Clinical rationale and application of the car push

"Really? And you're paying them to do this?"

  -Dr. Unger our back-door neighbor at the office.

Ah, the car push. Ask anyone who has actually completed a car push and they will tell you that it's well worth the price. You can have your hour on the elliptical, your "shoulders and tri's" bro-split weight session. I'd rather push cars.

"-Gasp!- I could never do that."

"I'll just strain something."

"That's for people who are really into it. Like hard core fitness competitors and nose tackles."

Is this activity justifiable as performance training? As rehabilitation? Let me tell you that YOU TOO will feel terrible and then outstanding for having pushed a car. It's much easier on the body than you think. There are no kinetic and kinematic studies, and the verdict is most definitely not in. That doesn't mean you can't dress it up as a therapeutic activity!

The car push is a low skill, open kinetic chain, isotonic power-endurance activity that provides the rare combination of very high intensity with low impact. The lower extremities provide reciprocal triple extension of the hip, knee, and ankle. The circumferential core muscles co-contract to resist trunk extension and provide a stable base for the scapula and upper extremities.

There. Does that make it more acceptable?

But seriously, I've witnessed what a few good car pushes can do. I've pushed and pulled various weight sleds, and nothing comes close to the feeling of pushing a car. The muscles engaged include, well, the body. The only inactive muscles during a car push are (possibly) the biceps and forearms. The legs burn everywhere, the lungs expand and abs tighten.

But don't take my word for it. Doing is believing. Here are a few tips on how to effectively push cars for functional awesomeness.


Step 1: Get 'yer car.
Step 2: Put 'er in neutral
Step 3: Push.

THE LONG VERSION (Yes I'm giving away my "training secrets" right here).

-The grade of the road is the most important variable. A nearly flat (or downhill) roadway is actually easy once you manage to overcome the resting inertia. But a -slight- uphill on the order of 2 to 4 % is just right. A car push track that's a bit on the steep side can be easily accommodated by having two people push the car at once.

-Make sure your shoes are on tight and the road is free of snow and gravel. You will walk out of loose shoes.

-The weight of the vehicle matters, but far less than you would think.

-A slightly sloped, sparsely used parking lot is the ideal location. Highway pushing is not recommended.

-The weight of the pusher is important. Simply being heavy or light helps and hinders a car push more than you would imagine.

-Strength athletes will fly and run out of steam quickly. Endurance athletes will move slow and steady and ultimately fail early. I've had the best results doing two to four efforts that demand 20 to 60 seconds of intense pushing.

Car Pushes at the Bonny Lane Club (my home) are like a right of passage. Those who complete their first sets of car push get a surprise that I have yet to implement at the PT clinic!

                                                             HAPPY PUSHINGS!


Pitching Paradox Part 3: (S)Train Those Shoulders

In Part 2 I hoped to impress upon you the idea that traditional "arm care" like the Throwers Ten may be of some benefit but is quite limited in scope. Since throwing is a high velocity, asymmetrical, total body movement, the best a pitcher can do to keep his arm healthy and strong is to train the entire body as a functional unit. The specifics of what such a training program would look like is somewhat variable and should be based off a detailed assessment.
Pitcher one needs to improve his scapular protraction and anterior pelvic tilt if he wants to stop overloading the anterior shoulder. Pitcher two needs to establish hip strength and internal rotation if he is to stop straining his lower back. In order to build velocity, pitcher three needs to build leg and rotational core strength, and learn how to decelerate on his lead leg.

These are a few real-life examples of what an assessment can tell you.

In this installment, we turn our attention to the question of exactly what is and is not safe and beneficial for pitchers. Since most (but certainly not all) pitching injuries are related to the elbow and shoulder, I'm going to focus in on a few of the most common methods of training the upper body.

Should pitchers bench press? Overhead press? Avoid training the upper body at all?

The Traditional:

The traditional approach to training pitchers has been covered in the intro above and in part 2 of this series. Run poles, throw, mindlessly rep through some general tubing and upper body resistance work. The Throwers 10 is likely better than doing nothing at all. Wait, the Throwers 10 includes seated dips? Like, on of the best exercises to provoke and precipitate anterior shoulder instability? Never mind, I take that back.

Suffice to say that we can and should do better than the Traditional approach to preparing pitchers.

The Lift Some Weights, Bro:

This mentality treats everyone like a fitness competitor and fails to consider the demands of pitching and the common patterns of adaptation in a pitchers body. It may work well for some, will injure some, and be sup-optimal for many.

Upper body exercises that are (questionably) acceptable for the general population may not be a great idea for pitchers who acquire multiple structural and dynamic adaptations from years of throwing. Loading up resistance with faulty movement patterns only leads to further ingraining of the poor pattern.
This is not acceptable training for most athletes, much less pitchers.

The Guillotine Press, where the elbows flare and the bar is lowered to the front of the neck.
Great mass builder for the "upper chest." Who needs a rotator cuff, anyway?

The Do Not Disturb:

The mentality is to be careful with a fragile 38-year old Major League All-Star who has accumulated years wear and tear and various asymmetry. For the far majority of athletes (all those without the million dollar contract) paralysis of analysis gets in the way of any training effect.

Treating every 15-year old with a desire to pitch as if he already has the million dollar arm with a well controlled, mid-90s fast ball is not doing the athlete any favors. All the corrective work and precaution is getting in the way of what they probably need most: getting bigger and stronger with sound fundamental movement patterns.

We don't all need to pretend that we're working on Eric Cressey's clients (many of whom do happen to be million dollar throwing arms).

The Narrow Way

The best approach to training, of course, combines the best of the elements above. Someday it too will have portions discarded while other parts are passed down.

Once again, exactly what exercises are warranted and safe depends on the athlete. A collegiate level pitcher who can already bench press 300 pounds will probably do well to focus his efforts elsewhere. A middle schooler who wants to gain weight and throw harder should learn how to bench press appropriately.

As they level-up over the years, many pitchers do develop muscular and joint imbalances that predispose them to injury while pitching. Most of the Olympic lifts are just not worth the risk to this population. Pitchers (and anyone who sits for the majority of the day) should also avoid resistance machines that lock you into a seated position with a fixed line of movement (like the seated overhead press or abduction machines). They should use great caution with dips and overhead barbell presses (though not avoid them at all costs).

The details of precisely HOW the exercise is performed also is relevant. Even the safest of movements can be problematic or ineffective if appropriate form and control is not attended to. A pitcher with tight lats and a GIRD (glenohumeral inernal rotation deficit) may want to be careful regarding how he does simple activities like pull-ups and push-ups.

Landmine Press: YES!

For some pitchers, a standing barbell press may not be out of the question, depending on what their movement screen looks like. One of my favorites is a standing unilateral dumbbell or kettlebell shoulder press where the shoulder can be maintained in a neutral position. As with all standing and kneeling presses, athletes are naturally prohibited from using any more weight than their hips and core muscles can support.

Lastly, I find it helpful to remind the more motivated trainees that they are using weights as a tool to be better elsewhere, not simply for the sake of lifting weights. This helps them check their ego and gives more incentive to train with intensity, intelligence, and purpose.

Factors favoring use in pitchers:

unilateral lift
neutral arm position
core muscles engaged to support
upper arm does not extend far past the torso
free resistance that must be controlled

Factors favoring avoidance in pitchers:

bilateral lift
pronated (palms forward or down) arm position
upper arm goes far into extension or horizontal abduction
seated or supine (less core engagement)
machine-based (locked into one movement arc)

- - - - -


Awesome is something you DO

Everyone can look awesome. That's just how it is with appearance.  Looking good has far more to do with confidence and a good camera person than with physical features.

Add a rain machine or some other creative bend to quality lighting and contrast, filter through thousands of images, and viola, you have a rock star. You ARE the rock star.

Now it's particularly interesting that the man behind these outstanding photos of everyday people repeatedly states how important it is to inspire confidence. He only guided his subjects to do things they are good at. He encouraged them and said they look great.

Confidence is undervalued. It doesn't come from a pill or keeping dietary rules, a certain body weight or percentage of body fat. It's the real treasure attached to effort. There are no shortcuts or confidence hacks. It comes with showing up win or lose, taking on challenges with an honest effort, and learning about yourself.

So do not worry about how you look, your sagging this or thin that. For everybody wants to be awesome and nobody is perfect. But instead focus on the process, the challenge, doing the right thing, the hard thing, on a regular and consistent basis.

Being awesome will always be simple to understand and hard to do.

Get your schedule and priorities in order. Learn how to lay a foundation of quality movement so that you don't hurt with every effort. Skip the diets and eat simple unprocessed foods 80% of the time. Do resistance training two to three days per week, and if you're relatively sedentary add 2 days of "cardio" or another physical activity. Get that un-assisted pull-up. Run 5K in under 20 minutes. Squat your bodyweight for 20 reps.

Keep at it for a while.

And by the time you can do something outstanding, something that took consistency and effort to achieve, you will have found gratitude for a sit on the ground and for the air in your lungs. You will own plenty enough confidence that you truly don't give a damn about your imperfect anatomy.

Holistic beauty...that's another thing.


The Great Pitching Paradox (part 2)

Part one introduced what I believe to be the greatest paradox that young pitchers face: two of the most important qualities for being a seasoned and effective pitcher (innings pitched and arm speed) are also two of the greatest risk factors for injury. I also briefly discussed some important considerations for pitching mechanics. While pitchers should not be forced into some cookie-cutter model, we should seek to identify and address known "red flags," especially when there is a chronic problem.

In this installment we address how a pitcher may train their body in order to improve the chances of remaining uninjured. What can you do off the mound, if anything, to throw harder and remain injury free?

The Throwers 10  use to be STILL IS commonly recommended as an effective means to increase performance and prevent injury. The program was designed by Dr. Craig Andrews and his team at the  Andrews American Sports Medicine Institute. It is my opinion (and experience) that we can and should do a lot better than The Throwers 10.

Take a quick look at the Throwers 10 here.

"Bro" doing shoulder internal rotation. 
I'll readily admit that there is a time and place for the Throwers 10. The program could be done in part during warm-up drills, as filler between more intense training activities, and in the early and intermediate phases of rehabilitation after an injury. But to my knowledge this has not been validated as an effective way to prevent injuries or increase performance in pitchers. And I'm certain that this is nothing near a comprehensive training program.

Pitching is indeed a fairly extreme activity. Baseball has been grandfathered in as a traditional sporting event rather than X-games material. But consider the demands of pitching.

-High intensity: In most instances, pitchers put forth maximal effort on every repetition.

-High speed: Rotational velocity of the shoulder approaches some of the fastest movement seen in all of sports.

-Total body effort: The shoulder complex and arm are the final moving segment of a functional whip that began with the generation of force from the ground.

-Asymmetry: Throwing is an inherently asymmetrical task that, when left unchecked, can contribute to side-to-side differences that progress over time.

-Repetetive: The intense, high velocity, asymmetrical, full body effort is typically repeated 80 to well over 100 times per outing, one or two times per week, for up to 9 months out of the year.

As I previously mentioned, it's no wonder that pitchers have always been plagued with injuries. We should consider re-framing the conversation to the "staggering number of pitchers who remain uninjured."

And now back to the topic of training and The Throwers 10. Do you truly expect that a handful of relatively low intensity, isolated shoulder/arm exercises are going to have much sway over what occurs in the heat of battle? I will grant that these exercises can be effective (IF properly coached) as corrective exercise to help form new movement patterns. But the light, controlled, isolation exercises of the Throwers Ten need to be translated to the high force, rapid, total body movement of throwing. It doesn't just magically happen. We should not expect that pulling on tubing and waving around light dumbbells will automatically translate to throwing.
500-pound bench press not necessary.

It's like saying that high level snowboarders should do foot exercises in case they fall from an extreme height.

On the other hand, some athletes (and personal trainers) put themselves through rigorous body-building type training routines. Often times these athletes train muscles rather than movement patterns, and end up with a less than efficient carry over to the demands of throwing. The common practice of pitchers running "poles" (long submaximal sprints) to condition the legs is yet another example of a challenging yet non-specific training method that holds little value to keeping strong and healthy on the mound.

Yes, the legs need to be in top shape! But running poles is far from the best way to ensure that the legs are able to do their prime job of generating and later dissipating the high forces on the mound.

What I'm suggesting is a detailed, total body training program that addresses the athletes individual structure and function. In general, pitchers need to train smart and hard to make the entire system efficient and resilient. The specifics of exactly how the athlete may achieve this depends entirely on the structure, function, and other needs of the individual athlete. This would include looking at passive joint flexibility as well as active multi-joint mobility, strength, and stability. Where is the athlete tight or weak? In what ways does he compensate for poor posture, misalignment or improper positioning?
YES-Bridging the gab between throwing and "small" rehab!

There is simply no substitute for taking the time and effort to have a thorough movement analysis. This enables the athlete to know what to do and often more importantly, what not to bother with. Really, you don't have to do thousands of prone rows if you can execute a *quality* pull-up, barbell- or "lawn mower" dumbbell row. You need not waste your time with "pointer dogs" if you can maintain a neutral spine with a moderately loaded dead lift variation. You need not focus on bench pressing 400 pounds when you can already press 300.

I could list many examples, but nevertheless, if the athlete is seriously considering higher level pitching, just schedule the assessment ; )


The Great Pitching Paradox (part 1)

Pitchers and paradox go hand-in-hand. Here I'd like to deal with the mother of #pitcherproblems which I've written as a haiku just for flare.

They need to throw fast.
And keep their arm in good health.
Or else there's no K.

In other words - pitchers need to throw with high velocity over the long-term, but high arm speed happens to be highly correlated with injury. Of many potential variables that have been identified, injury risk is most highly correlated with , uh, more throwing, less time off from throwing, and more velocity (see all the biomechanical indicators of high throwing velocity.

Guys, really, we can quit blaming the curveball. In fact, breaking pitches are thought to carry less risk of injury due to the fact that they typically occur with less velocity relative to throwing a fastball. With less arm speed there is less strain imposed on the shoulder and elbow.

So let's revise our perspective and expectations from the get-go. Pitching is awesome and rewarding and, in my opinion, worth it. But don't pretend that it's ever going to be healthy.  Instead of reporting how many pitchers get injured, we should see reports of the "staggering number" of high level pitchers who actually do NOT get injured.

And so we naturally arrive at the question as to what athletes can do to enable them to throw hard and remain injury free. While I fear there is no escape from the paradox, I do think that a thorough mechanical analysis and specific training is the absolute best we can do.

I will first speak briefly on pitching mechanics.

All serious pitchers should study what's happening under high speed video. All pitchers and their coaches, PTs, and trainers should work with their own unique rhythm of throwing. We should avoid any of the typical simplistic and over-confident advice on "the way" to pitch, because there really is no one way. But at the same time it is important to realize that there are clear biomechanical red flags to watch out for, especially if the pitchers is experiencing pain.

These should not be a foreign language to your coach, trainer, or PT:

-Maximum knee height (absolute and relative to height)
-Degrees of shoulder abduction at foot contact
-Degrees of lead knee angle at foot contact
-Stride length at foot contact (absolute and relative to height)
-Degrees of maximum external rotation (MER)
-Degrees of lead hip flexion at ball release

*Having awareness of these values does not demand highly sophisticated and precise technology. Someone with a little know-how can easily catch potential problems areas without need of a fifty thousand dollar motion analysis lab.

**Red flags are not guaranteed predictors of injuries or performance, but identified outliers as compared to a population of healthy high level pitchers.

When we analyze things mechanically and say something like "there's too much shoulder abduction at foot contact" or "he's opening the hips too early," most coaches are all too eager to jump in and fix it. Sometimes that works, and sometimes not.

As a physical therapist, I'm eager to ask more questions. Why are the hips opening up early? Is there a reason why stride length is only 70% of height? What, if anything, can the athlete do about it?

Part 2 to come: On the Inadequacy of the Throwers Ten