Today Rob and I have the opportunity to interview an orthopedic surgeon who has a knack for fixing shoulders. Luckily for us, he’s a crossfit athlete and is devoted to returning athletes back to their sport.
Why are people getting injured in Crossfit?
What are the most common shoulder injuries?
When should you try therapy and when should you try surgery?
What does the typical shoulder surgery consist of?
How do we prevent these injuries?
How to pick a good orthopedic surgeon.
Given the busy nature of Dr. Rockett’s profession, how does he manage to find time to train?
Hey let's face it, when the weights get heavy, the form gets sloppy. We try our best to avoid it, but why does this happen?
I feel that most people know that mobility can limit our technique, especially in the squat but will better mobility help us for those really heavy sets?
Well in a word, no.
If we can get into the proper position we need to for a given exercise without external resistance (ie: with an unloaded bar or with just our bodyweight) then we should be able to get into the correct position when we start adding weight.
However, our form still falls apart with heavier weights, what gives?
When your form starts falling apart with heavy weights it's because our body is searching for stability. What the hell does that mean? Well take a look at my squat here at 380lbs:
Fairly clean right? Now how about 400lbs?
Not so clean right? What happened?
I hit my limit as far as keeping everything in the proper position and had to rely on different structures in my body to finish the lift. What do I mean by that? Well let's break down each part of where the squat can go wrong under heavy loads.
Our feet flatten out
Our knees come in
Our hips internally rotate
Our upper back rounds (hopefully not your lower back too)
In the case of a heavy squat gone wrong, your body noticed that it wasn't strong enough to support the weight with the structures that are meant to support the weight, so it called in other players to get the job done:
1. Our feet flatten out
Your feet are composed of several joints and bones and are therefore very mobile. The muscles that support the feet and keep a healthy arch are fairly small. When the weights get heavy the arch tends to collapse. These small bones press together as your foot pronates (flattens) and the arch hits the floor. Now these bones are tightly packed together and are jammed up against the floor.
This is a position of stability but it isn't healthy for the foot, particularly the plantar fascia or the achilles tendon. You'll finish the lift in this position, but your body suffers the consequences.
We've got a meaty ligament on the side of the knee known as your medial collateral ligament (MCL). It often gets torn along with the ACL and medial meniscus in athletes (unhappy triad). When the knee falls into valgus under load the MCL is under stress as well. (This is the same thing that happens in athletes landing in genu valgus ie: the MCL, ACL and medial meniscus goes.)
So when our knees fall into a valgus position with squatting (knees in) the MCL helps to support our knees and get the weight up. (It also places us into a position where the adductors help us squat, further pulling us into dynamic valgus) However, this is accompanied by stressing the MCL which isn't meant to take stress. Along with it the meniscus gets some abnormal stress from gapping on the inner part of your knee and compression on the outside of your knee. Next, our knee cap does not track normally as it is supposed to. Good recipe for pain and damage, but we get the weight up.
3. Our hips internally rotate
This one is a bit difficult to conceptualize and if you're having trouble understanding it you can read this article. Your hip is a ball and socket joint. The head of the femur (long bone in your thigh) comes to a head and fits into a socket called the acetabulum in your pelvis (bone between your hips and at the base of your spine).
Femoral Acetabular Impingement
In deep hip flexion and internal rotation of the hip (which is the same position as the bottom part of a squat when your knees come in) the femoral head can butt up against the acetabulum. When this happens it causes a boney block and creates stability. This can help us drive out of the bottom position of the squat.
Unfortunately, the labrum in your hip can become trapped between the femoral head and acetabulum and become "impinged." This is the phenomenon known as femoral acetabular impingement (FAI) and can lead to labral tears in the hip. This is a well known phenomenon in physical therapy and there are even clinical tests for this issue:
4. Our Upper Back Rounds
The upper back also rounds when the weight gets too heavy in the squat. Like in the aforementioned areas, this is because our musculature support system is not strong enough to keep us in the proper position. Now we start to rely on other structures to get the weight up.
Our spine consists of vertebrae which stack up like boney hockey pucks all of the way up to our skull. We have several joints and ligaments within the spine that provide support and block motion when we reach the limit of our flexibility. When the upper back rounds during the squat we are challenging those structures and stressing them. Essentially we are moving to the limit of our flexibility in our upper back and relying on the ligaments and joints to keep us in place.
This is akin to bending your elbow backwards until you get to it's end range of flexibility and then relying on the joint to keep your elbow from hyperextending.
Just like at the foot, knee and hip, these structures are not meant to be loaded in this fashion. It'll help you get the weight up, but it also puts excessive stress on structures that aren't meant to be loaded.
To recap:
Lifting heavy things is cool
When our technique falls apart with heavy squats it's not a mobility problem
When our technique falls apart we're relying on structures in our body to finish the lift that aren't meant to be stressed.
The feet, knees, hips and spine take the bulk of the stress when our form falls apart. You can begin to fix these deficits by learning about the joint by joint approach popularized by Gray Cook
This phenomenon occurs with all lifts, not just the squat.
If you want to keep your joints healthy you'll do your absolute best to avoid poor technique at all times.
Now go squat a mountain and no genu valgus please,
Knee pain sucks, especially if you’re an athlete. Unfortunately runners, cross fit athletes and weightlifters commonly have knee pain. Terms like chondromalacia patella, patellofemoral pain syndrome, runner's knee and osteoarthritis have become commonplace. Despite the complexity of each syndrome they all share a common theme. They all come from poor movement. Poor movement strategies over time lead to pain and degeneration in our knee joints. It's easy to blame this on genetics and some of this is probably hereditary but a large portion of it is not. If we can fix our movement (our technique and the way we move) we can come away with a permanent cure to the root of the problem.
The only way to get permanent relief to knee pain is to fix the movements that caused the problem in the first place.
To reiterate: As with most injuries, once you’re hurt you’ll probably have to take some time off from exercises that bother your knees. This is a great time to see a physical therapist or chiropractor. Some soft tissue work and manual therapy is sometimes exactly what the doctor ordered to get this area to calm down and stop hurting. While the area heals up and your knee pain starts to decrease you can get to work on fixing your movement.
Obviously, each person is different. This is the internet and I’m not saying that everyone is going to have the same problems with the same solutions. However, I see a lot of the same things over and over again with knee pain in this athletic population, and applying these principles have been successful. If you’ve ever been diagnosed with chondromalacia patella, patellofemoral pain syndrome or IT band syndrome then this article is for you.
Fix #1 – Promote Ankle Mobility
If you lack flexibility in the ankle (Dorsiflexion) then whenever you challenge the end range of your joint, you'll end up compensating to complete the motions. Think about performing a deep squat or stepping down a step. If you lack ankle mobility it could be the cause of a compensation at the knee which is commonly called dynamic genu valgus. In lamen's terms that means your knees travel inwards. This puts you on the fast track to knee pain city.
Unfortunately this applies to every exercise that challenges the flexibility of your ankle (end range dorsiflexion in sciency terms). That means the same thing goes for running, lunges, pistols, jumping and landing! So let's fix this.
Fix your Ankle Mobility:
Stretch your soleus
Fix #2 – Promote Foot Stability
What’s important to keep in mind is that our knees are slaves to our feet and hips. If you’ve got poor movement (poor stability in this case) at the foot, you’ve got poor movement at the knee. When I refer to stability it means being able to support your foot in the proper position. This is known as the short foot posture.
***The biggest issue with retraining the foot is that it takes a lot of time, dedication and effort to build foot intrinsic strength and promote stability in the foot. As discussed previously we've been babying our feet and inadvertently weakening them over time by wearing supportive shoes.
Fix #3 – Promote Hip External Rotation and Abduction Strength
Since our knees are a slave to our hips it makes sense to attack the hips in order to promote efficient movement at the knee. I like to approach the hip with exercises specific to what we'd encounter in the gym.
Squatting Patterns
Lunging patterns
Single Leg Patterns
Notice how Pat does a great job of keeping his lower back and pelvis in a neutral position. All of the movement is coming from his hips. Ie: he isn't letting his lower back round or rotate.
Fix #4 – Promote Hip Mobility
If we are tight in our adductor (groin) musculature and limited in hip external rotation and flexion then we’re going to run into some problems. Limitations here will bring us right back into genu valgum at the bottom of a squat and that’s bad. If we've got issues here we're also opening ourselves up to hip pain and problems like femoral acetabular impingment (FAI) and subsequent hip labral tears. So what's the fix?
Mobilize your hip flexors and adductors
Working on hip external rotation mobility and mobilizing the hip's posterior capsule
Fix #5 – Promote Core Stability
This picture beautifully sums up the problem at the pelvis, hip and foot that leads to a poor knee position. Take note of what’s going on with that big bowl shaped bone in the person’s hips called the pelvis. It’s tilting to the person’s left. If we want to fix everything that's wrong with this picture, we need to address the core and we're going to do this by promoting stability.
Fix: Strengthen the Glutes, Hamstrings and Trunk musculature to reset the pelvis in a neutral position and keep it there while we move (exercise).
In this article we went over Lower Crossed Syndrome. Our goal is to fix lower crossed syndrome to regain control of the pelvis. We'll also have to select exercises that challenge our core to combat rotation and lateral flexion, the specific forces that will lead to knee pain.
From the picture you can see that strengthening and therefore shortening) the rectus abdominis (6-pack muscles), glutes and hamstrings will help us stay in a better pelvic position. A neutral position of the pelvis will help keep things downstream aligned better, including the knees.
Fortunately for us the exercises described to strengthen the hips have already started the process of strengthening the core.
In addition to strengthening the glutes and hamstrings (hips muscles), you'll need to hit a few additional exercises to challenge core stability. I'm a big fan of certain plank exercises and dead bug variations because they challenge our core to resist rotation and that's key for keeping our knees in proper alignment during exercise.
Dead Bug: Make sure to keep your lower back flat against the floor, or atleast in a neutral position.
Around the World Plank Variation
The Chop popularized by Gray Cook. We're integrating all of the musculature that helps put our pelvis in the correct position. We're also challenging our ability to maintain this position by chopping with a band or cable.
Fix #6 – Fix your technique
So when we’re looking to correct knee pain we’ve got to take a total body approach. I said it before and I'll say it again. I love foam rolling and other forms of soft tissue work, manual physical therapy and taping techniques as much as the next guy but…
The only real solution to the problem is going to be fixing the movement that caused the problem in the first place.
Treat each exercise you do in the gym as a skill. Keep the weights heavy enough to get a training effect (build some strength and muscle) but light enough to ensure perfect technique. Be honest with yourself.
Next time we'll go over how to put all of this together in a program. Until then remember, knee pain sucks.
