Shoulder Impingement: Part 4 – The Thoracic Spine and Ribcage’s Role in Impingement

So far we've gotten pretty deep on the concept of shoulder impingement but it's time to delve a little deeper.  Next in the line-up we'll talk about the thoracic spine and ribcage.  If you missed the previous parts you can find them here:

Part 1  Part 2  Part 3  

If we take a closer look at the shoulder joint and scapula we'll notice that we only have 1 true joint that connects the shoulder to our trunk.  The scapula attaches to the clavicle at the acromioclavicular joint and the clavical attaches to our thorax via the sternum at the sternoclavicular joint. These two relatively small joints are the only real joints that connect our arm to our trunk.

source: conornordengren.com

There is also a connection between the scapulae and the posterior element of our ribcage as seen to the right.  Although this is not a true joint we refer to this connection as the scapulothoracic joint.  The scapula lies directly on top of our rib cage and slides smoothly across the surface of the ribs during shoulder movement.  Because of this, efficient and healthy movement at the scapulothoracic joint has everything to do with the orientation of the ribcage that the scapula slides along.  If the position of our ribcage is off, it will change the position of our shoulder blades and as described later, can lend itself to impingement.

Our spine consists of a series of vertebrae stacked on top of each other that extend from the base of our skull down to our sacrum (and a bit lower to our coccyx).  The vertebrae that make up our neck are known as cervical vertebrae. The vertebrae in our trunk that attach to our ribs are known as thoracic vertebrae and the vertebrae that make up our lower back are known as lumbar vertebrae.  As mentioned previously, the vertebrae in our thoracic spine attach to the ribs.   Because of this, the orientation of our ribcage is directly related to the mobility of our thoracic spine.

Food for thought: The thoracic spine's attachment to the ribs creates stability.  This can make it difficult to gain mobility in the thoracic spine when we need to.

When we press a barbell overhead we need full mobility of our gleno-humeral joint (shoulder joint), full mobility of the scapulothoracic joint (scapular motion) and full extension range of motion of our thoracic spine in order to get the weight overhead efficiently.  If we don't have this mobility we run into issues. (Use this simple test to see if you've got enough mobility)

Now here is where things get interesting.  When compared to patients with healthy shoulders, patients with subacromial impingement syndrome have on average less thoracic spine extension mobility (1).

Food for thought:  Research from McClure et al. 2006 showed that there was no difference in thoracic spine posture at rest between healthy individuals and those with subacromial impingement.  This suggests thoracic spine mobility may be more important that static posture (3).

As we learned previously patients with impingement also present with increased anterior tilting of the scapula (2).  As we learned previously, anterior tilting of the shoulder blade decreases room in the subacromial space.  This impinges on the tissues that lie within the subacromial space and over time can lead to rotator cuff tears.

Food for thought: More recent research has shown that individuals with subacromial impingement syndrome may have increased posterior tilt when lifting their arms overhead. This may be a compensation pattern to help increase subacromial space and decrease pain and impingement. (3)  If this makes no sense don't worry, I found this interesting!

source: www.dynamicchiropractic.com

Thoracic spine mobility and posterior tilting of the scapula are synonymous.   Understanding this concept can be difficult.  Think of it this way.  As we raise our arms overhead the scapula is supposed to ride flat along the thoracic spine.   In healthy overhead motion the scapula will upwardly rotate, elevate and posteriorly tilt.  In order to posteriorly tilt properly, the ribcage must create an optimal surface to allow this motion.  Adequate thoracic extension creates a more optimal ribcage surface to allow the scapula to do it's job and get our arms overhead safely and efficiently.  If we have a large kyphosis and decreased ability to extend at the thoracic spine, the surface of the ribcage will make overhead motion much more difficult.

Now here's a little experiment to help explain the above details.  Stand with poor posture with your shoulders and head forward with a big round in your upper back.  Keep this posture and try to raise your arms overhead as much as you can.  Not too good huh?

Now fix your posture.  Pull back your shoulders and tuck your chin.  Straighten up your upper back.  Now reach overhead again.  Better?  If we're lacking thoracic spine extension range of motion it's going to make healthy efficient overhead motion impossible.

source: www.ericcressey.com

On top of that, normal overhead elevation of the shoulder is only 165-170 degrees(4).

165 degrees does not get our arms completely overhead.  We'll need full range of motion for all exercises that requires us to press weight overhead (Military Press, Push Press, Push Jerk etc).  Our body achieves those last degrees of full 180 degrees of overhead motion with thoracic spine extension.  As we learned previously a lack of thoracic spine extension opens ourselves up to shoulder injuries and leads to a pretty weak press.   To add insult to injury, a lack of overhead flexibility can cause a compensation somewhere down the chain in order to get our arms completely overhead.  Often times we try to achieve extra motion by extending our lumbar spine.  (Anyone else smell lower back pain?)

Well, there's the details on the thoracic spine.  I think I've strained my brain enough writing about this topic.  Give me some time to ice my brain and I'll get back to you next week as we talk about have breathing can effect the shoulder.  Until then...

Rotary cups of steel,

Dan Pope

P.S. If you enjoyed this article then head over to www.fitnesspainfree.com and sign up for the newsletter to receive the FREE guide - 10 Idiot Proof Principles to Crossfit Performance and Injury Prevention as well as to keep up to date with new information as it comes out via weekly emails.

Resources:

1. Meurer, A., Betz, U., Decking, J., & Rompe, J. (2004). [bws-mobility in patients with an impingement syndrome compared to healthy subjects--an inclinometric study]. Z Orthop Ihre Grenzgeb,144(4), 415-420. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15346302

2. Lukasiewicz AC, McClure P, Michener L, et al. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999;29:574–583.

3. McClure, P., Michener, L., & Karduna, A. (2006). Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. Physical Therapy, 86(8), 1075-1090. Retrieved from http://ptjournal.apta.org/content/86/8/1075.full

4. Gulick, D. (2009). Ortho notes. (2nd ed., p. 189). Philadelphia, PA: F.A. Davis Company.

 

Why Do My Hips Hurt When I Squat? Femoral Acetabular Impingement: Part 2

In part 1 we discussed what femoral acetabular impingement (FAI) is and how squatting can be causing pinching and pain in your groin and hip.  In part 2 we'll start troubleshooting the squat to figure out why you're getting the pain.

Now, remember the tests I spoke about that can rule in FAI or labral pathology?  Here's another special test for femoral acetabular impingement and hip pathology.

Do you notice how this test for hip labral pathology is eerily similar to the bottom position of a squat when things go wrong?

source: www.nunnsperformancetraining.com

No offense to this incredibly powerful gentleman here but he's got a good deal of hip internal rotation going on in the bottom position of his squat.  Notice how his knees are not over his toes?  He's placing himself into the same provocative and painful position that physical therapists test for in the above video.  This position of extreme hip flexion and internal rotation can be causing hip and groin pain.

Contrast that with the hips of this Chinese weightlifter in the bottom position of the squat.

source: www.crossfit55.com

He's got a lot more external rotation going on in his hips at the bottom of the squat.   Notice how his knees are forced out and and his knees are aligned with his toes.  If we can achieve this position in our squats then we can hopefully alleviate some of the pain we get.

Take a look at the first picture again.  Do you ever find yourself in this position when squatting?  If yes (and I believe this is the case in a lot of individuals) then we've got some work to do to fix this issue.  If you're getting internal rotation of the femur at the bottom of the squat (it doesn't have to be a lot) then you're placing yourself in a provocative position and risking hip injury.

So why might your hips fall into internal rotation in the bottom of a squat.  It could literally be coming from any part of the body that isn't operating properly during a squat.  We'll break down the overhead squat because if you can hammer a perfect overhead squat then you can really hammer any other type of squat.

Perfect Overhead Squat

1. Feet Flat - Not excessively turned out
2. Knees over toes
3. Hips back  with the hip crease below the top of the knee
4. Flat neutral spine
5. Upright torso
6. Externally rotated shoulder
7. Arms locked out
8. Bar over your center of mass

source: t-nation.com

Now, given that our body is a system of joints, if you've got a limitation in any one of these areas it's going to affect what goes on with your hips.  Everything up and down the chain needs to be addressed including the hips themselves, so let's get started.

1) The Feet - Your feet are the only thing that comes into contact with the floor and will therefore help to set the rest of your joints in the proper place for squatting.

Learn how to use the "short foot"

Now apply it to your squat:

You can practice this foot position during deadlifts and lunges also.

2) The Ankles - A lack of ankle mobility can cause internal rotation of the hips at the bottom position of the squat and end up causing impingement.

My favorite ankle mobility drill

Some additional mobility drills from Kelly Starret

3) The Knees - The knees are a slave to the joints directly above and below them.  The important thing to keep in mind is that the knees need to stay in line with the toes during a squat.

source: wg-fit.com

If your knees are aligned with the toes during a squat it's also a sign that your feet and hips are in an optimal position.   The cue "knees out" creates external rotation at the hip and that's what we want.  External rotation of the hips is going to decrease impingement in the bottom of a squat.

4) The Hips - As discussed previously, excessive internal rotation of the femur in the bottom position of the squat is the mechanism of injury in femoral acetabular impingement.  If you have your toes pointed out slightly and your knees are aligned over your toes, then your hips are going to follow suite and externally rotate into a healthy position.

The hips need a balance of mobility and stability to achieve this position.

• Here's a link to some of my favorite hip mobility exercises. 
• This video below demonstrates my favorite hip stability exercises.

5) The Lower Back (Lumbar Spine) - It's vitally important to learn how to keep the spine in a neutral position and move from the hips during the squat.  Individuals with femoral acetabular impingement tend to have decreased range of motion in their hips and can end up compensating to get deeper into a squat by rounding the lower back.   This can lead to what has been termed "butt tucking" or "butt wink" during the squat.  Now you've got hip and lower back pain.  So on top of getting your hips more mobile, learn how to use the hip hinge and move from the hips while keeping a neutral spine.

6) The Upper Back (Thoracic Spine) and Shoulders - Limited flexibility in the upper back and shoulders can decrease your ability to get your arms overhead into an overhead squat.  If you lack flexibility here, your body will try to gain flexibility from another joint and if that joint ends up being your hip, you'll end up with groin and hip pain.

My 6 favorite thoracic spine mobility drills

I think this is where we'll call it for today.  Next time we'll go over some stretching techniques for especially pinchy hips as well as the concept of joint centration and which exercises to use to help clean up your hip problems.

I love overhead squats,

Dan Pope

P.S. If you enjoyed this article then head over to www.fitnesspainfree.com and sign up for the newsletter to receive the FREE guide - 10 Idiot Proof Principles to Crossfit Performance and Injury Prevention as well as to keep up to date with new information as it comes out via weekly emails.

References:

Macrum, E., Bell, D., Boling, M., Lewek, M., & Padua, D. (2012). Effect of limiting ankle-dorsiflexion range of motion on lower extremity kinematics and muscle-activation patterns during a squat. Journal of Sports Rehabilitation, 21(2), 144-150. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22622377

Reiman MP, Weisbach PC, Glynn PE. The hips influences on low back pain: a distal link to a proximal problem. J Sport Rehabil. 2009;18(1):24-­‐32. 

Why Do My Hips Hurt When I Squat? Femoral Acetabular Impingement Part 1

Have you or your loved ones ever had a pinching feeling at the bottom part of your squat?  Does it kind of feels like it's deep in your groin?  Do you really have to warm-up a lot to make it go away?  If so call...

Seriously though if you have this feeling you might have some type of impingement going on in your hip known as femoral acetabular impingement (FAI).  
This is a common problem in young athletes and is often misdiagnosed (1).  It can eventually cause a more serious condition known as a labral tear of the hip.  Research shows us that patients visit on average 3.3 healthcare providers over a period of 21 months before being correctly diagnosed with a labral tear (2).

Here's the deal.  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. The acetabulum is part of your pelvis, a bone that sits between the hips and attaches to the base of your spine. (3).

source: www.mayoclinic.com

At the bottom position of the squat we can sometimes get the head of the femur (ball portion) to butt up against the acetabulum (socket).  This can be pretty uncomfortable to say the least.

Unfortunately, you've got a structure that encapsules the hip joint known as the labrum.  The labrum can become trapped between the femoral head and acetabulum and become "impinged" during a deep squat.  Some individuals can get this same impingement during other activities like running and jumping.  This is the phenomenon known as femoral acetabular impingement (FAI) and in the long run it can lead to labral tears in the hip.  There are a few good clinical tests to see whether or not you've got this problem (4).

FABER and FADIR tests

If these tests reproduce the same pain you've been getting in your hip, you might have some impingement going on.

Notice how similar this position is to a squat gone bad...

Unfortunately this pinching is sometimes the result of a boney abnormality that can't be corrected easily.  The two types of deformities are CAM deformities, Pincer deformities or a combination of both (Mixed) (1).

source: orthoinfo.aaos.org

Cam deformity: This boney deformity is from the femoral head (ball).

Pincer deformity: This boney deformity is from the acetabulum (socket).

As you can see from the images, having these boney deformities is really going to increase the amount of impingement we get when doing something like a deep squat.  In fact, those with these deformities have limited pelvic and hip motion during squats when compared to normal hips (5)

The way we can rule these conditions out is with an X-ray.  If you've got symptoms of femoral acetabular impingement( FAI) it would be wise to consult your physician to see if you've got one of these boney abnormalities.  On top of that, having these boney deformities and a subsequent flexibility limitation at the hip (internal rotation deficit) can lead to pain in the lower back (6) and at the pubic symphysis (7), more reason to go see your doc.

The issue with having chronic femoral acetabular impingement is that over time this can lead to a labral tear.  Once your labrum is torn we can only repair it through surgery.  What do you think that means for you if you continue to push through your pain?

An interesting dilemma: What came first, the chicken or the egg?

Bones in our body grow when they are stressed.  This phenomenon is known as Wolf's Law.  This means that if I chronically put pressure on my bones they will become stronger and more dense.  It also means that if I put an abnormal stress on my bones I can grow some bone in a place that isn't meant to have any bone.

The question to ask is whether or not people are born with a boney abnormality of the hip or they develop a boney abnormality because they are chronically stressing an area and as a result develop a boney abnormality.  ie:  If you keep impinging your hip, your hip might grow some bone in the area where it is getting stressed.

What I mean by that is that if we chronically move in a way that promotes impingement of the hip, our body could respond by growing one of these pincer or cam deformities.

We might not be born with these boney problems, we may be creating them.  So it is of the utmost importance to take care of these issues as they come up because we may be developing permanent boney abnormalities by continuing to exercise with pain and discomfort.

In part two we'll discuss some fixes to these problems and some modifications for athletes who have pinchy hips when they squat.

Until next week try some box squats,

Dan

P.S. If you enjoyed this article then head over to www.fitnesspainfree.com and sign up for the newsletter to keep up to date with new information as it comes out and exclusive deals and offers from new products and offers from yours truly.  

References:

1. Roling MA., Pilot P, Krekel PR, & Bloem RM, (2012). Femoroacetabular impingement: frequently missed in patients with chronic groin pain. Ned Tijdschr Geneeskd, 51(156), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23249508

2. Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients
with tears of the acetabular labrum. J Bone Joint Surg Am 2006;88:1448–57.

3. Behnke, R. S. (2006). Kinetic anatomy. (2 ed., pp. 35-56). Champaigne, IL: Human Kinetics.

4.  Reiman, MP, et al. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-­analysis. Br J Sports Med. 2012

5. Lamontagne M, Kennedy MJ, Beaule PE. The effect of cam
FAI on hip and pelvic motion during maximum squat. Clin Orthop
Relat Res. Mar 2009;467(3):645-650.

6. Reiman MP, Weisbach PC, Glynn PE. The hips influence on low back pain: a distal link to a proximal problem. J Sport Rehabil. 2009;18(1):24-­‐32.

7. Verrall GM, Hamilton IA, Slavotinek JP, et al. Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury. J Sci Med Sport. Mar 2005;8(1):77-84.

Best Around the Web #2 ACL, Knee Pain, Ankle Mobility

Love me some drop vertical jump testing.

We all know that landing from a jump poorly can lead to ACL injuries but we're also finding out that it can lead to good old knee pain (Patellar tendinopathy).  I feel like I've been talking about this ad nauseum.

• Here's some research in male basketball players correlating poor landing mechanics with increased patellar tendinopathy

While we're on the topic of ACLs it appears that females still have poor landing and movement mechanics at the knee even after they return to their sport.  Anyone else smell another ACL injury?

• Here's the research

So why are females showing poor landing mechanics?  Here's some food for thought:

• Females with poor landing mechanics have on average lower hamstring strength then those with better landing mechanics

Nordic Hamstring curls anyone?

While we're on the topic of the knee:

• Ankle joint mobility improves landing kinematics in chronic ankle instability patients

The above study used trained professionals in order to mobilize the subjects ankles:

• Here are some do it yourself mobilizations you can try on your own from Kelly Starrett.

Want more ankle mobility, I love Chris Johnson's stuff.

• Here are some ankle mobility drills he uses with his runners.

That's it for now!

Dan

P.S. If you love exercise and fitness and don’t want to give it up just because you have a few aches and pains then sign up for the newsletter at www.fitnesspainfree.com on the top right hand side of the page.  You’ll learn how you can continue to have your fitness pain free by staying up to date with new content as it comes out.

Why Maxing Out on Lifts Constantly is a Great Way to Get Hurt Fast

I'm a big proponent of lifting heavy stuff.  It's right up there with eating, sleeping and breathing for me.  Hitting a heavy workout and then going home to feast and fall asleep in food induced coma is about one of my favorite past times.

That being said, you'd think I max out with my lifting all the time.  Well, not so fast.  We know that we need to make progress from session to session but that doesn't always mean you've got to hit a new 1 rep max every time you lift. Sure, we need progressive overload (nerdy term for continuously using heavier weights over time).  That's important.  Patiently increasing weight by small increments every week, diligently working on your accessory lifts  and perfecting technique is what training is all about.   What I'm not a proponent of (but have been guilty of) is frequently maxing out your lifts at the mercy of your exercise technique and subsequent joint health.

Most powerlifters and strongmen I know (with deadlifts over 700lbs) very rarely max out.  They'll save it for a meet or competition.  It's like a holy event for them.  The moons have to be aligned, the evening breeze must be cool but comforting and the lift must be completed at the stroke of midnight.  Well, maybe not that specific, but you get the idea.

I personally max out on my biggest lifts about 1-2 times per year.  Once you build some experience lifting, it becomes daunting to max out.  It's also incredibly stressful on the body and mind.

My biggest issue with maxing out all of the time is that usually when we hit our limit with lifting, our form begins to fall apart.  Like I've said before, once your technique goes down the toilet you're opening yourself up for injury and becoming less efficient, two bad things.  I recently squatted 400lbs and it looked pretty crappy actually:

The weight came forward, the stress on my lower back went through the roof and quite frankly, I almost pooped myself.  Look at the set right before at 380lbs.

I smoked that weight.  It felt light, speed was good and I held my technique together.  This is what my reps should look like on a regular basis.

What happens if I chase big maxes week in and week out?  I'm fairly certain it will end with a lot of pain and a potential trip to the orthopedic surgeon.  This mentality can lead to have surgery.   The subsequent rehab for up to a year afterward is rarely the most efficient way to reach your training goals.

The problem I see is that a lot of beginners go out there chasing big jumps in their lifts and max out from week to week.  Their heart and courage is admirable, don't get me wrong.  If we keep this habit up we're just developing poor habits and asking for injuries.

Take away points:

1. Make technique a priority:
2. Have patience: Big time strength is built over a lifetime of training.  If you show discipline and patience, it will come.
3. Max Out Less Often: 3-4 times per year for newer lifters and 1-2 times per year for the most advanced.
4. Utilize other ways to get stronger: Rep Work, Singles above 90% of your 1 rep max and speed work are all great ways to improve your strength

Excuse my while I go deadlift,

Dan Pope

P.S. Like crossfit?  Want to be good at it and not get hurt?  Go to www.fitnesspainfree.com and sign up for the newsletter at the top right hand side of the page to get a 12 step guide to pain free performance to learn how to do it.  You'll also stay up to date on the newest content as it comes out with a weekly newsletter.

Best From Around the Web #1

1. Evidence Based Training tips by Chris Beardsley - Always excellent info, especially interesting this week.

• Stretching and strength and size gains
• Best warm-up for performance
• What difference in muscle activity is there between a deep squat and a shallow squat

2. Does a forefoot strike pattern (barefoot running) reduce injury? by the sports physiotherapist - Great new website I found.

• Benefits of barefoot style running (includes pose/chi/evolution running)
• This style of running for treating shin splints
• What the research says (or doesn't say) about injury prevention

3. Strength Training Consideration for those with Patello-femoral Pain Syndrome by John Snyder

• Evidence based article overviewing how to effectively treat PFPS (anterior knee pain)
• Should we train the quads?
• What range should we train in? ie: Should we use a full range of motion in squat/lunge exercises?
• Should we target the VMO?

Enjoy it, I know I did,

Dan Pope - www.fitnesspainfree.com

P.S. If you’re enjoying this content and wish to stay up to date with the newest content as it comes out as well as receive exclusive deals and offers then head over to www.fitnesspainfree.com and sign up for the newsletter at the top right hand side of the page.  You’ll receive a free guide, “12 Idiot Proof Principles to Crossfit Performance and Injury Prevention” to boot.

Why is Overhead Press Destroying my Lower Back

If you guys have been following this site for any length of time you know that I'm a huge fan of cleaning up your technique on all of your lifts.  It will do just about everything from making you a more efficient athlete and reducing your risk of injury to filling in your bald spot on the top of your head.

I think that most coaches and athletes understand the idea of keeping your spine in a neutral position and moving from your hips during exercises like squats, deadlifts and olympic lifts.  I know I run around like a madman at class screaming back flat!

Taken from eorthopod.com

The flip side of the coin is keeping your lower back in a stable position as we press overhead, perform pushups and work on toes to bar.  When I was competing more often in strongman I'd see a lot of athletes with something called spondylolisthesis.  Sounds bad right?  Well it is.  As you can see in the picture you've got a slippage of your vertebrae forward on the vertebrae below it.

Unfortunately you've got something important called your spinal cord that sits inside of your spinal canal and it can be pressed upon when you've got this condition.  Bad news bears to say the least.

Taken from nismat.org

How do we get it?  Overextension.  It's a common injury in gymnasts because they are constantly hyperextending their lumbar spine (lower back) as part of the demands of the sport.  Basically the spine is being bent backwards too far. It's not just spondylolisthesis that is problematic though.  Overextension of the lumbar spine can cause plenty of pain and damage to the lower back (facet joint damage, spondylolysis, spondylosis, arthritis etc. etc.) without actually causing the more severe spondylolisthesis.

Source: www.crossfit.com

Why is this a problem in crossfit and overhead pressing athletes?  Well, you can easily get overextension in your lumbar spine during things like overhead press, handstand pushups and as seen to the right, kettlebell swings overhead.

Well why does this happen?

1. Poor thoracic Spine and Shoulder Mobility
2. Poor core stability
3. The weight's too damn heavy.

Next week we'll go over strategies to fix this.  Until then don't go out there and destroy your lower back in the meanwhile!

Love and Push Press,

Dan

www.fitnesspainfree.com