toss this around

 - - - -

There's been some debate regarding whether or not a pitcher should be doing long toss. Each side has both sports medicine and traditional baseball "experts" claiming how wonderful or terrible it is to throw on a high arc for maximal distance versus direct line throws of shorter distances.

If this seem like a silly debate of minutia, it is. There are a lot of "big picture" issues that simply cannot be skipped. As I wrote about here, the data indicates that there are more important considerations, like the number of months of rest from throwing per year, total throws per game, innings pitched per year, and about 20 other factors that pitchers should be considering.  Intelligent training of the entire body is the best way to spare the throwing arm.

That being said, with 6 out of 10 pitchers sustaining a significant shoulder or elbow injury, athletes, parents, and coaches need to give some attention to the minutia.

Well, authors of a recent study advised against long toss for maximal distance based on their observation that the mechanics of long tossing are different than throwing for shorter distances, and that long toss throws cause greater torque at the shoulder and elbow.

From this I conclude, "Oh really?"

Long tossing, like, where the athlete takes a few skips and a crow hop and reaches way back, orients his chest to the heavens, grits his teeth, and launches the ball out and up... The "kinematic and kinetic" values of THAT are different than throwing from a mound? THAT move, which creates higher arm speed, causes more torque on the elbow and shoulder?

For reals?

Well, if we're talking about returning to rehab after an injury, it's pretty clear that you need to be careful. This study did affirm that long toss is probably not a very good idea for rehab. But lets talk about someone with a relatively healthy arm who wants to gain velocity and total body rhythm that actually helps decrease strain on the arm.

The  measured differences listed by the authors, like higher arm speed and the mechanical variation from pitching off the mound, these are exactly why long toss is a valuable component of training. Pitching with high velocity and good control is total body effort. Throwing should occur in three planes of motion {rotation, front to back, and side to side), not just linearly (front to back).

I think long toss is one of the best ways to "fix" pitchers who are all constipated in their delivery, "arming" the ball with a robotic linear pattern or without transfer of energy from their legs. It's a great way to create some sport specific strain that's a slight variation from the forces and trauma of pitching in games.

With pitching, even in the best case scenario, micro-trauma occurs throughout the entire upper extremity. The risk of injury certainly goes up if pitchers simply add any type of maximal effort throws to an already over stressed arm.

Like just about everything, long toss can be overdone and used inappropriately. But lets at least allow for long toss until we get more evidence that all pitchers should never long toss.

  - - - - -

Training for Power (II)

Power to the people

For athletic speed and power, should you lift weights or do plyometrics? The answer, without a doubt, is BOTH.

The specifics depend on you; your strengths and weaknesses, your current abilities and goals, and the demands of your sport or other activity. Of all those "depends," I think the best place to start is with your weaknesses. Identify your weaknesses so that you can set specific goals and start the journey, building off your strengths (for almost everyone already knows their strengths).

Many people fail, er, "workout routines" fail because they don't put much thought into that process. Or they try to accomplish two or more incompatible goals at once. Or they try to accomplish too much too quickly.

Typical situations

An 18-year old soccer player who would like to gain some strength and power over the summer should be doing strength training and plyometric training. Apparently, some coaches imagine that it's possible for active young men to gain 10 pounds of lean muscle, increase their peak speed and power, while also simultaneously achieving peak conditioning for distance/endurance type running. All this in 80 days of summer heat.

Regular intense 50-minute jogging gives the body numerous signals that are in direct contradiction toward the goals of increased strength and power. For soccer players, there is (questionably) a time for long distance running and grueling repeated 800 meter sprints; it's called the pre-season. Trying to achieve and maintain that type of peak "conditioning" year 'round is insanity.

Muscles with more cross sectional area (thickness) can produce more force, which can then (via plyometric and skill specific training) be applied to bigger and better skills that impress. It's the power that awes crowds. Endurance in team sports is important for sure, but nobody ever became elite because of their endurance. If you're carrying around an extra 10 pounds of powerful, opponent smashing muscle and get a little tired at times when there's no natural break in the action, well, that's why they have subs and time-outs!

Likewise, a person who's trying to drop a few pounds the right way, feeling a little too solid and slow, also needs to be doing BOTH strength training and plyos, with a bit more conditioning focus. Whether you'd like to do long drawn out cardio is up to you. You certainly don't have to, especially if you're able to eat non horse-sized amounts of mostly unprocessed foods.

Training program ideas

Whatever your goals and weakest link, be you male or female, footballer (US) or footballer (UK), the overall pool of strengthening and plyometric exercises that you really need are not all that different.

Just about everyone should include a variation of the deadlift and/or squats and a variation of loaded unilateral (single leg) work like lunges or single leg squats. For the upper body, there should be one horizontal and one vertical "pulling" exercise as well as one good horizontal and one vertical "pushing" exercise.Throw in some specific corrective/mobility exercises and core work and you have a nice program on your hands.

Yeah, that just about covers it.

Simple. Effective. I like it.

Template for strength/power focus:

Day 1: Bench press, deadlifts (or deadlift variation), and single leg squats, each performed for a few warm-up sets and then 3 to 4 sets of 4 to 6 reps.

This workout is very simple and miserable when you work hard on each and every work set, and see to it that, little by little, you are adding resistance to the movements. Finish with two or three circuits of an ab exercises (leg raises, ball tosses, or planks) coupled with an "arm" exercise like narrow grip bench or dips.

one or two days off

Day 2: Conditioning/plyo day includes 8 to 12 short (~40 to 60 yard) sprints followed by a series of double leg vertical jumps (Chairs!!), single leg side and forward hops up an incline.

one or two days off

Day 3: Incline dumbbell press, weighted pull-ups (or lat pulldown), seated overhead barbell press, and dumbbell rows, each for 3 or 4 sets of 6 to 10 reps, followed with a "finisher" of 20 reps squats. One miserable, I-hate-lifting-and-don't-even-want-to-look-at-a-weight-for-a-few-days, set of squats.

That's about it for the week. Bilateral and unilateral leg work, horizontal push and pull, vertical push and pull, a little arms and abs, all in less than 4 hours of training per week. It would take more like three if you would quit your yackin' between sets and if you don't have to get your kids a snack and a catfish bucket and off the swing and so on.

Template for power/conditioning focus:

Here we may do something similar but pick up the pace and add one day of conditioning for a total of 4 rather than three workouts for the week. That may look something like this.

Day 1: Deadlifts (variation) coupled with bodyweight dips, bench press coupled with single leg squats holding dumbbells (4 sets of 4 to 12 reps each). Finish with 3 one minute bike intervals coupled with a core exercise like medicine ball tosses or prone roll outs (praying mantis).

day off

Day 2: 6 to 8 80 to 100 yard hill sprints. Finish with corrective/mobility exercise and maybe some upper body plyometrics like medicine ball tosses, clap push ups, etc.



The perfect fitness equipment.

day off

Day 3: Chin-ups (or lat pulldowns) coupled with incline dumbbell presses, overhead barbell presses coupled with dumbbell rows, bicep curls coupled with a core exercise, and either Farmers Walks (carrying heavy dumbbells for distance) OR 20-rep squat finisher.

Day 4: Short sprints, plyometric hops and jumps (see day 2 of the other template), and possibly finish with some jump rope intervals or "X-drill" multidirectional short sprints.

So you're talking about 4 to 5 hours of exercise that counts. The weights involved in the conditioning focus template will obviously have to be less than those used when really pushing to increase resistances in the strength/power template. But please, don't ever go in wtih the mindset of "light weights and high reps for toning." You are still working hard and relatively heavy.

The rap

That's really it. There's no magic beyond semi-intelligent planning, consistency, progressing slowly with the long-term in mind, and a little attention to detail regarding exercise selection and execution. Remember that this is a template, and most everyone will need some variation to suit their specefic limitations and goals. Most people are suited for some movements better than others. Many people who say "I can't squat, press, deadlift, etc...) simply need a few weeks or months of corrective work. A trained professional may help with some of the details, and most people do fine with just a little guidance.

Yes, that's my own secret workout formula for athleticism and general neatness. You got it for the cost of some time. How neat is that?

  

The ab loung is a great piece of equipment.
If you pick it up and do lunges or farmers walks or press it overhead.



 - - - - -

power for living

 - - - - -

Life demands power, the kind that doesn't necessarily corrupt.

Being strong (able to produce a lot of force) is good and all, but most physical activities both on and off an athletic field require the ability to generate a high amount of force quickly. When it comes to everything from dunking a basketball to dancing the night away, carrying groceries up stairs to shoveling tanbark to catching yourself from a stumble, the name of the game is power.

Power is the rate of doing work, or [Force X Velocity]. As you can see, being able to generate more force and being able to move faster both factor in to generating more power.

Plyos: a nervous system tune-up

Plyometric training is the best way to "teach" the brain how to coordinate the body and body segments to rapidly generate high forces.

What's considered "plyometric" is definitely relative to the individual, but movements like various sprints, step-ups, jumps, medicine ball tosses, and lunges are typical. In the back yard we push the limits of our horizontal and vertical leaping abilities with single- and two-leg exercises. In the clinic I spot older folks as they attempt to rapidly lunge and reach various directions, then recover to their starting position.

You really don't need much space or equipment for plyometrics. At home I have some gravity, ledges and graded surfaces for lower body training. And CHAIRS (see video)! We sporadically attempt higher level upper body plyometrics (which includes abs!). This usually involves "clap" push-ups, a medicine ball for various tosses, and a sledge hammer for hitting the big tire over at the neighbors.

If you're older and haven't trained in this manner, go ahead and test your body control with a simple set of lunges. If you're generally young and fit go ahead a try a few circuits of, say, 10 split jumps coupled with 5 to 10 clap push-ups*.

Briefly on resistance training

Resistance training is still essential for pretty much every training goal that you can think of. The right weight training (i.e. not isolation exercises seated on fancy chrome machines) also fine-tunes the nervous system, primarily for body control and stability. And of course, weight training is by far the only thing for body re-composition. 

Getting jacked with bigger muscles is one thing, but resistance training is also critical for conditioning/weight loss purposes. I cannot understate how important it is in both the long- and short-term to "signal" the body to retain muscle and strength while you're in a calorie deficit. Lose the body fat and retain the magic-magic-magic.

I've said it before, but losing muscle when you "diet" sets you up for a frail and hungry cycle that usually ends with you either giving up or eating bland salads three meals per day and still not feeling very happy about the condition of those pesky "problem areas."

All we have is time

Not knowing the outcome. Pushing it. THAT's the moment.

The best part is that all of this really doesn't take much time. Cut the fluff, pin down a few goals, and get moving toward a fit, functional body. I train less than four hours per week and play hoops for about an hour once per week.

It's a matter of choices. This stuff is sort of a hobby that happens to be compatible with my profession. I live in a pretty modest home, drive a 98' Subaru to work, and have a pretty crappy tool collection. But I could care less. Today I wasn't worried about being in debt or hyper cleaning the house and I enjoyed plenty of time with my family and friends and I jumped over a freakin' 57-inch chair.

Do you know how far along those things will carry you into a productive, truly generous work week?

Training Plan

You do need to start slowly and give consistent effort and discipline over a long period of time. Training the entire body with "big" beneficial movements requires patience and some attention to detail. If you get bored or injured or stop prioritizing time for your physical well being after 6 weeks, well, now there's really no excuse.

You would have plenty of time and energy to do both strength training and plyos if you would step away from the seated leg extension/curl/abduction/adduction machines and cut back on all the random cardio and "split" body part routines.

Your shoulders are involved with almost all back, chest, tricep, and bicep exercises, as well as most squat and deadlift variations. So please don't tell me that you packed work clothes and toiletries and woke up at 5 a.m. and drove through traffic to do a  "shoulders and biceps" workout. While this does qualify as disciplined effort, it's not exactly practical or effective.

Part two of this will include some specifics geared more toward athletes, including a sound training template.

 - - - - - -

Split jumps - Begin with one foot out in front of you and one behind you. Jump high and land with the opposite foot in front/back. Upon landing, jump again, alternating which foot is in front/back. Start slow and pay attention to knee alignment. 

Clapping push-ups - Like a push up, but do a quick turn around at the bottom and throw your upper body off the ground so you can clap your hands, land and begin the next push-up.

 - - - - -

chairs !!!

Researchers are beginning to hypothesize that there's a link between "forward head posture" and sitting around most of the day with your head slumped forward.




  - - - - -

So You Wrenched Your Ankle (part II)

Part 1 - what to look for right away.
 - - - - -

You have rested, iced, and elevated your bum ankle for a few days or weeks, depending on the situation. It's likely still swollen, but you're at the point where you can bear weight on it. You need to get moving again. The first thing is to try some light stretching of the ankle to recover dorsiflexion.

Place a belt or towel under the ball of the foot and pull back to apply more stretch.

Make sure the feet are "aiming" STRAIGHT toward the wall, not flared out.

You MAY need a little help

As mentioned in part one, look for pinching when the ankle is stretched in this manner, or with real life movements like squatting or walking down steps. If the motion feels blocked and there's pinching toward the front of the ankle rather than a pulling/stretching feeling in the back of the calf and ankle, you probably should be evaluated by professional. This is a very common, stubborn problem after an ankle sprain that won't show up on an X-ray.

A skilled doc, trainer, or (yes) PT should be able to determine if there's excessive laxity (the ankle ligaments have been overstretched or torn) that would warrant further imaging or a period of immobilization. They can also perform a trial of manipulations aimed at restoring normal spacing between the top foot bone (the talus) and the lower leg bones (the tibia and fibula). 

Take dorsiflexion seriously. Lacking this movement causes you to unconsciously shift strain to other areas on the same leg or to the other leg. Chronic ankle dysfunction can be particularly hard on the knee and low back, and researchers have measure differences in joint movements and muscle activation all the way up into the trunk.

The reccurance rate for ankle sprains is somewhere between 50 to 70%; pretty horrible numbers. My friends and I have definitely walked hobbled down this road. Exercises and braces are your first steps toward better...steps.

A word on exercise

This is one time when exercises I like to make fun of are actually called for. In the weeks to months after ankle (or knee) sprain, you should be working on balance and controlled movement on both stable and unstable surfaces. We won't get into the specifics of exercise progression right now, but here's a quick screen for sprained ankles:




The intermediate phase of ankle (and knee) rehab is one time when goofy squats and reaches on unstable surfaces are actually beneficial and I shouldn't make fun of you for doing it. Unless, well, yeah, this guy.






-Try to balance on one leg with your eyes closed - no wrapping the "up" leg behind the balancing leg.
-Try to do a full toe raise on one foot - no holding onto anything with your hands. 
-Try to stand on an 8 to 10-inch step and lightly tap the "good" heel forward on the floor - don't transfer your weight, just lightly touch the floor.
-Do a deep squat with your feet straight ahead and heels staying glued to the floor and your knees staying over your toes and your chest staying up without a forward trunk lean. 

Compare your injured side to the "good" side. People often feel wobbly on their injured side, or have to use different movement strategies due to weakness and inflexibility.

A word on bracing and shoes


The absolute BEST device for stability when you need stability, and explosive movement when you need explosive movement, is a primed and efficient nervous system! The best way to shut down all your lower leg muscles and hinder the ability of the brain to fine tune movement is to lock the foot in a concrete block of a shoe and brace/tape your ankles.

Many studies have examined the performance effects of wearing ankle braces. Although there's some conflicting findings in this area, recent work from the Division of Orthopedic Surgery at the University of Utah (and a few others) showed that ankle braces do decrease vertical jump height, broad jump distance, and maximum sprint velocity.

Other studies specifically address the price your body pays for increased ankle stability. Braces and tape at the ankle allow for less movement and sensory feedback from that joint, removing a large part of the shock absorption system of the leg. This leads to measurable increases in shear strain and torque (twisting strain) at the knee. Protection of the ankle may cost you at the knee, over time.

We do need to reach a balanced perspective, however. Sometimes athletes need to get back to the game sooner than later; before their ankle is completely recovered. Many sports involve hard cuts on uneven terrain and/or lanky athletes jumping and landing all over each other. In that instance, braces and tape just plain make sense. They may be the lesser of two evils.

The athlete that makes a living out-running, out-jumping, and "out-cutting" people should consider taping or bracing WITH an end-point in mind - maybe three to six months as they rehab in controlled environments. If taking a few percent from sprinting or jumping performance really doesn't mean that much, brace or tape for nine months to a year. But there should be an end in mind, for the sake of your knees, hips, and back. 

Surgery is sometimes needed. Rarely. I have a few specific stories on this for anybody who wants to hear, but this is already too long. Maybe a part 3 or maybe not.

 - - - - -

"Ron"

 - - - - -

He appears headless from behind. Literally. Ankles plantar flexed. Knees flexed. Hips flexed. Kyphotic thoracic spine, flexed. The whole thing, orthopedic nightmare, culminates in a neck and head stuck forward like a weepy Dr. Seuss tree.

We've been working with Ron (fake name) for months. He wasn't always like this, not before weeks of bed rest for a pulmonary complication left every joint fragile and locked tight, perfectly fit for a soft couch.

Lay him down on a treatment table. Massage the neck muscles. Apply traction, and pull that baby back. Pressure under his jaw and pull back. Out and back, out and back, out and back. Crank on the ankle and lower leg while pushing down just below the knee. Throw a whole leg over the therapists shoulder and lean in, again bringing force to straighten the knee. Drop the leg over tables edge to open a hip. Extend and rotate the spine.

Each position is held twelve or twenty times. Every single repetition feels like stretching a piece of wood. Who knew these Dr. Seuss trees were oak? 

The entire sequence is repeated on the other side.

More than half an hour later, Ron has gained some mobility. Maybe five or fifteen degrees, depending on the joint. It all adds up to a slightly looser, longer Ron. It's time to rise. In less than a minute, about one fourth of the time it takes him to gain his feet, it all falls apart. Ron strains hard to look you in the eye, standing right in front of him.

The therapist strains hard to look Ron in the eye. It hurts.

Ron needs to gain strength and postural stabilization to maintain the effects of all the discomfort that he (and the therapist) just endured. It is easier to climb Everest. His posture has annihilated various braces and corsets that we have tried.

Kim, my sweet assistant, treats Ron like a king. Jokes with him. Patiently waits fifteen minutes for him to walk from the rest room to the pulley system he tugs on. Purchases Easter eggs from Ron's steadfast, beautiful wife.

I think Kim prays for Ron more than I have.

Ron takes it in stride. Slow, short stride. He's awfully kind and gentle for someone that spends so much time looking at the floor. Ron's posture isn't the only thing that other patients notice. He's joyful, even.Yes, king Ron.

Ron chooses to keep pushing. Rehab gives him hope, if nothing else. I don't think that qualifies as skilled, medically necessary health care. Surely we are part of the reason why Ron can live independently at home without other medical issues. I don't feel too bad about those Medicare dollars.

We push with him, fighting gravity with his frail body, fighting despair with his strong mind. He'll eagerly show up for the fight and enjoy the therapists efforts and company, for as many days that God and Medicare "authorize."

I tend to think that number may be one and the same.

 - - - - - -

So You Wrenched Your Ankle...

 - - - - -

You slipped, got hit, or came down on an uneven surface. Your ankle twisted, things popped, bones jammed and gristle disengaged. You dropped and rolled around gritting your teeth. 

Someone assisted you back to your feet, suggesting ice and compression and it will be fine in a few days. You stood there, mostly on one leg, wondering how the first step on your blue balloon is going to be. Someone else advised you to get an X-ray. Another bystander announces that the ankle will never the same. 

You were hoping for less advice and more Advil.

 

You, my friend, have wrenched your ankle. Don't feel too bad - it is estimated that about 23,000 other people in the United States have wrenched an ankle on the same day.

It's probably going to be fine. But maybe not. Really.

PTs get to deal with this.

If you can bear some weight through the injured foot and it's not highly sensitive to moderate pressure to the inside or outside of the lower leg, you don't need an immediate X-ray. I've seen ridiculously huge ankles displaying all colors of the rainbow recover fairly well in a week or two. Had a few of those myself.

I've also seen simple ankle sprains go from acute pain to chronic nag in no time. Had of few of those myself. It's April and I'm just now getting over an ankle sprain in October. The truth is that until you have the pain just a bit under control and some of the swelling down, it's difficult to determine if an ankle sprain is going to cost you days or months. 

Evidence of two mistakes:
Falling off my mountain bike and getting a Soundgarden tatoo.

Since about 15% of ankle injuries involve fractures, if you can't bare much weight on it two or three days later, you should probably get an X-ray. Fractures require (at least) a period of immobilization before moving on to much of what's described below. Otherwise, it's clearly beneficial to work on a few things sooner than later.

The typical ankle wrenching causes persistent swelling. Supporting muscles and ligaments loosen. The result is vastly decreased proprioceptive (positional sense) feedback to your brain, which further weakens muscle drive as you unconsciously unload that leg. Researchers have measured altered movement patterns all the way up through the hip and trunk in people with a history of chronic ankle instability.

 The "high" ankle sprain involves separation of the lower leg bones as the talus (the top foot bone) is essentially driven up between them like a (wood) splitting iron. This injury usually has a longer recovery period and  different course of treatment than the typical inversion sprain pictured below. 

Early movement has been demonstrated to be helpful in many ways. Use common sense, of course. Don't go jumping and running around on a recently wrenched ankle. But that same ankle probably can and should be doing non weight bearing stretches and active movements that help restore mobility, decrease swelling, and add enough strain (but not too much) to stimulate a strong repair of collagen and other connective tissue. 




The typical inversion sprain.

MRI studies have shown that with even modest inversion sprains, the talus and outer ankle bone may slip forward, causing  some motions to increase and others to decrease. You're left with a predisposition to more ankle sprains and a mechanical blocking of movements needed for everyday life. 

One of the best indications of displaced ankle bones and loose ligaments is a pinching feeling in the front of the ankle when flexing the knee out over the foot (ankle dorsiflexion). If you get this anterior pinching after some of the swelling subsides, you really should see someone skilled in hands-on manipulation to address this. 

As far as how soon to start pushing the envelope with higher level exercise, I often go by how much pain and laxity (looseness) is present with ligament stress tests. If those tests cause a lot of clunking around and pain, then a more conservative pace is needed.

The only option that doesn't involve a lot of whining is to take a break, do some corrective exercise, and follow a structured progression of impact activities.

The recurrence rate for ankle sprains is anywhere from 50 to 70%. What do helpful "higher level" exercises look like? Do you need to tape, brace, or buy different shoes? Will there be more pictures of nasty, probably stinky, swollen feet? 


See part 2 for details.
- - - - -