflammation in the joints. The two most common types that can cause knee pain are osteoarthritis and rheumatoid arthritis.

Osteoarthritis is a degenerative disease that causes the cartilage in the joints to break down. This can cause pain in your knees, as well as other joints in your body.

Rheumatoid arthritis is an autoimmune disease that causes the body’s immune system to attack the joints. It may cause swelling and pain around the knee, leading to pain, stiffness, and inflammation.

Load management is key in managing arthritis. This is because we want to keep the muscles around the joint nice and strong, without irritating the joint too much.

How to Prevent Knee Pain When Squatting

Aside from performing some of the killer squat variations listed above, you can do a few other things to prevent knee pain while squatting.

Warm Up Properly

A good warm-up will help to increase your heart rate, loosen up your muscles, and make your body’s tissues more elastic. I recommend doing a light jog or bike ride for 5-10 minutes, followed by some dynamic stretching.

Use the Correct Weight

Another important consideration to prevent knee pain while squatting is to use the right weight. If you go too heavy too soon, it will put extra stress on your knees and could lead to pain. Utilize progressive overload by starting with a light weight and gradually increase the amount of weight you’re using as your body gets stronger.

Blood Flow Restriction Training

Another great way to improve strength whilst using light weight is by incorporating Blood Flow Restriction Training into your routine. This involves using a BFR band to reduce venous blood return from your muscles, making them work harder.

This means that you can use lighter loads to achieve the same result from your workout. BFR training can be a great addition if you are struggling with knee pain from squatting or trying to train with an injury.

Use a Smaller Range of Motion

Squatting through a smaller range of motion by reducing squat depth will reduce the load going through the knee joint, and is a great way to modify the exercise if you are struggling with pain.

Listen to Your Body

If you still experience knee pain while squatting, stop the exercise and rest for a few days. If the pain persists, consult a doctor or physical therapist.

Wrap Up

If you’re experiencing knee pain when squatting, try one of the variations I suggested and see how they work for you. Remember to always start light and gradually increase the weight as your body gets stronger.

And, most importantly, have fun with it! Squatting can be a great way to improve your fitness level and get in shape, but only if you do it correctly and safely. Give these variations a try and let us know how they work for you.

About the Author

This article was written by Dane Ford, the founder of Lift Physiotherapy and Performance in Sydney, Australia. Lift Physio aims to help you overcome injury, optimize your health, and unlock your full movement potential.

August 16, 2022 Tony

Corrective Exercise Program Design Rehab/Prehab

What Would I Say to Someone Starting Out?

Being human means being enamored by a litany of things in the health/wellness/physical preparation realm. Some people are easily swooned by fancy watches and elaborate looking exercises

Others by cryochambers and Paleo recipes that taste like sawdust.

I am not here to play judgement police. For the most part, everything has a time and place² and everyone responds differently to different things.

What works for me may not work for you (and vice versa). It’s all good.

Back in 2009-2010, while at Cressey Sports Performance, I was introduced to PRI (Postural Restoration Institute). As a collective, we adopted some of their principles & protocols (specifically positional breathing) and applied them to our athletes’ and clients’ programming, I’d say with a high degree of success.

In the years since, PRI has grown in popularity and is still something I “subscribe” to. However, the key term I want to highlight here is “some.”

I’ve adopted some of their principles.

The thing about PRI (for better or worse) is that it has an uncanny ability to suck people in and plop them into a never-ending rabbit hole of mystery and multi-verses.

Today’s guest post is via Boston-based physical therapist, Mike DeMille, and offers a needed perspective on this phenomenon.

(PS: I’d encourage anyone interested with PRI to check out Mike’s course/mentorship below).

What Would I Say to Someone Starting Out?

In a world of biomechanics, neurology, complex chronic pain, and a desire to create resilience, it can be difficult to decide as a Physical Therapist or movement specialist what continuing education courses to take and why.

Personally, I have been a PRC (Postural Restoration Certified) Physical Therapist for five years, and anyone familiar with the Postural Restoration Institute (PRI) knows how easy it can be to go down the “rabbit hole”

Note From TG: I wrote a bit about this “rabbit hole” a number of years ago when PRI was first gaining steam in the S&C side of the spectrum. You can check it out HERE.³

After taking different courses, it can be very difficult to sift through the information and add principles to your practice (or programming), while leaving behind minutiae that ultimately won’t contribute to the further results of your clients.

via GIPHY

What is that minutia you ask?

What are those techniques, exercises, prehab/rehab protocol, cues, sick hip-hop rhymes that probably do not need to come along for the ride as you build out your systems as a coach?

That is exactly why we are here today.

After working in a cash-based Physical Therapy and Personal Training setting over the last four years and starting my own clinic (just outside Boston,. MA) I’ve developed rules (or tenets) of information to hold on to and which ones to leave behind.

Let’s dive in.

Think Practitioner/Coach, Speak Client

Your clients do not care what things are called, and neither should you.

Exhale, eccentrically orient, compress, early-mid-late stance, inhaling from an exhaled skeleton expansion, these terms can get complicated, if not bordering on someone speaking Elvish.

via MEME

A general rule of thumb would be if you cannot explain a concept in very simple terms to your client, then you likely shouldn’t spend a ton of time thinking about it yourself.

I like to think of this as writing a letter with a big bold sharpie instead of a small fine pencil that is difficult to see and read.

For example, if you have a client who you feel like is in a position of lumbar extension and they need to learn how to exhale to help get them out of pain, then you can leave the messaging at just that.

You will create the buy-in from spinning a simple story and allowing your client to feel the difference when undergoing your program. You do not need to explain all of the varying “compensatory strategies” to them in an effort to create belief in your program.

This will more likely than not lead to confusion, in addition to increasing the urge they’ll want to punch you in the face.

Nothing Is New; It Just Has a Fancier Name

Remember that these principles existed long before the most recent course that you took. One of the biggest problems that I see mentees and fresh PTs and movement professionals face is shiny object syndrome.

Understandably, when you go to a course and watch someone’s shoulder flexion increase from 140 degrees to 8000 after a fancy breathing exercise, you want to give everyone that fancy breathing exercise.

via GIPHY

Remember, there is a difference between a new technique that creates transient changes, and principles that create long lasting repeatable results.

Examples of a few principles that could make sense in a movement practice geared towards clients with pain:

Sound communication (avoiding nocebo).
Axial skeleton position that creates pressure underneath load bearing joints.
Progressive overload.

Does it feel less exciting to not be blowing all of your clients minds?

Sure it does.

But will these principles give you a sustainable business where you can more accurately sell results to potential clients?

Definitely.

Closing Thoughts

There is nothing wrong with taking new courses, finding helpful information, and creating buy-in with prospective clients, as well as appreciating the nuances of Physical Therapy and Strength and Conditioning.

But let’s not forget: the name of the game is being able to tie your name to something that can produce consistent results, and that is why we decided to take on this profession in the first place.

PRI Pique Your Interest?

Does this message resonate with you? Are you a Physical Therapist or movement professional looking to sift through the information and take the relevant principles into your practice?

Tyler Tanaka and I have created a community where we take individuals that are looking to finally apply the information that they have learned and effectively communicate with their ideal clients to build the business that they have always wanted.

This is your chance to learn the system of two PRC PTs and ask any and every question that you have ever had. In the 10 week Solidify Program you will undergo a detailed curriculum as well as take part in one on one Refinement calls to get your questions answered about those difficult patients that are the ”non-responders” as well as big picture questions about your practice and business.

Click HERE for more information.

Solidify begins June 6^th and the spots are limited.

May 19, 2022 Tony

Program Design Rehab/Prehab

I Jacked My Low Back, Now What? Workout

Back tweaks are an inevitability.

They happen to people who lifts weights regularly, and those who just look at weights. They happen when doing something as inane as bending over to tie your shoes, as well as when you’re doing some less inane, like, fighting crime at night.

They happen on a Wednesday.

There’s no way to predict when they’ll happen, they just will. Especially if you’re someone who’s had the unfortunate misfortune of it happening once or twice (or many times) in the past.

What can you do when this happens?

I Jacked My Low Back, Now What(?) Workout

This happened to me several months ago.

The culprit wasn’t anything “cool” like a 1-rep max, or, I don’t know, wrestling a lumberjack.

Nope. Not even close.

This time it came about doing nothing more than bending over to perform my last set of Landmine Rows. As soon as I grabbed the handle I felt that slight zappy “zzzzzzzzzzz” feeling in my lower back and it seized up.

I was hoping to persevere and follow suite with my normal coaching schedule with clients, but it became apparent I was going to be uncomfortable the rest of the day. I went home a little early, stayed horizontal with a heating pad, caught up on all the episodes of Atlanta I hadn’t watched yet (season 3 has been spectacular if you ask me), and woke up the following morning feeling marginally better.

I skipped my scheduled training session that day, but didn’t skip it altogether. Instead I elected to follow my own advice and went into #findyourtrainablemenu mode.

I.e., focusing on what I COULD do rather that what I COULDN’T.

I came up with a brief, albeit BALLER circuit that made my back feel infinitely better. And, in the months since, whenever someone reached out to me asking for advice (or if a client happened to tweak their back⁴) I’d often revert back to the circuit I laid out for myself and encourage them to follow it as well.

I had been meaning to share the circuit before now, but life has had an uncanny ability of late to get in the way of me doing any writing.

And by that I mean “I’ve been binge watching waaaay too much tv.”

It just so happens, however, that my wife had a bit of a low-back niggle during her training session the other day and I ended up forwarding her my “super secret” workout to tide her over for a few days

She loved it.

In fact, she sent me a text saying something to the effect of…

…”OMG, babe, this back circuit is the best. I am so grateful. In fact, I am so grateful that you never have to empty the dishwasher ever again. And we can watch WWII documentaries whenever you want. Also, let’s make out.”

(just a slight exaggeration there).⁵

Long story, short…below is the workout. There’s a degree of predictability and a host of exercises that won’t surprise anyone.

But who cares?!?

What works, works.

That said, there’s also a few that should be relatively new.

Shut Up Tony and Show Us the Workout For the LOVE OF GOD

Deadbug

This falls into the “no big surprise” category, but it’s a drill that, when perfected, is an outstanding anterior core exercise (as well as one that helps to dissociate hip movement from LUMBAR movement).

Perform 8-10 repetition per side

90/90 Hip Switches w/ End Range IR

This drill works both hip internal and external rotation simultaneously. Be sure to maintain a braced core throughout the set and really focus on moving through the hips and ramping up tension on the IR hold with each repetition.

Perform 4-5 repetitions per side (one rep = 3-5s IR hold)

Side Mermaid

This is a drill I borrowed from my guy Vernon Griffith. I don’t know how else to explain it other than it feels AWESOME once you’re done.

I mean, it sucks while you’re doing (but feels great afterward).

Here I’m focusing on pressing my bottom knee into the ground (not foot) while also keeping my (bottom) hip off the ground. Also, try to keep your top leg straight throughout the set pushing your heel through the wall. This will really get that glute firing on all cylinders.

1 rep = 5-10s hold.

Perform 3-4 repetitions per side

Glute ISO Hold

Another doozy I got from Vernon and does a superb job of isolating the glutes and learning to “own” spinal position and full-body tension.

Make a fist with one hand out to your side and then lift your OPPOSITE foot (also off to the side) off the ground making sure to maintain a braced core and to NOT move through the lower back. Hold for a 5-10s count each rep.

You should feel this in your glutes, abs, soul, eyeballs, everywhere.

Perform 3-4 repetitions per leg.

Barrel Roll

Nothing fancy, but the idea here is to think about locking your ribcage to your pelvis and rotating the entire body side-to-side as one unit. This can be regressed to performing from the knees if performing them from a full plank is too challenging.

Perform 8-10 repetitions per side.

Tall Kneel to Stand

Press your hands together to engage your core and to increase full-body tension. This will help to posteriorly tilt the pelvis encouraging more of a “canister” position where the pelvis is stacked underneath the ribcage.

Focus on maintaining a neutral spine and moving through your HIPS as you transition from the tall kneeling position to standing (and vice versa).

Do not rush this drill; perform it with intent.

Perform 4-5 repetitions per leg.

Birddog Band Press

Regular Birddogs will work wonders here. Just make sure you’re doing them correctly.

But lets up the ante.

The idea here is to lock in a neutral spine and move through your extremities only. There should be very limited motion through the lower back (I like to tell people there’s a glass of water on the lower back and they don’t want it to spill).

Perform 8-10 repetitions per side.

In-Place Chaos March

I like to think of of these as a “side plank that doesn’t make you want to toss your face into a brick wall.” I think we can all agree the side plank is boring, right?

I mean, it’s a fantastic exercise when done correctly and I’d highly encourage most people to start there. However, we’re on some Liam Neeson “I have a particular set of skills, I will find you, and I will kill you” type of shit right here.

via GIPHY

Think about locking your ribcage to your pelvis and keeping your pelvis steady throughout the set; you want to limit any “teeter-tottering.”

Another way to think about it is to pretend as if your hips are on train tracks. They should remain level the entire time.

You also want to keep the “kettlebell quiet.” It shouldn’t be bouncing around while marching in place. Slow and controlled. No rushing!

Perform 8-10 steps/per leg/side

And That’s It

And that’s it.

I typically recommend performing all the exercises above in circuit fashion resting as needed between each one. All told I’d also recommend performing the entire circuit 2-4 times 1-2x per day for several days (or until symptoms subside and you feel you’re able to begin sprinkling in your normal routine again).

May 17, 2022 Tony

personal training Program Design Rehab/Prehab Uncategorized

Should You Train Through Pain?

We live in a world surrounded by inevitabilities:

Summers in Florida will be hot.
Winters in New England will be cold..
People will perform stupid antics on social media (the latest being the Milk Crate Challenge)

Additionally, if you’re an active person, particularly if you lift weights, unless you’re name is Wolverine, it’s inevitable you’ll (probably) experience pain during exercise.

Maybe your knees will feel a little cranky after a serious squat session or your shoulders will be mad after prioritizing the bench press for several weeks.

What’s more, many people after a hiatus due to injury have to navigate the rehab process, which can be a painful experience and about as fun as sitting on a cactus.

Pain is never desirable.

Then question, then, is…

…should you train through pain if it’s present?

Should You Train Through Pain?

Well, it depends.

If you have a knife lodged in your thigh, no.

You should go to the ER.

However, if we’re discussing any of the aforementioned scenarios highlighted in the introduction my response is an emphatic “YES!”

Albeit, with some caveats.

If you want to elicit change, you need to move. When we move, we induce something called mechanotransduction, which is just nerd speak for “tissue begins to heal.”

Pain, when DOSED ACCORDINGLY, can be beneficial during exercise. When we push into a little pain there’s generally better short-term results than if not.

Whenever I’m working with a client/athlete experiencing pain during exercise (especially in a rehab setting) I like to use a “pain threshold” scale.

On a scale of 1-10 (1 = no biggie, I got this and a 10 = holy shit, a panther just latched onto my carotid), exercise should hover in the 2-3 realm.

Elaborating further, my friend and colleague, Tim Latham of Back Bay Health in Boston, uses a stoplight analogy when it comes to pain during exercise:

0-3 on the pain scale = green light. GO.
4-5 = yellow light. Proceed with caution and modify ROM, technique, sets/reps, etc
6-10 = red light – stop and revisit at a later time.

Let’s Put This Into Action

Let’s say I have a client who had ACL surgery a few months ago and has been cleared by their doctor and physical therapist to begin more aggressive strength training.

My expectation isn’t that (s)he is going to walk in on Day #1 and feel like a million bucks; there’s going to be some degree of discomfort. However, I am not going to shy away from it and attempt to avoid it at all costs.

Remember: A little pain is okay, if not preferred. It’s imperative to challenge the body. I’d make the argument that a lot of what inhibits or slows down the rehabbing process for many is the threat of UNDERloading.

I.e., doing so little that the body is never forced to adapt to anything.

Tendons, muscles, and bones NEED (appropriate) load in order to heal and come back stronger.

Taking my ACL client through the process I may have them start with a deadlift. So long as their pain stays within the 0-3 range, it’s all systems a go.

If that number jumps to a 4-5 it doesn’t mean we have to omit the exercise altogether. Instead we do the following:

Modify ROM – Elevate the barbell off the ground (less knee flexion)
Modify Tempo – When in doubt, slow down. It’s actually quite profound how effective this simple tweak can be.
Adjust Technique – Play around with foot position or stance to see if something feels more comfortable.
Adjust Volume – Sometimes we’re too overzealous with volume and need to ramp up more slowly.

If the pain threshold at any point falls in the 6-10 range then we know we’ve overstepped our coverage and we need to stop that exercise immediately and regress.

It’s not a perfect system and there’s no doubt an aspect of subjectivity to things, but I hope this helps encourage people to not be deterred if pain is present during exercise.

It can be an important cog in the healing process.

August 27, 2021 Tony

Program Design Rehab/Prehab Strength Training

Find Your Entry Point: How to Train Around an Injury

If you make a habit of lifting heavy things it’s inevitable you’ll likely experience a few setbacks along the way.

These can range anywhere from the “no big deals” (bloody shins from deadlifting, shoulder niggle) to the dire (disc herniation, explosive diarrhea).

…or worse case, forgetting your squat shoes on squat day.

Suffice to say: Getting hurt is frustrating. Attempting to work around an injury can be even more so.

It bothers me when people default to tossing their hands in the air and surrendering themselves to a two-to-four week window of “rest” and Netflix.

There’s a lot of good that can be done, even underneath the umbrella of injury.

Instead, I’ve long championed the idea of trainees finding their Trainable Menu and focusing more on what they CAN do rather than what they can’t.

Another way to re-frame things is to find your entry point.

Find Your Entry Point

Speaking of entry points: I sat down with my four-year old this past weekend to watch Jurassic Park. Now, most coherent parents would start with something a little less scary.

You know, say, Dino Dana or, I don’t know, Care Bears.

Nope, I went with the ginormous, scary T-Rex.

In hindsight, it probably wasn’t the best “entry point” for someone who has no idea dinosaurs aren’t real. Again, maybe Toy Story or, hell, Mighty Morphin Power Rangers would have been a more germane choice?

I gotta say, though…

…Julian handled the T-Rex like a champ.

He didn’t blink once. He giggled when the guy sitting on the porto-potty met his demise.

I didn’t know whether to be proud or scared shitless.

Kid’s the next John Wick in the making.

Okay, Cute Story Tony. But WTF Are We Talking About Here?

Yeah, yeah, yeah…

Lifting heavy things.

Entry Points.

I’ve recently been making my way through Dr. Michael Mash’s excellent resource, Barbell Rehab, and giving credit where it’s due…he’s spends quite a bit if time throughout the course discussing the idea of entry points and how to use the concept to guide anyone’s return back to a specific lift after injury.

Let’s use the bench press as an example.

If someone has pain when he or she bench presses with a straight bar, finding their entry point is nothing more than altering the lift the minimal amount possible in order to gain the minimum desired training effect.

For the visual learners out there it may look something like this:

Adapted from Barbell Rehab

TO BE CLEAR: If pain exists in the shoulder the idea is NOT to automatically regress all the way back to a push-up.

I know some people who’d rather swallow a live grenade than do that.

Instead, the goal is to be as specific as possible in order to elicit a (relatively pain-free) training effect.

If someone has pain with a straight bar FLAT bench press, however it alleviates significantly when you switch them to a decline bench press.

Sha-ZAM.

You just found their entry point.

Maybe it’s DB Floor Presses for one person, and yes, maybe it’s a push-up (albeit loaded) for another. The idea is to TRAIN.

Moreover, it also could just come down to tweaking their grip slightly or adjusting some component of their technique.

Rehab doesn’t always have to result in sending someone to corrective exercise purgatory.

Likewise, using the squat as an example, sometimes the entry point is using a different bar (Duffalo or Safety-Squat Bar) if the shoulder is the issue, or maybe it’s having someone squat ABOVE parallel if it’s their knee(s) or hip(s) bothering them.

Sometimes, and hear me out, we may have to combine the two: Not a straight bar AND above parallel.

Tha fuck outta here.

Yes, it’s true.

And everything’s going to be fine.

In fact, more than fine.

January 28, 2021 Tony

Corrective Exercise Program Design Rehab/Prehab

Measures to Strengthen and Prevent Achilles Injuries

Hi, my name is Tony and I ruptured my Achilles tendon earlier this year.

It was the first significant injury of my life and one that, as it happens, happens often (and without warning). Since my injury six months ago I’ve met numerous people who have gone through the same dumpster fire of an experience.⁶.And as a result I’ve documented my rehab and post-surgery training via my IG account using the hashtags #findyourtrainablemenu and #achillesgate2020.

However, I figured something more in depth and robust with regards to explaining the mechanism of Achilles rupture (as well discussing prevention) could be of benefit to the masses. To that end, my fellow coaches and colleagues – Dr. Bo Bobenko and Shane McLean – offered to write something for the site to cover exactly that.

For what it’s worth: I peppered in a few comments myself along the way.

I hope it helps and enjoy.

Copyright: lassedesignen / 123RF Stock Photo

Measures to Strengthen & Prevent Achilles Injuries

When admiring yourself, flexing away, do you ever give thought to the unsung hero of muscle? You know, the things that attach the muscles to your bones: the tendons. You probably don’t give much thought, until it’s too late.

Unless you’ve had your head in the sand, you know our resident funny man and light saber fighter extraordinaire, Tony Gentilcore tore his Achilles tendon while hanging out with the in-laws in Florida six months ago

NOTE FROM TG: It’s important to remember that correlation doesn’t equal causation here. My in-laws didn’t cause my Achilles rupture…;o)⁷

Tony, a big strong guy with no history of serious injury performs a drill he has done before and boom, suddenly it’s not his day, week, month or even his year….

NOTE FROM TG: For those interested, HERE is a great depiction of the exercise (and mechanism) that served as the impetus to my injury.

The “Jump Back” Start

This video almost exactly showcases what happened. The only difference is that I didn’t preload my sprint with a three-hop thingamajig (just one), and in my case, once my back leg planted, I fell immediately to the ground.

Plus I may or not have been wearing a cape.

A Little Background On The Achilles Tendon

The tendon is named after the ancient Greek mythological figure Achilles (and not Brad Pitt) as it was the only part of his body that was still vulnerable after his mother had dipped him into the River Styx. Plus, we all know where he got shot with an arrow, at least in the movie.

The Achilles tendon is the thickest and strongest tendon in the human body. It’s the tendinous extension of the three-headed calf muscle soleus and the two-headed gastrocnemius and it inserts on the calcaneus (heel).

The contraction of the calf muscles transfers a force through the Achilles tendon, which enables plantar flexion of the foot and allows for actions such as walking, running, jumping, bounding, sprinting, and skipping.

During these movements, the Achilles tendon is subject to the highest loads in the body, with tensile loads up to 10 times the body’s weight.

The reasons for this are twofold: First, the Achilles consists of type II fast-twitch fibers, and this elasticity allows for rapid forward and backwards movement. Secondly, the tendon type I fibers of collagen and elastin which are lined up parallel from calf to heel, are responsible for the Achilles tendon strength. (1)

The Achilles due to its strength and its ability to handle high loads makes it a resilient tendon, which is good and bad. Good because it can handle lots of load and bad because it’s not always going to send pain signals to the brain every time something goes wrong.

This is one reason why Achilles tears can happen without warning.

Types Of Achilles Injuries

When your achilles hurts or you feel pain you’ll often be told ‘You got tendonitis bro’ But there are few different types of Achilles injuries besides tendonitis.

1. Achilles Tendon Tears

This is the mack daddy of all tendon injuries and like with Tony, it often happens without warning. If you hear a pop and a pain that radiates up your lower leg, there’s no second guessing what you’ve done.

NOTE FROM TG: The best way I can explain the sensation is that it feels like someone taking a sledgehammer right to your ankle. It doesn’t tickle.

2. Achilles Tendinopathy

Tendinopathy is a degeneration of the collagen protein fibers that form the Achilles. Its symptoms include increasing pain at the heel, stiffness, swelling at the back of your ankle, and a grating noise or creaking feeling when moving your ankle.

3. Achilles Tendonitis

Tendonitis is acute inflammation of the tendon and its symptoms include pain and stiffness in the morning, pain that worsens with activity, extreme pain the day after exercise.

There are two types of Achilles tendonitis: insertional and noninsertional.

Insertional Achilles tendonitis affects the lower portion of your tendon where it attaches to your heel bone often caused by bone spurs.
Noninsertional Achilles tendonitis involves fibers in the middle portion of the tendon.

4. Achilles Tendinosis

Tendinosis is the non-inflammatory degeneration of the collagen fibers of the tendon. This includes changes to the structure or composition of the tendon that results from repetitive strains without proper healing.

Achilles and calf tightness are common causes of Achilles tendinosis. Plus insertional Achilles tendinosis is often associated with heel spurs as it rubs against the achilles causing small tears.

Activities That Cause Achilles Tears

Achilles tendon tears happen to people who do things where they quickly speed up, slow down, or pivot, such as:

Running
Gymnastics
Dance
Football
Baseball
Softball
Basketball
Tennis
Fighting Zombies, Salsa Dancing, Talking About Feelings (<— things added by Tony)

Achilles tears tend to happen when you start moving suddenly as you push off and lift rather than land. Sometimes these abrupt actions can be too much for the tendon to handle.

Here is the statistical lowdown on how tears happen.

90% of injuries occur with an acceleration/deceleration movements mentioned above
Only 15-20% of men reported any sort of heel pain/tendinosis before the injury
50% of men who have an Achilles Rupture had tissue degeneration before the injury
Typically occurs 30 minutes after moving around

Research has shown Achilles tears include clear degenerative changes before the rupture but many of the Achilles tendon ruptures occur suddenly without any preceding signs or symptoms. (2)

For instance, Tony’s tear was caused by aggressive eccentric load (jump back start) combined with poor load management and then “jumping” right back into sprinting.

NOTE FROM TG: Exactly. Part of the problem was sheer bad luck. But too, up until that point – eight or so weeks into pandemic quarantine – I hadn’t been doing much (if any) plyometric activity.

Unfortunately, this doesn’t count.

👇👇👇👇

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A post shared by Tony Gentilcore (@tonygentilcore)

But he wasn’t in any pain.

In his mind it was all systems go. The main point here is there’s not one definitive “cause.” of Achillies tears. It’s equal parts shit-happens and bad luck.

Big Picture With Tendon Pain Modulation

1. CNS Response

The CNS is incredible at responding to and adapting to pain modulation. This is a good thing to keep going and for our survival but makes understanding our tendon health much trickier because damage can exist without pain.

2. Load Management and Exposure

This is probably the single most important component to tendon health that we should seek to understand and pay attention to. It can be intimidating to truly track your loads/exposure, but the better we get at it, the more we increase our chance of avoiding injury.

All of the research continues to bear out controlling the load on tendons is the best way to make any kind of change. The analogy I often use when explaining this to patients is the comparison to a wall that continues to take damage or have a crack and we need to keep adding spackle to it every 48 hours to reinforce it and strengthen the overall structure.

How To Prevent Achilles Tears

The experts and research are a bit mixed on this therefore the safest approach in my mind is to increase the variety of loads you place on the tendons.

Unless training for a specific sport or activity, then we should focus on preserving the natural capacity of what the tendon is meant to do, which is to absorb and transfer forces effectively in the simplest of terms.

Pogo Jumps

Heel Taps

A Daily Routine to Incorporate Into Your Movement Prep

You need tendon loading with multiple angles and a plan for tempo for the long term. My go to is often for heavy slow resistance, four seconds eccentric, three seconds concentric, carefully plotted over 12 weeks. There is strong research to support this concept.

A quote I really like about this:

“We start dying when we stop jumping.”

Assessment can be vital, but there is no Gold standard. Personally, I use my hands to assess pain tolerance to pressure at the tendon as one way to track progress of tendon health, but this is not well supported by research and requires me to have physical access to you which can be limiting indeed.

If you haven’t loaded the tendon recently, some easy options are

Calf raises with full range of motion, faster up slower down, aiming for 20 reps per leg as a baseline for tendon health. This allows us to look for asymmetries as well as an overall deficit based on training age.

In terms of a plan to increase your activity tolerance:

Firstly, I like to think of the principle of 10% per session as a safe progression. Meaning, in terms of a weekly volume a nice progression is to add 10% to the previous week.

Secondly, the quote that drives me here is:

“We tend to overestimate what we can accomplish in a month and underestimate what we can accomplish in a year.”

Therefore, a long term strategy for tendon health should be implemented.

Exercise Is Important But So Is Diet

It goes without saying reducing stress, sleeping soundly, and eating nutritious foods not only helps you…

…but your tendons specifically.

But I said it anyway.

However, there are a few supplements on top of eating and sleeping well, reducing stress and moving better which help heal and keep tendons resilient. Notice the word supplement. These should NOT be your priority to help your tendons stay healthy or heal after an injury.

Primary should always be eating real high quality foods.

The first and most obvious supplement is Vitamin C.

Vitamin C is absolutely essential for synthesis of collagen which makes the tendons type 1 slow twitch fibers strong. Pre clinical studies have shown vitamin C has the potential to accelerate bone healing after a fracture, increase type I collagen synthesis, and reduce oxidative stress after a tendon injury. (3)

Supplementing with Vitamin A helps the process of forming new tissue (collagen) and your immune system. A stronger immune system can prevent microorganisms from further damaging your tendons.

Vitamin E has anti-inflammatory properties which helps reduce tendon inflammation, and helps the healing of damaged tendons which can lead to a reduction of tendon pain. (4)

The science and research is limited on diet and tendon health and there are probably other things out there that can help. It is an ever expanding field so stay tuned.

NOTE FROM TG: At the moment, I like the Collagen Peptides from Momentous because they use Vitamin C, and FORTIGEL® , which is a formula designed and tested to promote collagen synthesis in tendons and ligaments.

(👆👆👆 Discount: GENTILCORE25 gets you 25% off your first order when you sign up for a subscription 👆👆👆)

Most collagen out there is basically like buying a pack of J-E-L-L-O, focusing on hair, skin and nails, but this stuff is solid and provides a bit more heft.

Here’s the daily “Wolverine Cocktail” I’ve taken every day since my surgery on June 1, 2020:

1 Scoop Momentous Collagen

1 capsule each Curcumin, Boswellia, Bromelain

5-10g Omega 3

1 Energon Cube (but only every other Thursday)

I’d like to think the cocktail added an extra “x-factor” toward my recovery.

I mean, here’s me hitting a relatively easy 500×3 on my deadlifts six months later:

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A post shared by Tony Gentilcore (@tonygentilcore)

Wrapping Up

Tendon tears often happen without warning and it doesn’t discriminate on whether you’re fit or not. One moment you’re about to move quick and the next you’re on the ground.

The best things you can do before engaging in risky tendon activities:

Warm up properly
Load the tendon appropriately
Reduce stress, eat and sleep better.

But as you’ve seen by Tony’s experience, there are no guarantees. Please do your best so you don’t hear the pop from hell.

Authors’ Bios

Shane “Balance Guy” McLean, is an A.C.E Certified Personal Trainer working deep in the heart of Louisiana with the gators.

Dr. Bo Babenko is the owner of FitCare Physio focusing on virtual health coaching and helping people attack the 5 pillars of health: movement, nutrition, recovery, mindset, connection.

References

Michael Wong; Achraf H. Jardaly; John Kiel.Anatomy, Bony Pelvis and Lower Limb, Achilles Tendon.
. T A Järvinen et al. Achilles tendon injuries. Curr Opin Rheumatol 2001 Mar;13(2):150-5
Nicholas N DePhillipo et al. Efficacy of Vitamin C Supplementation on Collagen Synthesis and Oxidative Stress After Musculoskeletal Injuries: A Systematic Review. Orthop J Sports Med 2018 Oct 25;6(10)
Christopher Tack ,Faye Shorthouse Lindsy Kass. The Physiological Mechanisms of Effect of Vitamins and Amino Acids on Tendon and Muscle Healing: A Systematic Review. Int J Sport Nutr Exerc Metab 2018 May 1;28(3):294-311.

December 7, 2020 Tony

Program Design Rehab/Prehab

3 Unconventional Shoulder Health Exercises

I was going to run with the title “3 Unconventional Shoulder Health Exercises (That Aren’t Band External Rotations)” but I didn’t want to come across as a pompous a-hole.

😉

Alternatively, I was considering “3 Unconventional Shoulder Health Exercises (That Aren’t Band External Rotations) and STOP DOING KIPPING PULL-UPS FOR THE LOVE OF GOD.”

But again, kinda douchy.

To that end, I suck at intros.

3 Unconventional Shoulder Health Exercises

Just so we’re on the same page: I am NOT against external rotation drills (band, side lying, whatever else you can come up with here).

On the contrary I use them often when working with clients who exhibit shoulder discomfort or have a lengthy history of shoulder pain – specifically with the rotator cuff.

Many EMG studies have shown that when it comes to activation…

…Side Lying External Rotations are the Don Corleone of rotator cuff exercises.

They’re wonderful and are a home-run for most people, most of the time (when done correctly). They’re also, you know, about as exciting as watching another parent’s kid’s Clarinet recital.

No one gets excited to head to the gym to perform Side Lying External Rotations. You can make them more palatable, of course:

But even still…

…ZZZzzzzzz.

I’m a firm believer that training, especially rehab, should look (and feel) like training. So today I wanted to pass along a few drills I think you should add to your repertoire.

1. Seated Reach & Row

I got this one from strength coach (and person who makes me feel like an old curmudgeon), Conor Harris.

I’m starting to fall into the camp that addressing Serratus weakness is the answer to everything:

Shoulder pain?
Neck pain?
Back pain?
Lawnmower won’t start?

More Serratus work my friend!

Reaching (or protraction) is a bonafide way to target the Serratus anterior and improve shoulder health. Likewise, working on ribcage expansion is also part of the equation.

The ribcage is shaped in a convex manner.

The scapulae (shoulder blade) is concave, or rounded, in nature. The ability for the two to play nicely together is an often overlooked mechanism of what I like to call “my shoulder fucking hurts syndrome.”

A stiff ribcage can lead to one of two things:

Lack of rotation.
Inability to expand during inhalation.
BONUS: Also less likely to win an arm-wrestling match vs. a Lumberjack. Trust me.

By combining a reach with an alternating row (and then adding a pause to INHALE in order to induce posterior expansion of the ribcage) we can sorta “unglue” it, which can have profound implications (in a good way) to shoulder health; namely, the scapulae have an increased ability to move.

I think we’ve been programmed to think that shoulder health begins and ends with rotator cuff. I’d make the case that the more germane approach – or attack point – is to address scapular function via the ribcage.

If the ribcage can’t move, neither can your shoulder blades.

2. Elbows Up Banded Press

Pigging back off my Serratus obsession above (<– totally not creepy),⁸here’s a splendid drill I stole from my friend (and person I hate because he’s way stronger than me), Dr. Jonathan Mike.

Too, what I dig about this exercise is that it very much has a meathead vibe to it.

OMG – the pump you feel after performing a set of these is insane.

After a killer upper-body session, instead of Band External Rotation drills, do this for 2-3 sets of 10-20 reps.

3. 1-Arm Band Upper Cut

This is a drill I’ll often pair with things like squats or deadlifts. Both entail “setting” the shoulder blades in place in a more downwardly rotated (or depressed) position.

This is ideal for lifting heavy things – and for keeping the joint “safe” – but as I alluded to above, not for overall shoulder health.

The scapulae are meant to move in a myriad of ways up, down, and around the ribcage.

The Banded Upper Cut not only targets the Serratus (reaching), but also the upper traps which aid with scapular UPWARD rotation.

The key is to make the movement one seamless movement by thinking about directing everything through the pinky finger. I like to tell clients to think about pointing their pinky out in front of them…

…then UP towards the ceiling.

This ensures the shoulder blades moves around (and up) the ribcage. It feels great.

Want more similar ideas (and then some)?

The Complete Trainers’ Toolbox

TODAY through this Sunday (7/5) The Complete Trainers’ Toolbox is on SALE at $100 off the regular price. Included here is my 60+ minute webinar on How to Improve Overhead Mobility, but you also get 16+ more hours of content from the likes of:

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And then some.

There’s even an option to split your payments into four monthly installments (and you earn CEUs). And we’ll become BFFs.

There’s really no downside here.

Go HERE for more information. And remember: you only have through this weekend to take advantage.

July 2, 2020 Tony

Program Design Rehab/Prehab

Simple Shoulder Savers (Minimal Equipment Edition)

Since I’m on the topic of shoulders:

Subtle (but not really) reminder that mine and Dean Somerset’s (Even More) Complete Shoulder & Hip Blueprint is now on sale through this weekend.

In fact, you can purchase that OR the combo pack (includes both version 1.0 & 2.0) for a hefty discount in addition to taking advantage of a payment plan option.

Other benefits:

Continuing Education credits.
Instant digital access.
30 day money back guarantee (you will learn something that’ll improve your coaching skills and business).
Comes with a 5×7 autographed copy of Tony’s pecs (limited time offer).

For more info and to purchase go HERE.

Okay, let’s talk shoulders…

Copyright: twinsterphoto / 123RF Stock Photo

Simple Shoulder Savers (Minimal Equipment Edition)

A lot can go awry when it comes to the shoulders.

Anyone who’s been lifting weights for a significant amount of time will, at some point or another, have a shoulder (or two) that isn’t too pleased with them.

Sometimes it’s a niggle —> you know, something that doesn’t feel good but also isn’t something that’s going to derail your workout plans.,

Sometimes it’s a lot more than a niggle —> but you’re an idiot and proceed to max effort bench press anyway; you idiot.

Needless to say, niggles happen – to varying degrees. Here are a few short-n-sweet preventative measures you can implement TODAY to keep your shoulders from hating you.

1. You Can Never Do Enough Rows

A simple audit of one’s program often gives a lot of insight.

It’s no surprise that the bulk of people who come to me with cranky shoulders tend to have a programming issue. Meaning, they perform a lot more pressing compared to pulling movements.

In other words: People like to train the muscles they can see in the mirror.

This can lead to an infatuation of sorts with pressing movements.

I find it rarely ever hurts to add more ROWING variations into everyone’s programs. A one-to-one (pull:push) ratio is a nice starting point. However, a 2:1 or even 3:1 (pull:push) ratio is often what’s needed.

We need to take an UNBALANCED approach to “balance” things.

In other words: More rowing variations.

Sometimes it’ll be something heavy – Seal Rows, Bent Over Rows, DB Rows, Seated Rows, Chest Supported Rows.

Sometimes it’ll be something medium – TRX Rows, Face Pulls

NOTE: This isn’t to imply that the exercises listed after “heavy” can only be done heavy and that the ones listed after “medium” can’t be performed with more challenging loads. Rather it’s just to point out that those exercises tend to be better suited for those type of loading parameters.

And sometimes it’ll be an exercise that is better suited for “lighter” loads.

Like this:

Split Stance 1-Arm Band Row

2. Reaching = MONEY for Shoulder Health

I wrote about this in detail a few weeks ago in THIS article, but you probably didn’t read it because I titled it something lame:

“Exercises You Should Be Doing: This Is One That Will Make Your Shoulders Feel Better”

See? Lame.

What I should have done is title it something like:

“101 Bicep Variations That’ll Make More People Swipe Right on Your Tinder Profile.”

And then I would have LOL’d because you would have been expecting an article on how to build swole biceps and what you would have really have clicked on is an article about the Serratus and the benefits of reaching for shoulder health.

Okay, I’ll shut up.

Just READ IT.

3. Do This Before Your Upper Body Lifts

Inspired by my good friend and Baltimore based personal trainer, Sivan Fagan, this is a SUPERB movement prep series to get your shoulders primed and ready to handle some subsequent big boy (or girl) weights.

Or if you just want a good ol’ fashioned shoulder pump.

All good.

4. The Arm Bar

Outside of sounding like an 80’s WWF finishing move, this is easily one of the most under-rated exercises for shoulder health out there.

I like to use this one as an extended warm-up for those clients with a history of shoulder issues because it hits a few major big rocks:

Grip (irradiation = more rotator cuff activation).
Trains the rotator cuff in a more “functional” manner (keeping humeral head centered in glenoid fossa).
Scapular stability (I actually like adding a reach/protraction at the top to help train scapular motion AROUND THE RIBCAGE)
Thoracic mobility (namely extension; great for those stuck in front of a computer for hours on end).
Julian is LOCKED IN to Spiderverse over there in the corner.

5. Following a Ketogenic Diet

The fuck outta here with that nonsense.

6. Bottoms-Up Carry Variations

I love bottoms-up carries because they’re a supreme way to train the shoulders in a more “functional” manner with minimal load.

There aren’t many exercises more humbling than this.

I suck at conclusions.

Isn’t my t-shirt awesome?

April 3, 2020 Tony

Program Design Rehab/Prehab

Why You Can and Should Lift Weights With a Herniated Disc

You all know the stat: upwards of 80% of the population will experience some form of debilitating back pain – often times a disc herniation – in his or her’s lifetime.

It can strike with one dubious rep on a set of deadlifts, bending over to pick up a child, or, I don’t know, during a random after hours office Fight Club.

However (0r whenever) it happens, it sucks. But what also sucks is the often archaic advice many receive with regards to what to do when a disc herniation happens.

In today’s guest post by UK based physical therapist and strength coach Alex Kraszewski, he helps to set the record straight.

Enjoy.

Why You Can and Should Lift Weights With a Herniated Disc

Just like Crossfitters, Vegans and Anti-Vaxxers⁹, if someone has back pain and they think it’s a disc herniation, it’s probably the first thing they’ll tell you.

There’s not many days that go by where I don’t see someone with back pain, and in more cases than I’d like – the opening conversation tends to go like this;

Me: “So what brings you in today and how can I help you?”

Client: “My doctor/chiro/shamanic healer said I’ve got a disc out, a trapped nerve and my MRI proves it. It hurts and I need you to put it back in.”

Me:

The intervertebral disc has become the scapegoat for a lot of back pain and disability. When the word ‘disc’ is used, it tends to create a cascade of fear, anxiety and worry for the future.

Do I need surgery? Am I going to have problems later in life? Can I still lift and get jacked? Will Dr. Dre ever release Detox?

I don’t know if we’ll ever hear Detox, but the answer to the other stuff is more promising.

I had a great follow-up question from my webinar on Flexion & Extension based back pain as part of The Complete Trainer’s Toolbox, and it gives us a great opportunity to discuss this and think critically about this topic:

“Do you consider exercises with reasonably high compressive and shear load to be risky for someone with disc herniations?”

Short Answer: No.

Long(er) Answer: It depends. We know that only Sith’s deal in absolutes – particularly on Tony’s site, because six other articles have made this gag. Lucky number seven for me.

Let’s break this question down into two smaller questions:

1) Are disc herniations always bad or problematic?

2) Will exercising under high levels of shear or compression increase the risk of pain, injury or further problems?

Are Disc Herniations Always Bad or Problematic?

No.

Many of us jump to the conclusion that when told we have a bulging or herniated disc, we’re doomed.

It’s normal to worry – our back hurts and we’re told there might be a problem with it that could threaten what we enjoy doing and how we earn money.

Whilst disc herniations can contribute to back pain, it doesn’t mean they absolutely will contribute to back pain.

One of the best things here is to look at research investigating the low back in pain-free populations. This study from 2015 pooled over three thousand pain-free people, and at least 30% of people had either a disc bulge or protrusion with no pain.

Nada.

Zilch.

The other biggie here is a steady increase in pain-free findings as we age.

The older we get – the more likely it is to find ‘stuff’ on MRI, that doesn’t have to be a straight up cause of a client’s back pain.

So again, no, disc herniations are not a death sentence for your quest for jacktitude.

But

Pathology can still contribute to pain.

This research is great, but sometimes the pendulum swings a little too far, and these findings can be dismissed without proper assessment. Want to piss off your client who believes their back is due to a disc problem? Tell them outright it’s not a problem with no real justification other than ‘the research says MRI findings don’t matter’.

Rapport = gone.

But how do we know when to take notice of an MRI report or not?

Consider the concept of an active wound or healed scar to weigh up how relevant pathology is to pain. I picked these terms up from Dr. Stuart McGill, who knows a thing or two about spines.

He also knows a thing or two about awesome mustaches.

An active wound is where symptoms, assessment findings, and imaging reports all match up enough to connect the dots.

A healed scar is the presence of pathology on imaging, but without clear correlation to assessment findings. The dots are there, but not clearly connected at this point time.

Remember that an MRI is a single snapshot in time of your client laying on their back, doing nothing. It might look ‘bad’, but they might also be in no pain and crushing their training without fear or worrying about it.

How do you figure out whether you’re dealing with a wound or a scar?

Work with a healthcare professional who knows how to lift and help come to a clear understanding of your client’s back pain. Trainers are one million percent qualified to work with clients with back pain and disc herniations, when they have been screened and assessed properly.

Will Exercising Under High Levels of Shear or Compression Increase the Risk of Pain, Injury or Further Problems?

Short Answer: No.

Longer Answer: You need to ‘dose’ things appropriately.

As a quick refresher, spinal compression is the force that approximates each vertebrae. Spinal shear is the force that tries to pull one vertebrae forwards or backwards on another (at least in the sagittal plane).

Compression (image via Stronger by Science)

Shear (image via Stronger by Science)

The spine is designed to bear load, and the interactions of motions, loads and postures will load the spine in different ways.

What counts as ‘high’ levels of shear and compression?

If you’re a Sith dealing in absolutes:

High shear loads come from a more horizontal torso angle and increased spine flexion
High compressive loads come from greater loads lifted, more intense bracing strategies and a more extended spine position

If you’re a Jedi and want to consider context:

‘High’ for a super heavy powerlifter will be different to ‘high’ for a yoga instructor
‘High’ for your client who has never lifted a weight is different to ‘high’ for your seasoned lifter who has accumulated decades of time under the bar.
‘High’ for someone in pain is different to ‘high’ for someone who is pain-free.
‘High’ is the upper end of an individual’s tipping point to tolerate load at that moment in time

This is where the science & art of training and rehab meet.

Science tells us that a conventional deadlift and back squat can probably allow us to lift the most load, but knowing your client would benefit more from front squats and trap bar deadlifts whilst their back hurts or if they are learning the ropes of lifting, is the art.

Don’t be this guy.

So what happens if we apply the appropriate ‘high’ level of stress with a disc herniation?

Just like everything else – discs will adapt

The body is a wonderfully adaptive organism that will react to the stresses placed upon it. If you get the dose of ‘high’ in the right ball-park, you will create positive adaptation. We’ve known about this the 80’s, where this study found the intervertebral disc positively adapts compressive load, yet it’s often viewed as a fragile structure that, when injured, spells game over.

Seems not.

This can be incredibly empowering for the clients suffering from back pain, whether it’s a diagnosed disc pathology or otherwise, that things can get better. This case study showed a huge improvement in a patient with an L4/5 herniation in just 5 months:

Credit – New England Journal of Medicine

Not sure if this applies to lifters?

Check out Brian Carroll’s MRI before and after working with Stuart McGill.

He started being disabled by pain with a broken sacrum and pretty banged up lumbar spine, but returned to the Powerlifting platform to set new world records at a lower bodyweight.

Credit – Brian Carroll

For me – this is where we need load within a low back rehab program.

If back pain stops us exercising, we will lose some level of fitness and adaptation as a result, which means we need to find a way back to exercising, based on what we can currently manage. I think this is why a lot of rehab programs don’t do well – it’s either too much load too soon which lead to flare ups and setbacks, or not enough load over time which means symptoms linger for longer than necessary.

So if we can say with confidence that disc herniations are not permanent, can get better and need load to return to our meaningful activities, how do we decide how to push it, when to push it, and how far?

Let’s answer these too.

How Do We Push It?

If you’re working with someone with back pain (or any pain really), your assessment should tell you this by answering this question;

“How much load can this client currently tolerate right now, and how can I best safely apply this?”

Don’t be afraid to use load in your assessments.

In fact, USE LOAD IN YOUR ASSESSMENTS.

A table and movement assessment is the starting point to see what the foundation is like, but how does what you see ‘at rest’ compare to when you’re at working weights?

Your client might have a perfect air squat, but if it resembles a melting handle at their working weight, you probably want to find that point where it looks good enough. Not perfect, not scratch-my-eyes-out terrible, just good enough.

Your 3/3 on the Overhead Squat won’t save you if you look like this under load.

If you start running into pain or problems under load, be comfortable enough to tweak the load, change the exercise variation, or coach it further. It’s OK if your assessment starts to resemble a training session, because it will give you way more information for your initial program with that client than relying on unloaded tests alone.

This is where you need the nuts and bolts of exercise progressions/regressions, coaching cues, and loading/tempo schemes to find the sweet spot for your client at that moment in time.

When Do We Push It?

Adaptation takes time, but it shouldn’t take forever. Your assessment gives you your starting point and how you feel during and after your lifting should guide how you progress. You don’t have to be pain-free, but you shouldn’t be pushing yourself through agony either. Here’s how I tend to work;

Pain settled within 2 days and below a 3-4/10? Carry on wayward son.
Pain longer than 2 days and/or above 5/10? Slow your roll.

Previous injury, pain, surgery or a lot of concern from your client will influence how quickly you choose to reapply the ‘stress’.

It’s ok to give it a little longer if needed, so know you can be flexible.

If things do go beyond what’s deemed acceptable, it doesn’t put us back to square one, but it might just require a little course-correction from time to time. No return from pain or injury ever moves in a nice linear, expected direction.

Credit – Sports Physio

As long as the loads, intensity and your client’s confidence and pain are steadily improving over time, you’re on the right track. Where ‘how’ is the science, ‘when’ is the art – know when to hit the gas, and when to pump the brakes, because it’s rarely a straightforward process.

How Far Do We Need to Push It?

What’s your client’s endgame?

The greater the demand of what your client is asking their body to deal with, the more time you’ll probably need. The new parent with a month or two of back pain wanting to pick up their kids without hurting and get 2-3 workouts in a week, will have a vastly different course to the powerlifter who’s been beaten up for years and wants to be out of pain and setting new world records.

Not everyone needs to hit soul-crushing, nose-bleeding levels of intensity, but if a client wants to work on their true maximum strength, you better be ready to take them back to working to 90% and above.

The goal of any rehab plan should be to build both physical and mental robustness that allows us to remain resilient to the stresses we want to place on ourselves, and still have enough in the tank to deal with the stresses we have to put on ourselves. As much as we want ourselves and our clients to crush their training sessions, it shouldn’t come at the expense of living the rest of their life the way they want to.

Remember – Disc Diagnoses Aren’t Death Sentences

The biggest challenge when someone is in the depths of an episode of back pain that may or may not have involved the ‘D’ word, is that they have the opportunity to get better and it’s not game over.

If we can get past this barrier, it becomes a matter of ‘when’ will they get better, not ‘if’. The intricacies of getting can be incredibly individual, but with the right approach, there’s no reason why you and your clients can’t get back to crushing it.

If you want to take a deeper dive on this – check out the Complete Trainer’s Toolbox, where I spend nearly three hours talking through what influences spinal loading during exercise, and how to plan a way back to beast-mode if back pain is a problem.

Ps – disc’s don’t ‘slip’ (courtesy of The Honest Physio).

About the Author

Alex works as a Physiotherapist in Essex, United Kingdom, with a special interest in working with those involved in strength and barbell sports.

Alex holds a triple bodyweight deadlift, and regularly publishes content through Rehab to Robust on Facebook & Instagram.

April 4, 2019 Tony