CategoriesUncategorized

Managing Laxity in Lifters and Athletes – Part 2

Note from TG:  Continuing on from yesterday’s post, today in part deux strength coach Joe Giandanato takes the reigns and talks about his own battles with laxity and how’s he’s been able to manage his symptoms and pain through dedicated strength training as well as some attention to detail with other things.

For those looking to geek out on anatomy and assessment talk (me, me, me!!), Joe breaks down ligamentous verbiage, talks about rate of force development, as well provides some sage words on medical treatment.  For the record:  it does NOT include watching old Jean Claude Van Damme movies like Blood Sport or Kickboxer or Double Impact.

OMG – those movies were so awesome.

And don’t roll your eyes at me – you know you watched them back in the day.  Don’t kid yourself!

Anyways, I’ll let Joe take it from here.

Challenges of Dealing With Lax Athletes

Perhaps one of the greatest challenges I’ve faced as an athlete, lifter, and coach is dealing with ligamentous laxity. I’ve found through my years as a coach and personal trainer that athletes and lifters with ligamentous laxity need to be “slowed down” in the gym. They must master first bridging and planking variations to find a stable core and hips before progressing to barbell exercises.

I’ve found that tempo training works well, especially when the eccentric or isometric is accentuated. Prolonging both help provide the athlete or lifter greater proprioceptive benefits along with a smoother transition to more advanced exercises.

Nine times out of ten, I’ll usually scrap static stretching in the post-workout portion of the training session and in its place, I’d have the athlete perform lower threshold activation exercises for the muscles of the hips, shoulders, and upper back as well as those encircling the knee. (such as what?)

 

I’ve found these areas to be the most problematic and they’ll typically require the most programming attention. As you’ll soon read, working with athletes with ligamentous laxity can be highly rewarding. Many times, these are explosive individuals who are shrouded by inefficient movement patterns and in some instances dysfunction and pain. With sound programming and proper care, these individuals can blend the best of both worlds – elasticity and strength, unearthing the explosive athlete within.

Joe’s Story

My brief story involves a lifelong love-hate relationship with congenital laxity. My athletic career actually began in a gymnastics studio as a five year old who was enamored by all of the things the older neighborhood girls were capable of. Though my stint in gymnastics didn’t last very long, I remember being just as flexible as all of the girls in class. As I continued my athletic pursuits, which included soccer, basketball, and eventually football, I began to notice that my extreme flexibility had become a detriment of sorts.

Although there was an incredible amount of spring to my step and I was typically one of the faster athletes on the field or court, I was also one of the weakest and most susceptible to joint injury.

Once my mediocre athletic career concluded, which consisted of a brief stint of walking on my local college’s soccer team and flirtations with semi-pro and minor league football, I solely dedicated my extracurricular efforts to the iron.

Although I competed in an unsanctioned push-pull meet a number of years ago, I’ve struggled to keep my body intact long enough to make a concerted attempt in a full powerlifting meet.

The unraveling of my musculoskeletal health triggered an extensive amount of reflection and research. For the past decade I had been bogged down by a cranky sacroiliac joint. If anyone has suffered from SI joint issues, you’ll know that virtually any activity or posture has the capacity to piss that joint off.

SI joint issues aren’t conducive to the “big three” and they certainly don’t lend themselves to productive training sessions.

My maligned speculation of what was causing it was limited to muscles. Although no muscles connect the ilium to the sacrum, the joint itself is governed by the musculature of the lumbopelvic hip complex. A faulty firing pattern could lead to a lateral or anterior pelvic tilt influencing movement of the SI joint.

When the sacrum tips forward, it nutates, when it tips rearward it counternutates. When the SI joint loses its ability to nutate and counternutate effectively, biomechanical compensations occur, which are typically accompanied by pain. Initially, I made the mistake of zeroing in on the muscles responsible for my pain and decreased strength while I overlooked the ligaments.

Ligament A&P Briefer

Ligaments are strong, fibrous bands of connective tissue which connect bones to each other across all joints. Ligaments are composed of both solid and liquid components. The solid components include multiple types of collagen as well as elastin, actin, and proteoglycans, which are glycosylated proteins that play a number of roles in connective tissue health, relevantly the regulation of collagen fibrillogenesis and stimulate cell growth.

The liquid components are mostly comprised of water, which influences cellular and viscoelastic functioning. I should also point out that ligaments are not independent of our body’s neurovascular network as the epiligament, or outer ligament, has a rich supply of proprioceptors and blood.

Individuals with congenital laxity typically have ligaments that are loose, or for a lack of a better term, “stretchy”. These stretchy ligaments do more than allow laxity sufferers to perform parlor tricks such as stretching a muscle beyond a normally safe end range, they can pull joints out of centration which alters proprioceptive abilities as Miguel alluded to before.

Since stretchy ligaments do not allow an individual to maintain joint stability, much less establish it in first place, then joint health will erode over time. Individuals with congenital laxity are at a greater risk for developing osteoarthritis, degenerative disc conditions, and patellofemoral issues. They are also more susceptible to joint sprains likely due to compromised proprioception.

Benefits of Being Lax

However, having ligamentous laxity doesn’t relegate you to the good girl/bad girl machines tucked away in the corner of the gym. Lax individuals can ramp up rate of force development due to their enhanced elasticity. RFD isn’t just limited to a muscle’s force generating capacity.

RFD is also linked to the contributions of the parallel elastic component (PEC) and series elastic component (SEC). Anecdotally, I have found that trained individuals with laxity are more proficient in absorbing force during eccentric movements, which is likely why many lax pitchers can hurl ched as they gather elastic energy during the windup and cocking phases of the pitch.

Assessing Laxity

Typically congenital laxity is assessed via the Beighton Scale. The test features nine domains which include: bilateral passive thumb apposition, bilateral pinky dorsiflexion, bilateral knee hyperextension of at least 10 degrees, bilateral elbow hyperextension of at least 10 degrees, and bending at the waist and placing your hands on the floor while the knees are locked out. Scoring 4 points will earn you a laxity diagnosis.

Registering a 9 out of 9, like Miguel did in his self-administered exam, will get you enshrined in the laxity hall of fame. As thorough as the test may seem, it is rather limited as it overlooks a number of potentially problematic joints.

Watch as my physician, Dr. Hartman assesses me on the table and demonstrates the examination to Miguel and three medical students who are getting napalmed with knowledge.

 Medical Treatment

Receiving treatment from Dr. Hartman has been a godsend. When I first visited him a few months ago, nagging SI joint pain had flared up again rendering mundane ADLs such as bending over to tie my shoes, colossally painful. The closest thing I came to squatting and deadlifting was from a spectator’s perspective, observing my athletes perform these lifts while I was writhing in pain, hunched over a power rack.

While medical management of laxity isn’t necessary for everyone, I can personally attest that Dr. Hartman’s treatments have worked wonders for me. Though pedestrian by powerlifting standards, I can crank out sets of deep squats with 405 and conventional deadlifts with 500 pounds on command. Though there’s still a lot of room for improvement on my end, I have come a long way through Dr. Hartman’s care.

One of the treatment modalities that Dr. Hartman utilizes is prolotherapy. Prolotherapy or “prolo” for short involves injecting a hypertonic dextrose or saline solution into the joint. The injection incites an inflammatory response which promotes tissue repair, thereby improving ligamentous integrity and reducing or eliminating musculoskeletal pain.

Medical research indicates prolotherapy as an effective treatment option for those with laxity of the anterior cruciate ligament (4) and knee osteoarthritis (5). Another study suggests that prolotherapy is effective in treating lower back pain in conjunction with additional interventions (6).

If you’re interested in what a round of prolotherapy treatment entails for the SI joint, check out the video. If you’re squeamish, it’d be in your best interests to avoid the 1:09 mark in the following video.

REFERENCES

1.“Clinical Application of Neuromuscular Techniques, Volume 1: The Upper Body [Hardcover].” Clinical Application of Neuromuscular Techniques, Volume 1: The Upper Body: Leon Chaitow, Judith DeLany: 9780443062704

2. Lephart, Scott M., and Freddie H. Fu. Proprioception and Neuromuscular Control in Joint Stability. [Champaign, IL]: Human Kinetics, 2000. Print.

3. http://posturalrestoration.com/products/cd/

4. Reeves KD, Hassanein KM. Long-term effects of dextrose prolotherapy for anterior cruciate ligament laxity. Altern Ther Health Med. 2003;9(3):58-62.

5. Rabago D, Patterson JJ, Mundt, M, et al. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2013;11(3)229-237.

6. Yelland MJ, Del Mar C, Pirozzo S, et al. Prolotherapy injections for chronic low back pain: a systematic review. Spine (Phila Pa 1976). 2004;29(19):2126-2633.

About the Authors

Miguel Aragoncillo, B.S., CSCS, H.F.S, is a strength coach at Endeavor Sports Performance in Pitman, NJ. Miguel is also a Personal Trainer in the Philadelphia area. Miguel enjoys short sprints on the beach, lifting heavy things (sometimes even in competitions), and dancing on the weekends. You can check out his musings on his blog HERE, as well as follow him on Twitter @MiggsyBogues.

Joe Giandonato, MS, CSCS, FSBSCC is the Head Strength and Conditioning Coach and Fitness Director at Germantown Academy in Fort Washington, PA. Giandonato is also a Personal Trainer at the University of Pennsylvania, Department of Recreation. He also serves as the Senior Sports Science Editor on joshstrength.com, a website dedicated to strength athletes and those desiring improved body composition and performance.

In 2012, Giandonato was named a fellow of the esteemed Society of Balding Strength and Conditioning Coaches, hoping to one day join the ranks shared by Tony and Eric (Cressey).

CategoriesRehab/Prehab

Managing Laxity in Lifters and Athletes – Part 1

Note from TG:  Given the special, niche population we work with at Cressey Performance – baseball players – it’s no coincidence that we deal with many athletes who walk in on day one with a preponderance towards being “lax.”

Too, it’s not uncommon to see this in the general population as well, as we’ve also had our fair share of yoga instructors, dancers, and overall “stretchy” (for lack of a better term) people walk through our doors.

It’s a unique circumstance to put it lightly.  Is laxity bad? Yes and no.  For some, being lax allows them to do what they do – and be successful at it.  While for others it can be the bane of their existence. All told if it’s not approached with delicate hands and some careful thought to programming, as a coach or trainer you could be causing more harm than good.

In this guest post by former Cressey Performance intern (and resident breakdanceologist), Miguel Aragoncillo, he dives into this often overlooked (and under-diagnosed) phenomenon.  It’s a two parter, but it’s chock full of awesome information.

I hope you enjoy it!

My own story of hypermobility begins with breakdancing throughout high school and college, and later dealing with it while taking up the sport of powerlifting, and still managing it to this day. I have quite a bit of congenital laxity – in some ways it helps, other times it hurts.

When I worked as a personal trainer for a few years after college, I was convinced that the general population displays tightness due to a combination of work demands, poor posture, and a lack of exercise. This would be illustrated through tightness in their hamstrings, back, and pectorals, and that they would usually need to static stretch in order to decrease that tightness.

From my own time spent breakdancing, I was aware that I was fairly flexible, but it wasn’t until I began reading Eric’s and Tony’s blog that perhaps there was some genetic predisposition that allowed me to slip into certain positions without stretching for hours on end. This point was driven home further after completing an internship at CP in the fall/winter of 2012 last year.

While my time in Massachusetts was filled with pitchers with laxity, talks about glenohumeral instability, and deadlifting to techno (<—- Note from TG:  YES!!!!!!), I discovered that there was more to this self-flexibility observation than I had imagined.

Hypermobility or being congenitally lax involves a series of tests that present themselves in various joints and ligaments due to a lack of specific protein called collagen. In fact, I determined that I was indeed hypermobile through a self-adminstered Beighton Laxity Test.

Personal anecdotes aside, hypermobility affects enough of a population to be documented, namely in those who have African, Asian, and Arab origin, along with youth due to growth and structures not fully developing quite yet. (Chaitow & DeLany).

Concepts Behind Congenital Laxity

Namely, as a strength coach and personal trainer, it comes down to managing the effects of laxity, whether it is taking a pro-active approach through exercise selection or referring to further treatments through a physician’s care.

To break it down, joint stability is a combination of passive stability (think ligaments and tendons), and active stability (agonistic and antagonist co-activation). Further…

“Functional joint stability is determined by the interaction of several factors… joint geometry, the friction between the cartilage surfaces, and the load on the joint caused by compression forces resulting from gravity and the muscles acting on the joint. Of all the factors contributing to the functional joint stability, the load imposed on the joint is one of the most important.” (Lephart and Fu, p15)

Theoretical Approach to Joint Instability

If there is a lack of stability within any movement, there could be several reasons for said instability: weakness of a stabilizer, lack of bony congruency, lack of synaptic signaling from the brain to the affected joint, along with a proprioceptive deficit in said joint.

While each case of hypermobility is unique to the individual, there are a few overarching themes that should be reinforced when talking about stability, namely, co-activation of “agonistic and antagonistic muscles to create stability and coordination for functional joint stability” (Lephart and Fu, pg 15)

Putting this into action would involve proper positioning during exercises that you may be familiar with already: planks, push-ups, rows, squats, lunges, and Tony’s fave – deadlifts.

With hypermobile athletes, there are two points to be made: 1. Stopping a joint from reaching full hyperextension and 2  Encouraging a partial range of motion as variations for beginner athletes. By encouraging a safer range of motion, there will be an increase in proprioceptive feedback on top of increased muscular activation in the major stabilizers of the shoulders and hips. With these tools you can create a safer environment for your athletes, along with adding a more varied exercise selection to choose from at the same time.

To use a common ankle sprain as an example, there is a prevalence for inversion of the ankle to occur. Signals from the brain must be sent to the ankle to provide an equal or greater eversion force to prevent an injury from occurring. “The response (of an ankle injury) is still the body’s dynamic response to a potentially dangerous situation, however, and it seems reasonable to assume that the faster the reaction is, the greater the degree of protection achieved.” (Lephart and Fu, p243)

However, there are a few instances which may present themselves, namely the muscles that must be activated through a conscious awareness of a possible injury from occurring due to an over-inversion of the ankle will be insufficient to react in time.

When discussing injury prevention, the discussion for bracing and taping vs zero bracing is brought to mind. The argument for bracing and taping includes providing proprioceptive feedback from the skin’s mechanoreceptors. These receptors can provide proprioceptive information or may facilitate joint proprioception by increasing sensitivity or motoneuron excitability. (Lephart and Fu, pg.306)

So in regards to the extremely lax athlete, there may be some theoretical benefit to wearing a brace, but at the same time there should be a push towards encouraging an increase in joint position sense during both static exercises and dynamic exercises.

So whether you believe in joint centration and encouraging those activation of joint stabilizers after centration, or utilizing bracing to increase proprioceptive feedback, the end goal should be the same – increase proprioception and re-establish proper stabilization of major joints.

I personally would like to have my cake and eat it too, or food analogies aside, I’d love to see training encouraged in a proprioceptive rich environment, sans the bracing, and after training and outside in the regular world, perhaps wear the brace or taping to help in “everyday activities”. After a period of time, retest various movements and joints by using a variety of stabilization tests or assessments and reassess the plan of action.

With athletes who display  Cirque du Soleil-like flexibility, here are a few drills and exercises that may be more beneficial and specific to helping establish this proprioception that I keep on harping on about, particularly reactive, perturbation-like drills, and finding reference centers for the body.

Managing Hypermobility with Exercise Selection

For lower body reactive drills, progressions involve hurdle hops, single leg hurdle hops, all the way to lateral bounds (or heidens) – all involve “sticking” or landing the movement.

Emphasis should be on maintaining tension through the hip external rotators and avoiding a “knees-in” movement during landing. These exercises can serve as a progression for youth athletes and advanced general population clients, as the cause for knee internal rotation during flexion is increased due to structural variances of passive structures in the knee in a hypermobile population. (Lephart and Fu, p60).

Upper body drills involve perturbations during various drills – whether it is during a static movement such as a quadruped med ball perturbation, or a more dynamic movement such as perturbating a side lying windmill, these are all great variations to use to reinforce proper stability of the humerus within the glenoid socket.

Further, after being exposed to the philosophy along with attending a few seminars held by the Postural Restoration Institute, there seems to be a manageable series of movements that will help encourage viable movement within the hypermobile population.

Speaking with several coaches, physical therapists, and fitness professionals, there seems to be a concerted effort to finding “reference centers” within the body for those who may be “floating in space”, a common feeling for those who are affected by hypermobility.

These reference centers are facilitated through various positional breathing techniques, and a few of these breathing exercises have been referenced by Greg Robins and Eric Cressey throughout their blog. Specifically, these “reference centers include the left abdominals, left ischial seat (sit bone), left heel and right arch.” (-3)

A hierarchy for exercise progressions would be first to develop force in a static or isometric fashion, and from there develop the force through dynamic movements to help increase proprioception in specific stabilizers. This in turn will help to create a protective mechanism within the faulty joint for healthy movement – whether in everyday life or on the field.

And that wraps up Part 1.  Tomorrow I’ll delve into some more challenges facing the “lax” athlete, assessment, as well as provide a unique case study.