Struggling with tendonitis

Typing on a phone is so bloody annoying -- forgot to mention, farmer's walks tend to be rather effective in scap setting, and are pretty fun at that. It's difficult without assessing a person fully, obviously.

What's your background in this regard? I'm curious.

 

I used to be an S&C coach. I started as a CrossFit coach, but fell out with CrossFit for a bunch of reasons. Then I moved to an S&C gym with a focus on competitive powerlifters, but also worked with olympic weightlifters and athletes from other sports and some general population.
I picked up some injuries from another career and the treatment I received was mostly terrible, so I spent several years learning on my own to try and keep clinicians on their toes. Outside of movement selection, programming was never my strong suit (compared to other coaches in the gym), so I became their 'rehab guy.' Now I'm doing a bit of consulting where I coach other coaches, teach them how to screen clients, break down movement and some other stuff.

I have to disagree with you on some of that. Chiropractic adjustments do have something inherently wrong with them and they certainly don't provide a neurological reset. While adjustments to the lumbar and thoracic spine are normally low risk, cervical manipulations aren't. Due to anatomic variation within the population, vasculature around the cervical spine is not always consistent. Cervical manipulations can cause internal haemorrhaging. It's a while since I looked at this stuff and I think the transverse and spinous processes can cause a rupture, but the main concern is the dens (part of C2 vertebra). The dens is a vertical protrusion that comes through a hole in C1 and can rupture or sever vasculature during a cervical manipulation. This is why you're supposed to go to hospital if you get whiplash. Furthermore, there's a pretty solid body of evidence regarding cervical manipulations and stroke. The risk of stroke compounds with every cervical manipulation.

This is one of the ways that hokey principals make chiropractic dangerous. The manipulation itself is dangerous and the justification for it is chiropractic's idea of chiropractic subluxation and how that inhibits nerve flow. Firstly, chiropractic subluxation has been proven again and again not to exist. It can't be repeatedly palpated by chiropractors, it can't be seen on imaging, and perhaps most damning of all - partial and full dislocations of vertebrae of been shown not to inhibit nerve flow. So when they tell someone that they're manipulating their cervical spine to restore nerve flow they're working from false principles and putting someone's life in needless danger. In the worst cases those principles are extended to treating infants with colic, curing cancer, and used to avoid vaccination.

The positive effects of manipulation are not due to the mechanisms chiropractors claim, but a general effect from 'popping' joints and the phenomenon of therapeutic touch. I used to know more about this stuff, specifically what chemicals 'popping' a joint releases, why that feels good and why it temporarily increase range of movement, but I can't remember what that is.

Deadlifting is great if it's done properly, but I'm not sure how it changes centration of the humerus, or how farmer's walks do the same and set the scapula. Doing the movement may move bones into a better position, but those effects are usually caused by the load itself and disappear afterwards. It's also not necessarily changing the neurology that causes muscles to shift the humerus away from the glenoid fossa. What you want to look at is how motor control stabilises those joints without any load, so that you're not getting a false sense of progress or security.

 

I don't remember the direct reference -- it was partly discussed by Stuart McGill, I believe, as well as my former boss who was very skeptical of chiropractic treatment. It does function on a neurological level, to some extent (from what I recall), as perceived "tightness" tends to be neurologically controlled. There's a chemical release process, but it again acts on the nervous system. Either way, the correct type of adjustment can be rather handy, though I know many chiros who aren't doing cervical manipulations and never have. I thought I remember reading a meta-analysis on this a few years ago, but I don't remember the conclusion. There was a lot of controversy on this matter, however. In any case, it's rather widely accepted throughout the field of elite-level sports rehab that your run of the mill thoracic (and lumbar, as far as I remember) adjustments are perfectly valid and are merely a tool in the tool box.

Again though, this doesn't make "chiropractic" as a whole, dangerous. Look at practitioners leading the field of effective rehab, and even consensus from people like McGill who acknowledge that some types of adjustment have value and don't mention subluxation. I'm not defending it as a whole, but outright saying one ought to disregard chiropractic in a blanket manner is to disregard the massive progression DC's have made in part with DPT's and the like in the field of rehab, as well as their own uses of the technique. You're lumping good chiros in with kooky backalley chiros, and this isn't really fair. I don't know a single good DC who has spoken positively on subluxation treatment -- most bring it up as quackery they want no part of.

Admittedly it's been a while since I was involved, so I may be a bit out of the loop.
It can be hard to do properly, which is why single leg deadlifting became such a staple of strengthcoaches in the US.

This summarizes it briefly -- it's been a long time since I delved into this, but I think he talks about it more in his Training=Rehab, Rehab=Training DVD. Will see if I can pull it up if you're interested. I think the point Charlie and Gray Cook and the like make is that increasing stability through carries like this creates meaningful changes in the long run.

http://charlieweingroff.com/2010/12/shoulder-traction/

True re: motor control stabilizing joints, but then again the whole underlying principle of strength training is that one creates better motor patterns through loaded training (read: creating stability in relevant areas) -- there isn't really any other way to change motor patterns. If loaded training didn't train motor patterns, there wouldn't be any changes in a person's FMS or SFMA screening post-training.
This doesn't necessarily mean weighted exercise, as DNS rehab is typically done unloaded, but there's still resistance applied in various rehab positions. This goes all the way back to crawling as a baby.

 

I'm a huge fan of McGill and it's great to see that someone else knows who he is.

I misunderstood your point about manipulation's '"release" effect. I agree with you that it has that effect, what I'm saying is that it's not due to the mechanism claimed by chiropractic.

I'm not saying that some chiropractors don't get things right, I'm saying that they don't get there through chiropractic principles. So a good chiropractor isn't good because of chiropractic principles, but because of things they borrow from other disciplines. I'd love to see a bridging course for these people where they can re-qualify in a different field, rather than drag the baggage of chiropractic with them.

I'm not sure how single-leg deadlifts link to what I mentioned. You'll have to explain that one to me.

Don't get me started on Gray Cook. The FMS is so flawed that it can't even detect current injuries, let alone predict future ones.

 

We hosted a seminar he did out in western Canada, fantastic guy. Really amazing to watch him work and how quickly he gets results. I wish I could have picked his brain for hours.

Ah, well in that case I'd agree. Ditto on manipulation of the hip joint or the like, where a run of the mill DC will say "you were born with one leg shorter than the other". Nope, that's an extremely rare condition, and if adjustment or manipulation of any sort is going to make a difference, it will be a purely neurological change whereby the joint/surrounding tissue gains a window of mobility or "release". You're not going to magically increase the length of someone's femur through manipulation.

Haha, well in that case, I definitely agree. I personally would rather become a DPT as long as I was given the same privileges. There have been some substantial changes to chiropractic up here in Canada in the last few years, largely in thanks to people like Craig Liebenson. The problem is that it takes an awfully long time for research and treatment methods to hit textbooks and curriculum, but R2P is a club that started when my boss was at chiro school and seems to have extended down into the US. For the record, if a random person were asking me who would go to a randomly selected chiro, I would say not to trust chiros; but talking to people in a

Oh this is purely in response to "done properly". It's a hell of a lot easier to load legs and take out the potential weak link of the lumbar spine by loading up one leg at a time. Lots of people we trained didn't have the requisite stability or mobility for conventional deadlifting, at least not deadlifting close to their potential.

I used to think this way too, and heard it a lot from strength coaches, but seeing people like Charlie change his mind on the usefulness of the FMS piqued my interest (I don't think the SFMA has really been in question in this regard):
http://charlieweingroff.com/2010/09/when-someone-says-the-fms-doesnt-work/

In short, the study that came out about injury prediction and the FMS was certainly valid, but off-base in its assumptions about what the FMS is useful for and what it's intended to do. I didn't spend much time listening to Gray, quite frankly, but there are highly respected people in the field who have found utility in what he's developed.
In any case, my main point was that while assessing motor patterns unloaded is extremely important, of course, it's often through loaded exercise that unloaded patterns are improved, whether through increasing relevant stability, RNT, etc.

 

You're right about the bone-length stuff. More importantly, it has a poor predictive relationship with pain and dysfunction. Eyal Lederman did an outstanding summary of this stuff here. http://www.cpdo.net/Lederman_The_fall_of_the_postural-structural-biomechanical_model.pdf

I haven't caught up on the FMS in some time, but Paul Ingraham is an outstanding resource on this stuff. He also updates his resources frequently which allows him to change his position based on new evidence. https://www.painscience.com/articles/functional-movement-screen.php

 

Thanks for the article -- I do recall reading some of those criticisms in the past. I'm admittedly rather out of the loop myself, but it's interesting to see the increased interest in the system from high-level clinicians.

A few thoughts on the article from a non-clinician (myself) as well as what he cites (i.e. "The Core Stability Myth"):
-Often, by the time research is out, what's being researched (for instance, using FMS as a hard predictor for injury, or as a diagnostic tool) is something that highly respected practitioners have already long ago discarded or modified (i.e. the Charlie Weingroff article -- the comments section is especially valuable), and have long since moved on and found other applicable uses. It's a field that doesn't have a great deal of funding for research, and practice tends to lead formal research by years. As Charlie states, the FMS can be a useful tool if you know how to use it and what to look for (he's got a podcast on YouTube where he's interviewed about it). To narrow applicable uses down is notoriously difficult in formal research. This comes down to research methodology, which in complex fields like this raise equally complex issues and tend to address only very specific questions with narrow parameters, some of which aren't relevant, and variables take a good deal of cogent thinking and extreme care in insolating variables (short clip, but illustrates it well:

.
Charlie, Liebenson, etc have addressed many of these issues and questions, and their track records and influence seems to demonstrate that what they do is indeed effective. Has the FMS been misrepresented and misapplied? Obviously, given the research cited. Is it useless? Probably not.

-Similarly to above, articles like "The Core Stability Myth" are indeed illuminating, especially in regard to very basic exercise instruction (i.e. Pilates and the like) -- however, most of what it addresses isn't what relevant practitioners and coaches mean by "core stability" (including Stuart McGill), nor what's contained in the joint-by-joint approach, DNS, etc; the majority of the issue is already addressed in the idea that high-threshold strategies are a sign of dysfunction. It's important information, certainly (i.e. the cue to "suck in" is terrible and creates dysfunction), but it has relatively limited application to what high-level practitioners are doing, and often times articles in this sort of critical vein (not this one in particular) end up being pointlessly pedantic from people with no real relevance to the field. I know there were a number of people prominent in the S&C/Rehab field (i.e. Patrick Ward) who responded to the article with "So if there's a better way, then what is it?".

For the most part though, the article raises criticisms that clinicians who use the FMS raise (my boss had a discussion with me about many of those points a few years ago, but we again found some usage for it). It's dead-on about coaches and trainers trying to play "clinician", but I can also sympathize with people who don't have good help to refer to and as such try and do the best they can with what they have. I often think of it this way as a "better vs best" kind of thing -- while it isn't ideal, it's probably better than an underexperienced coach uses the FMS as a guide to programming than conventional personal-trainer "wisdom". Sympathy aside, it's certainly been misapplied/used.

 

Part of the difficulty with the 'core stability' is that everyone seems to have their own definition. Same deal with the term 'functional.' It's a great buzzword, but good luck trying to nail down a meaning that's consistently applied.

I can't remember where I got my own definition of core stability from, but I've probably borrowed from McGill. Essentially, "create enough proximal stiffness for the limbs to gain leverage and express power." That doesn't necessarily mean a rigid spine, or a straight spine. One of the things I picked up form McGill is that rigidity is key during axial compression of the spine. However, rigidity becomes impractical during certain gymnastics movements. So it goes back to that some principle - create enough stiffness for the limbs to gain leverage and express power.

The unspoken part of that equation is the shoulders and hips, which I've begun referring to as the 'interfaces,' as they are the link between the legs/arms and the torso and necessary to gain useful leverage. Failure at any point (core/interfaces/extremities) increases stress at other points.

 

The variation in definition is likely true with the average personal trainer, but all of the guys I've mentioned (from what I remember anyway) agree that simply firing the TrA isn't really that helpful. Regardless of background then tend to agree that an "inside out" approach (namely, proper function of the diaphragm in the stabilization of the spine, rather than focusing on specific muscles as "core") is what is needed, and this starts with making sure that what's "programmed" is correct and appropriate reflexive function.
Re: functional -- haha, I want to slap trainers who think that getting their clients to stand on bosu balls to "improve balance" is functional.
I think the best definition of functional, which tends to be how "correct movement" is drawn upon by various disciplines, tends to come from neuromuscular development and the patterns found in developmental kinesiology (IIRC), which is what DNS uses as its foundation.

 

A little late back to the thread, farmer walks are waifu.

I actually finally got a set of farmer bars a bit before my injurty, which was awesome - because dumbells just don't do it justice after you gain any reasonable amount of strength at it... Really felt good to load it up, because at the house I only have bumper plates - so I'm kind of capped out on how much weight I can load onto the bar/hex bar. I was able to max out a farmer deadlift at 460, with still some room to load up more plates.

Shame I got them, played with them a bit, and then ended up deciding to try to brute force my bench press out of completely pitiful territory. It worked, I used to have a max of 185, but since I rarely ever benched - it would slip back pretty quick, and when I had a hard time benching 175 for a single - I decided to spend some time on it, and take a break from any other work besides that and using the opportunity to work on my posture/strengthening/stretching.

Unfortunately I think overworking/overstretching everything that kept my spine safe - caused it to be unstable during bench... and since I've got kyphosis - and a pretty hard bench(I don't like much padding) I think it was just a situation where instead of bending inwards - it just shifted to the left. In that month though, I did push past my goal of 200 to a pretty quick 215 single. Still failed 155 OHP for a single, couldn't even push press it. Was secretly hoping improving my bench would help me break my OHP plateau.

But yeah, farmer walks are HUGE. Infact I've had friends do farmer walks before deadlifts and it's like 900% easier for them to end up having non-snap city form. Literally owe my safe deadlifting/spinal stability to farmer walks and unilateral farmer walks....

 

There's something weirdly magical about loaded carries and what they do. I'm not too well-read on it but they're about as close to a magical exercise as I can think of.

Sam: You've got me all distracted and reading on this again. I'd love to know your thoughts on this (as well as your take on addressing movement issues/motor dysfunction/pain in regards to poor scapular dynamic stability (I've actually experienced nerve tension and pain in my fingers from this, oddly -- hugely important).

http://www.hanslindgren.com/articles/core-stability-from-the-inside-out/

 

There's a lot in there and most of it seems focussed on the diaphragm and breathing, as well as a move away from TA orthodoxy. I've only just woken up and am a few sips into my first coffee, so bear with me if this is a little discombobulated. I've had to break the post down into two posts due to its length.

The earlier stuff about becoming obsessive over certain muscles, especially the TA has felt like ideology for some time. In the sense that an ideology provides one answer to all problems, the TA/hollow fanaticism has had this air to it for a while. For my taste it's just too simple and one dimensional to be true. I agree completely with the stuff about instability training being moronic, because it ignores neurology. The assumption is something like this: "if I stress the body in a certain way, those muscles will always come on." This is blatantly untrue and the issue is exacerbated by arthrogenic muscle inhibition. Just because something looks good from the outside doesn't mean everything's good on the inside. I've worked with powerlifters and weightlifters at national and international levels and almost every single one looked good technically, but on closer inspection they had faulty motor patterns in the glutes, in the shoulders, or both.

Furthermore, unstable surface training needs to be very, very carefully controlled. You need to pick the right movement and you need to pick the right way to destabilise someone. I've used destabilisation in the past, but for very specific things and only after I've confirmed that their core, glutes and shoulders function correctly. Destabilisation challenges someone's ability to maintain correct motor patterns under stress. Unfortunately, people get it backwards and think that destabilisation teaches correct motor patterns because of stress.

But this raises another question - what is the correct function of the core? The job of the core is to act as a fulcrum for the rest of the body. This is why I fall into line with McGill's stuff about core stiffness, rather than contraction of certain muscles. In training the core I largely avoid situps, side bends etc. and focus on challenging the core's ability to remain stiff while being acted upon by external forces. This is something that Louis Simmons, Stuart McGill and Pavel Tsatsouline understand well - the primary job of the core is not flexion and extension, but to maintain it's position while the rest of the body gains leverage from it. Movements like the farmers walk, yoke walk and pallof press all fall into that category. I'll also use the Hollow and Arch position to teach and test the endurance of core stiffness. For more advanced athletes I'll combine the two and have them roll repeatedly from a Hollow to an Arch position while breathing. Breathing without losing midline stiffness is difficult, but crucial for movements like the farmers walk and yoke walk. Therefore I take issue with the article's point about a big breath creating a more effective brace. It can, and is easier for untrained people, but as soon as a second breath is taken the position is changed. Instead, brace first, then breathe into that compressed space. It's practical application is far greater than taking a breath and bracing around that.

With regard to heavy lifting and the core being more effective than specific 'core activation' exercise, I agree for the most part. But you still need to be careful not to fall into the trap of thinking that if a movement looks good that everything is correct internally. Just because a deadlift or a squat looks perfect from a visual sense doesn't mean the glutes are working correctly, that the core is working correctly etc. I'm sure you've seen people overhead squat or overhead press with an extended spine. They get the weight moving, but they haven't learnt how to stabilise the core. Instead they've locked the vertebrae in extension to create a hazardous form of stability. You need to get your hands in there and palpate certain muscles, you need to screen them effectively etc.

I'm trying to think how to answer your question about addressing movement issues, motor function, scapula function etc., but there's a lot to deal with there. I'll try and provide a condensed version and I'll provide a link to some older writing I did to answer your question on motor function.

 

When addressing movement issues my first task is to try and find out roughly where the issue is, and what type of issue it is. That process is a large part of what I do when teaching other coaches. I've been trying to develop my own systematic approach for it, but it's still early days. So forgive me if its a little longwinded.

That systematic approach starts at the core, then goes to the interfaces (hips/shoulders) and finishes at the extremities (upper/lower body limbs). I use that order because it's how leverage is applied and power is expressed - if the core is compromised everything downstream will suffer. If the interfaces are compromised there is increased stress on the core and extremities, and the extremities will be working from a point of instability. If the extremities are compromised there is increased stress on the core and interfaces, and the extremities are still working from a point of instability. As a side note, understanding all of that may explain why rotator cuff injuries coincide with a dysfunctional scapula and why rotator-cuff exercises alone are a poor solution.

In testing those areas I'll use provocative testing to expose the fault under different types of stress. Stress is broken down into two types - passive and active stress. Passive stress looks at structural limitations like bone length, bone shape, and tissue length. Passive limitations are always the first thing I'll look at because it's efficient. If the fault is caused by a structural limitation the solution is simple - modify or avoid that movement. You're not changing those passive structures.

Next is active stress, which can be broken down further into coordination and proprioception. Coordination includes motor patterns (order of contraction, movement complexity), contractile potential (strength) and endurance (repetition). Proprioception is obviously sensory feedback, but it's also knowing what 'doing it right' feels like. If you don't know what 'right feels like,' you have no reference point for when you're doing it wrong.

From there I’ll proceed through that workflow I mentioned earlier - Core > Interfaces > Extremities. Whether I test the shoulders or hips first depends on the movement, and the same with upper and lower-body extremities. If it’s a deadlift I’ll look at the hips first. If it’s an overhead press I’ll look at the shoulders first. It’s rare that I’ll ever get to the extremities. Almost everything tends to be a problem with the core or the intefaces.

For the glutes I’m looking at the order of contraction and the ability to maintain contraction. The order of contraction should be glutes then hamstrings. If it isn’t you can’t lift with your hips, only your legs and your back. If the motor pattern is faulty, the hip flexors and the hip’s deep external rotators become overactive, as do the spinal erectors.
But it’s also more difficult to contract the glutes concentrically than eccentrically, and that contraction gets more difficult at acute angles of hip flexion. This is usually why butt-wink occurs in the squat and why it looks different descending and ascending. When descending you’re combining concentric contraction and acute hip flexion, so the glutes switch off and the hips tuck under early. When you’re ascending you’re using an eccentric contraction and getting out of that acute angle, so the glutes switch on earlier and the hips come back around at a lower position in the squat.

Remediating the issue is long and boring unless you have a compex. If you don’t you can still recondition the motor pattern, but you need to begin with learning to contract the glutes without co-contracting the TA, hip flexors and hamstrings. That alone could take a couple of months. From there you have to reintroduce the glutes to different motor patterns and progressively increase those active stressors - load, repetitions and complexity. It takes a long time for the brain to myelinate those patterns and disuse the old neural networks, so it's an arduous process. The compex moves around that problem entirely because it contracts the muscle for you. The brain doesn’t seem to know the difference, but I’m happen to be proven wrong.

For the shoulders I’m looking at what muscles stabilise the scapula and the humerus, and in what order. Upon movement the scapula should retract towards the spine and compress towards the ribcage. What I see instead is the pecs and anterior delt picking up the slack. Those muscles are necessary to press weight overhead, but because they’re also being used to stabilise the humerus they can’t let too much tension out. So people create some pretty gnarly movement patterns to work around the issue. A common one is extending the spine to finish an overhead press.
Retraining the scapula without a compex is an absolute fucking nightmare because it’s very difficult to teach someone how to do it deliberately, or to tell them what ‘doing it right’ feels like. The cool thing with the compex is that once it’s contracted the muscles once, people have a lightbulb moment where they know what it should feel like and can do it a bit. After that the challenge is to get them to do it deliberately without co-contracting pec minor, at least in the initial stages. Reconditioning that motor pattern without a compex takes a lot of time and patience, as well as some creative exercises with a band. To begin with I’ll give them some homework exercises to practice moving the scapula without pec minor and we’ll use band work in the gym. The band work revolves around distracting the humerus and using the rhomboids and traps to retract the scapula. But you’ve got to be very careful with the angle of pull so that you’re biasing the right muscles.

A better option though is to screen clients and athletes before they start work. I ended up creating my own, borrowing some techniques, creating some, and repurposing other exercises. They all fall into that system I mentioned earlier - provocative testing, passive and active stress. It’s not meant to do anything other than limit mistakes and inform exercise selection.

This link will take you to an article I wrote about motor patterns and arthrogenic muscle inhibition. There should be two other parts on there. https://thecriticalcoach.wordpress.com/2015/01/21/joint-injury-rehab-bill-knowles-part-one/