Last week we discussed the importance of load ordering on squat mechanics. Had some great response to it so this week I want to discuss the analog to this in the upper extremity - pressing/pushing movements.

Here's the problem:
Are there any movements that have destroyed the human upper extremity more than the bench press, push-up, and dip? Seriously think about how many guys at the gym throw up a ton of weight on bench only to sneak away and rub their anterior shoulder in the corner. Or insidious elbow pain that kicks in after your set of dips. Nasty levels of performance and skill transfer to athletic and everyday movements - such moving boxes or blocking a defensive lineman - require proper load ordering of the joints and tissues.

There are two main foci when looking at pushing mechanics: load ordering (essentially motor control) and mobility (particularly of the shoulder into extension and internal rotation - read this post on how to improve shoulder position for pressing). Both are pertinent but in sticking with our theme from last week, let's look at load ordering as motor control is always the top priority when improving human movement. As discussed, the joints and tissues loaded first in a movement are the joints and tissues loaded most. Specifically, erroneously loading the elbow first during pressing activities (think push-ups, bench press, or moving/lifting things in the home). Just as with loading the knee first in a squat, loading the elbow first in presses (including dips - a huge elbow destroyer!) subjects the elbow and triceps complex to crushing forces that cannot be avoided once under tremendous external load. And good luck generating triceps force with such over-tension in the elbow/triceps complex.

Proximal stability of the shoulder drives distal (elbow) mobility. Without properly loading the shoulder, which is the powerhouse of the upper extremity (analogous to the hip), the elbow and triceps are unable to do their job which is to straighten the arm. The result: crushing elbow pain and shoulder instability due to your movement inadequacies! By screwing up the load ordering (elbow instead of shoulder), athletes have now lost valuable stability of the upper extremity; bleeding power and performance throughout the kinetic chain - and think this doesn't carry over to other movements of the upper extremities? Think again bro, you move how you move.  Imagine starting in a poor shoulder position as an offensive lineman trying to block a large human coming at you - less than optimal loading results in poor performance and injury potential.

Dropping into a dip, push-up, or bench press with the elbows bending first is an immediate fault. Try this yourself: set up for a push-up in the mirror. As you initiate the movement, if your elbows shoot back or flare out first, that's a fail. And once the elbows are loaded and the athlete tries to unload them, the shoulders come forward in the socket and destroy the anterior labrum and biceps tendon - not good.

Here's the solution (these apply to push, press, and dip movements):
1) Organize the spine. Midline stability is ALWAYS priority #1. Squeeze the glutes and tighten the abs. Overextension of the spine can impact shoulder position creating loss of internal rotation.

2) Load the shoulders. Imagine separating the floor with your hands (read this on how to set-up your grip width) and having the cubital fossa facing forward - basically get your elbow pits facing forward. This will stabilize and activate the external rotators, helping to optimize the position of the shoulder in the socket prior to the movement.

3) Drop towards the floor with forearms vertical. This is huge - just as you'd keep your shins vertical during squatting, you must keep your forearms vertical to prevent dangerous elbow forces and over-tensionng the triceps complex. The athlete should think about pulling the body towards the floor/bar to load the shoulders first. Just as with squatting, the first 6-8" of the movement is crucial. The body should move forward and over the hands/forearms to keep the center of mass over the hands and load the shoulder (and unload elbow and wrist). Athletes tend to drop straight down over the hands, causing the elbows to shoot back and breaking the vertical elbow rule. Instead, the body's center of mass should move forward as you descend to maintain vertical forearms (note the differences in the relationship of my center of mass in the pictures above). This optimal position also helps to improve the concentric (or 'up') phase of the press and improve movement consistency and repeatability as the triceps are able to function as an elbow extensor without being over-tensioned.

4) Box push-ups in which a box (such as a shoe-box, phone book, etc.) is on the floor between the athlete and floor is a great way to teach the first 6-8" of the movement. Motor control is huge here and that initial loading is crucial for optimal movement. This also allows adequate gradation depth of the movement (can do the same for dips, bench, etc. - get creative) to progress the athlete with emphasis on the initial 6-8" of the movement. For athletes that struggle with this, I will have them practice creating an actively stable shoulder at the top of the push-up, dip, or bench prior to even initiating the movement.

Here's the bottomline: athletes must be able to appropriately load order ALL movements and the upper extremities are no exception. Too many athletes (novice AND "experienced") load presses/pushes/dips poorly resulting in ugly skill transfer to more dynamic environments causing broken performances and bodies. Try the steps above and post your results/thoughts to comments - let's optimize this movement!

-Seth

Any time you perform squats, pick up something from the floor, walk up the stairs, or even jump and land your body is making a compromise depending on how you initiate this movement. The result may leave you with you anterior knee pain (think Patellofemoral Pain Syndrome), glute inhibition, and poor force production. And that leaves you landing from a jump like a 6 year old, which is super lame.

So here's the problem:  The tissue or joint loaded first in a movement is the tissue or joint loaded the most. Too often we see athletes and patients (even "strong" ones) initiating squats with the knees coming forward - loading their quads instead of their high posterior chain (glute/hamstring complex). This quad dominance sets off a cascade in which the quads continue their powerful force and literally crush the patella against the knee as the athletes descends into the squat, jump land, etc. There is good evidence out there to suggest that the greater the knee flexion angle, the greater the compression forces on the patellofemoral joint - in a nearly linear fashion - and we're not really into crushing our own joints. Once the tissue/joint is loaded, it is virtually impossible to unload it during the middle of the movement - especially with an external load (think a heavy back squat).
You'll see how the athlete load orders their squat in the first few inches of the descent. Knees coming forward first in the descent is an immediate fault. By loading the knees first, the athlete is essentially rendering their glutes and hamstrings incompetent and preventing their substantial ability to not only protect the knee from gnarly compressive and valgus forces, but also greatly limiting power production and stability as you are unable to generate sufficient hip extension force (think jumping). The glutes control the hip and knee in all 3 planes of motion, rather than the quads which control the knee in the sagittal plane only, limiting their ability to stabilize and protect the knee. Quad dominance is seen often in athletes (particularly females - no wonder they are 4-6 times more likely to tear their ACL) and is a faulty movement

Try this yourself: Perform an air squat in front of the mirror. Your initial movement should come from the hip/trunk complex, not the knees coming forward. If you're knees are the first thing to come forward... epic fail. Think about those landing from a jump or descending into a squat while coming forward onto their toes - it's an unstable, weak position. Going into the squat in a poor position makes the finish even uglier: dropping vertical jump height, weakening triple extension, and killing power. Why? Because once a movement is loaded, poor muscle activation and poor position cannot be overcome! Trying to come out of the loaded knee forward position by shooting the hips back will only overextend the athlete and exponentially increase shearing forces.

The solution:
1) Prioritize motor control and emphasize loading the glutes and hamstrings first. Tilt forward at the torso to tension the posterior chain and stabilize pelvic position.  Following the load-ordering concept, at the bottom of the squat the posterior chain tissues are now under high amounts of tension having been loaded first. This allows for some highly modulated force production (i.e. a lot of oomph) and reducing forces on the patella.

A common error is to have the athlete stick their butt back first and keep the chest up during the squat descent. This faulty movement instruction can compromise spinal position resulting in overextension of the lumbar spine. A wide-open chest and overextended spine is commonly coached but woefully incorrect - causing the athlete to complain of low back pain (big surprise) during/after squats.

2) Have the athlete shove their knees out laterally while keeping feet forward to pre-activate the glutes and create torque to take up tension in the system (glutes, hip capsule, hip adductors all control the pelvis) rather than finding tension with the knees tracking forward - this unloads the knee . Think about pulling yourself into the bottom position rather than dropping into it.

3) The shins should stay vertical as long as possible during the squat, tracking forward only at maximum depth (and that's butt to heel - limiting squats to 90 deg in perpetuity is NOT normal nor natural for humans). Tilting the torso forward at the hips while maintaining a stable, neutral spine is key and will assist in loading the posterior chain first in squatting.

4) Box squats are a great way to teach and improve control of the squat as you can vary the height of the box while teaching midline spinal stability. Box squats also help to cue driving back with the hamstrings as targets are useful in motor planning and control. Just don't reach with the butt causing overextension - instead coach tilting forward at the hips and shoving the knees out to stabilize the pelvis.

Elite and non-elite athletes alike need to be able to squat correctly and avoid this "quad dominance" seen so often in athletes - otherwise you're putting dangerous forces through your knee complex and gutting athletic potential. Appropriate load ordering is critically important in both human movement and mobility exercises and can/should be applied to all movements.

-Seth

Anterior (front) shoulder pain is a common complaint in athletes and gym-goers, particularly with high-rep push-ups and presses. This problem may be a motor-control issue (poor movement pattern and muscle activation/control), but oftentimes it appears to be a positional fault of the scapulothoracic complex (shoulder and scapula). How do we know this? Improve the athlete's position and push-up performance improves while nagging pain is ameliorated. Check out the video below:

It appears that pain and poor performance during movements involving shoulder and scapulohumeral coordination are often a result of positional inhibition. What I mean is that as a result of our desk-driven, sitting on the computer way-too-long liftestyles, often the shoulder is forward in the socket and the scapula is stuck down and moves poorly against the ribs. The scapula provides a stable base for the shoulder and rotator cuff to function. When put into a poor position, such as the shoulder too far forward in the socket, the rotator cuff's ability to stabilize the shoulder is altered and movement control is lost.

Ever see someone with those rounded, forward shoulders? Yeah, that affects their scapular coordination and muscle activity and may cause shoulder impingement. By better positioning the shoulder complex and particularly the scapula which is where the rotator cuff actually attaches, you may improve activity of the rotator cuff (which acts to provide active stability to the shoulder explained here) and in turn cultivate better stability and function of the shoulder girdle.

The guy in the video above (don't worry, what I lack in genetic height is made up for with pristine movement) also has a history of an AC joint (acromioclavicular joint) sprain in which there is a separation of the clavicle from the acromion process of the shoulder blade. Because the AC joint needs to move to accomodate scapulohumeral position, this further disrupts the mechanics at the shoulder and underscores the need for improved positioning. You will see poor scapulohumeral positioning in those whose elbows fly out to the side during pressing/pushing which is typically indicative of a lack of internal rotation of the shoulder. You can see on the push-up test and re-test in the video that he is better able to maintain his elbows close to his side, indicating that the humerus is more towards the back of the socket allowing better expression of motor control instead of relying on non-contractile tissues like his joint capsule and labrum causing nasty dysfunction and chronic pain in his AC joint.

Try this technique for a few minutes (2 minutes at minimum) to improve your push-up or possibly bench press. I tend to like this technique for push-ups due to the kinetic chain demands: we need to mobilize in a closed-chain to match the position of restriction during push-ups. Remember, the goal is to train the movement so we need to treat the movement. If you are doing a lot of push-ups (and you better be) try this out.

-Seth

P.S. You can vary the load/intensity by making your body more parallel to the ground. Use a bench to increase the load of the stretch compared to the wall.

It's clear in the video that sprint coach Jared Krout of KroutPerformance.com, is lacking full (terminal) knee extension. Normal knees are able to extend past neutral into hyperextension approximately 5 degrees. Restoring terminal knee extension is one of the first tasks your PT will take on post-surgically and it's one of the first things I look for in my athletes. You may have seen or even done the above exercise for quad-strengthening albeit with less resistance. However, the advantage of the way I've done it is to provide both an anterior glide to the tibia parallel to the joint surface in the Maitland/Kaltenborn method of joint mobilization and cue the quads to contract in a closed-chain function allowing what is essentially a two-for-one: mobilizing the joint into the position of restriction and activating the quads (which have an anterior joint glide moment in terminal extension) at this end range against some considerable resistance. Do NOT do this if you are early post-op ACL, patellar/quad tendon repair, or have some funky unstable knee (listen to your MD and PT - don't be a bozo). You can find these bands here.

So why is terminal knee extension so important?

1. If your joint does not have full range of motion in all directions, it is not normal/healthy. Now, an athlete can manage this restriction in terminal knee extension for some time, until they can't and they come to me with pain - in the knee or elsewhere. Without this critical range of motion they are predisposing the joint to high loads at a mechanical disadvantage.

2. If your knee is unable to get straight and then we stack some loading on top of it, think deadlift or jumping/landing, the joint is unable to fully disperse this load across the joint surface. A fully extended knee is considered the close-packed position of the knee because it is the position in which the articular surfaces are most congruent and the ligaments are the most taut. If you cannot obtain full extension, the load is poorly dispersed and cartilage does not do well with repetitive loading to a localized area. Here is some great evidence on the correlation of knee motion and early arthritic changes. Don't wear a hole in your knee!

3. In addition to the cartilage loading, lack of terminal knee extension means that you are unable to lock out the knee and the angle of pull on the patella and patellar tendon is altered, causing increased compression of the patella against the knee. This may lead to Patellofemoral Pain Syndrome and possibly patellar tendinitis due to the increased off-axis pull on the patella.

4. Perhaps most importantly, you need full knee extension to generate optimal quad force production. We will typically see poor quad function toward knee extension in those who are restricted in this motion. I don't need to tell you how important force development is for your quads. Any loss in quad function can destabilize the knee and increase joint loading.
Here's the kicker, loss of terminal knee extension will likely cause deficits up and down the kinetic chain. If you're unable to get your knee straight during triple extension (ankle plantarflexion, knee and hip extension) which is needed in basically all athletics, the hip cannot get into neutral extension causing you to overextend at the lumbar spine in order to keep you upright. Blow through some reps like that with hip flexors that are now super tight and it's hello spondy, plus it just looks like weak sauce.  You may also have difficulty with appropriate foot strike during running, but that's a whole other topic.

Bottomline: Athletes must have full knee extension for optimal performance of the entire kinetic chain. If you are walking around and can't get your knee straight, get it together! Try the video above as a starting point (I realize that the screw-home rotational component may still need addressed for full extension, though not discussed here).

- Seth