Low Back Pain: Get Started with Abdominal Exercises

Low back injuries usually do not occur from one single incident or event like lifting a heavy box.  Instead, most back injuries occur from small incremental stress or load applied over time.  Sitting slouched for prolonged periods at a desk or repeatedly performing bending and twisting can overload sensitive spinal structures.  These structures include the muscles, facet joints, ligaments, discs, and nerves.   Muscle weakness, poor endurance, poor position awareness, and previous history of injury can make one more susceptible to low back injuries.  Most of these injuries are not serious and do not require extensive testing or treatment.

The core muscles function to spare the lumbar spine and surrounding structures from excessive load.  These muscles include the abdominals, low back musculature, diaphragm, and pelvic floor muscles.  No single muscle is more important than the others.  Human movement and low back pain are more complex than one muscle or structure.  Instead, all muscles should ideally function together in coordination.  Pain interferes with coordination and control.  The specific task being performed determines the magnitude and timing of core muscle activity.  Some tasks require a very low load and level of muscle activity such as bending to tie the shoes.  Other tasks require greater muscle activation patterns at high speeds such as swinging a baseball bat.

Exercises to train the core musculature should begin with low loads focusing on control and endurance.  Exercises performed lying on the back targeting the abdominal muscles is a great place to start.  The following exercises can be performed by those with low back pain or those with a history of back pain looking to prevent recurrences.  Once these exercises are no longer challenging, progression is needed.  Future articles will address proper progressions.

Abdominal Bracing

Begin lying on your back with the hips and knees bent.  Find a neutral spine position by gently rocking your pelvis back and forth.  Your neutral position is somewhere between a fully arched and fully flattened position.  In your neutral position, you should be able to hold a small grape under your low back without crushing it.  Maintain a neutral spine and gently contract your abdominal muscles in the front and sides continuing 360 degrees around to the low back.  This muscle contraction should be gentle and no movement should occur.

Once a neutral spine can be maintained with gentle bracing, breathing is added.  Diaphragmatic breathing is performed while maintaining a neutral spine and gentle bracing.  This involves expanding through the belly and rib cage in a 360-degree fashion.  Minimal or no movement occurs in the upper chest and shoulders.  Five deep slow breathes are performed while maintaining a neutral spine and bracing.  No breath holding or movement of the spine should occur.  It is helpful to place one hand on the abdomen and the other hand on the chest to ensure a proper breathing pattern is maintained.   This exercise forms the foundation for all subsequent abdominal exercise progression to follow.

Bent Knee Fall Out

The bent knee fall out is performed after abdominal bracing and diaphragmatic breathing have been mastered.  Begin with a neutral spine, bracing, and diaphragmatic breathing.   Lower one knee to the side towards the floor in a slow and controlled fashion.  No movement in the spine or hips should occur.  It is helpful to place the hands on the hip bones to ensure no movement is taking place.  With each repetition alternate sides.  To increase the challenges add a resistance band around the thighs.  Perform 10 slow repetitions on each side.

90/90 March

This exercise begins with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate lowering the heels to the floor.  Gently touch the heel to the floor without relaxing.   Perform 10 slow repetitions on each side.

Heel Hover

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate extending of the knee so one leg straightens without touching down.  As you lower the legs, it is important that the low back does not arch away from the floor.  Perform 10 slow repetitions on each side.

Double Leg Lift

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Both knees and feet are then simultaneously elevated so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly lower the legs together.  Do not touch down or relax the feet to the floor.  It is important that the low back does not arch away from the floor.  Perform 10 to 20 slow repetitions on each side.  To increase the challenges add a small ball to squeeze between the thighs.

Closing Thoughts on Abdominal Exercise for Low Back Pain

Pain interferes with how our brain transmits signals to our muscles.  This is especially important when your low back pain has persisted for more than several weeks.  These 5 abdominal exercises re-program the lost connections between the brain and core muscles.  Slow coordinated and controlled movements are crucial for success.  Absolutely no holding of the breath should occur.  Breathe holding increases tension throughout the body and interferes with retraining of the muscles and nervous system.   Practice these exercises, master them, and improve your endurance by increasing repetitions.   Once these goals are achieved, you are ready to build strength and resilience with more challenging exercises.

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Gluteus Maximus Exercise: Training in Multiple Planes

The gluteus maximus is the most powerful hip extensor.  This is important for functional activities performed in one plane such as walking, running, and climbing stairs.  However, this muscle also has important functions outside of straight ahead planes of movement.  The gluteus maximus also helps control balance and generate power in other planes.  Rotational and lateral movements in everyday life and sport require important contributions from the gluteus maximus.

Training the gluteus maximus should incorporate single-plane hip extension exercises and exercises in multiple planes.  Single-plane exercises such as the squat and hip hinge do not fully develop the glutes.  Training programs should also include exercises with rotation of the trunk or lower body on one leg.  These types of exercises prepare athletes for changes or direction, throwing, and jumping from one leg.   Performance improvements and reduced risk for injury often occur with long-term training in multiple planes.  The five exercises included in this article are only examples.  Many other exercises can be adapted to train the entire body with rotational movements.

Crossover Step Up

The crossover step up helps expose and improve any side to side difference in gluteus maximus strength.  Stand to the side with your left leg next to an elevated step or box.  Cross your right foot in front and step up onto the box.  Keep your hips square throughout the exercise.  Next, cross your right foot behind the left while stepping down to briefly touch the floor on the opposite side.  When descending think about sitting back into the hips.   Reverse the movement in the opposite direction.  Perform the exercise slowly with control.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hands or close to the chest.

1-Leg RDL

The single-leg Romanian dead lift (RDL) is a single-leg exercises which requires stabilization of the trunk on the lower limb in multiple planes.  These exercise begins by standing on one leg with the opposite hip and knee extended.  The weight bearing knee can be slightly bent throughout the exercise.   Initiate the movement by slowly flexing at the hip, keeping the back straight.  The non-weight bearing leg extends straight back behind the body.  Both the descending and ascending parts of the exercise should be performed in a slow and controlled manner.   Also, maintain control and the position of the weight bearing leg during the exercise.   Perform 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

Transverse Lunge

The transverse lunge starts standing with the feet near each other and hands on the hips.  Throughout the exercise the trunk is maintained in an upright position, so the knee and hip of the lunging leg can be flexed to 90°. This prevents the knee from moving forward past the toes.  Also, the knee remains over the toes so it does not cave inwards into valgus.  During the transverse lunge, the body is rotated 135° towards the lunging side.  This involves twisting behind the body and lunging in one motion.  Add load by holding a dumbbell or kettlebell in the hand opposite the lunging leg or against the chest.  This exercise shows high activation of both the gluteus maximus and gluteus medius.

Skater Squat

The skater squat introduces rotation of the trunk on the lower limb.  The exercise begins by standing on one leg and performing a squat to a comfortable depth.  The depth is determined by the ability to maintain balance and good control of the trunk and entire lower extremity.  The non-weight bearing leg extends at the hip and flexes at the knee. The torso slightly rotates and the arms swing reciprocally as if skating.  The toe of the non-weight bearing leg can touch the floor between repetitions if needed.  Hold the downward position for 2 seconds then return to the starting position.  Add load by placing a resistance band around the thighs just above the knees.

Rotational 1-Leg Squat

 The rotational 1-leg squat is a progression of the skater squat.  Both exercises have a rotational component to the squat.  This exercise further challenges the balance and stability of the hip.  Begin by balancing on one leg holding a medicine ball in both hands.  The non-weight bearing knee and hip flex to approximately 30°. Slowly lower toward the floor being sure to maintain control of the trunk and supporting leg.  The depth of the squat is determined by the ability to maintain balance and control the movement.  Rotate the hands and medicine ball upwards and towards the weight bearing leg as you perform the squat.  Return to the starting position and keep the knees over the toes to prevent knee valgus throughout the exercise.

Glutues Maximus Exercise: Closing Thoughts

Gluteus maximus weakness is common in those with chronic back pain, hip bursitis, hip arthritis, knee arthritis, and runner’s knee (patellofemoral pain).  Training the glutes primary function of hip extension is important but often not enough for most demands of sport and everyday life.  These five exercises are challenging and not for everyone.  If you are unable to maintain balance and stability on one leg try other exercises first (basic gluteus maximus exercises).   If you are still unsure how to start, contact your physical therapist for help.

 

Gluteus Medius Exercise Progressions

The primary role of the gluteus medius is to stabilize and control movement of the pelvis during weight bearing functional activities.  This is required for efficient walking, climbing stairs, running, jumping, and throwing.  All of these activities require at least a brief period of single leg support.  The gluteus medius maintains a level pelvis and prevents the opposite side from dropping.  Without adequate functioning of this muscle, balance, strength, power, and performance will be compromised.  Also, abnormal movement patterns, such as dynamic valgus, occur in the presence of inadequate gluteus medius function.

It is advantageous to progress exercises for the gluteus medius from non-weight bearing to standing positions.  The exercises included in this article are 5 options but there are many others.  The most important aspect of these exercises is that they performed in a slow and controlled manner with appropriate body alignment.   The emphasis should first be on proper technique before adding repetitions or resistance.

Band Hip Abduction

Band hip abduction is performed with an elastic band tied around the ankles standing in an upright position with the feet together.   The feet are then pulled slightly apart.  Stand on one leg while keeping the pelvis level.  Abduct the other leg about 25° while maintaining the trunk in an upright position.  The most common mistake is to abduct too far and tip the body to the other side.  It is also important to keep the toes pointing straight ahead throughout the exercise.  Tension should be maintained on the band so the feet do not touch.  Both the supporting and moving side gluteus medius are very active during this exercise but the standing leg receives the greater training effect.

Band Internal & External Rotation (IR/ER)

Band IR/ER is performed with an elastic band tied around thighs (just above the knees) standing in an upright position with the feet together.  Once the band is in place, separate the feet to shoulder width or slightly wider.   During the exercise the knees and hips are flexed about 30°.  The hands are placed on the hips.  Initiate the movement by slowly moving one knee inwards over a 2 second period.  Maintain the position of the opposite knee.  Then slowly pull the knee outwards over a 2 second period.   Perform 8 repetitions in a slow and controlled manner on one side before switching to the other leg.

Lateral Band Walk

The lateral band walk is performed with an elastic band tied around the ankles standing in an upright position with the feet together.  During the exercise the knees and hips are flexed about 30°.   The hands are placed on the hips.   Sidestepping is initiated by leading with one leg over a distance slightly wider than shoulder width.  It is important to keep the toes pointing straight ahead and the knees over the toes throughout the exercise.  Tension should be maintained on the band so the feet do not touch.  Three slow steps are performed in one direction followed by 3 steps in the opposite direction.  Each cycle constitutes 1 repetition.  Typically, 6-8 repetitions are performed each set.   To increase the challenge of this exercise, two bands can be used.  A second band can be placed above the knees.

Dynamic Leg Swing

The dynamic leg swing begins by standing on one leg with the opposite knee flexed to 90 degrees.  Initiate the movement by swinging the non-weight bearing leg (with the knee flexed).  Move into hip flexion and extension at a rate of 1 second forward and one second backward.   Move through a smooth range of hip motion and do not allow the trunk to move out of the upright position.  Also, maintain control of the position of the weight bearing leg during the exercise.   Perform the 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

1-Leg RDL

The single-leg Romanian dead lift begins by standing on one leg with the opposite hip and knee extended.  The weight bearing knee can be slightly bent throughout the exercise.   Initiate the movement by slowly flexing at the hip, keeping the back straight.  The non-weight bearing leg extends straight back behind the body.  Both the descending and ascending parts of the exercise should be performed in a slow and controlled manner.   Also, maintain control and the position of the weight bearing leg during the exercise.   Perform the 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

Closing Thoughts

These 5 exercises can be used as a standalone program for improving gluteus medius activation and strength.  However, all 5 exercises do not need to be performed.  Choose 2-3 exercises to perform 3 days per week.  These exercises are also ideal for athletes and exercise enthusiasts to incorporate into their warm-up routines.  Specifically, try 2 or 3 of these exercises prior to performing compound lifts such as the squat or dead lift.   Next week we’ll highlight some more advanced progressions to load the gluteus medius.  If you any further questions, give your physical therapist a call.

 

 

Five Exercises to Train the Abdominal Muscles

Abdominal muscle weakness and poor control of the trunk (or “core”) can negatively influence athletic performance and activities of daily living.  Poor trunk muscle strength has been associated with injuries in baseball players and several other sports.  Also, exercises to improve trunk muscle strength have been shown to improve soccer and distance running performance.  Trunk muscle weakness has also been linked to falls in seniors and low back pain in adults and children.

Exercises to strengthen the abdominal muscles and improve coordination of the trunk should be integrated into a comprehensive total body strength training program.  Training should never focus on any single muscle or body part.  In general, abdominal exercises should start in supported positions, such as supine lying, and progress to more functional positions, such as standing.  Exercises are predominately training for muscular endurance with short sustained holds (8 to 10 seconds) and a progressive number of repetitions.  As exercises become less challenging, the number of repetitions should be increased or the exercise itself should be progressed to a more challenging position.  The five exercises which follow are ordered from the most basic to the most challenging.

Dead Bugs

Begin in a supine lying position with the arms held straight up and the feet off the floor.  The hips and knees should be bent to 90 degrees.  Gently flatten the low back into the floor and maintain this abdominal contraction throughout the exercise.  Simultaneously raise the right arm overhead and extend the left leg without touching down.  Hold this position for several seconds and maintain low back contact with the floor.  Reverse the movement back to the starting position. Then, perform the opposite diagonal pattern with the left arm and right leg.  You should alternate sides with each repetition.  Maintain low back contact with the floor throughout the exercise.

Stability Ball Roll-Outs

Begin in a tall-kneeling position with both hands on the ball.  Roll the hands along the ball until the elbows or upper arm contacts the ball.  The elbows should remain extended as the hands and hips move together.  Engaging the gluteus and abdominal muscles help maintain proper position during the exercise.  As you lower the body towards the floor, maintain a neutral spine position and avoid arching the low back.  Hold this position for several seconds before reversing the movement back to the starting position.

Side Plank with Rotation

Begin in a side-lying position resting on one elbow.  Raise the trunk and knee off the floor until you are fully supported by your elbow and feet.  While maintaining the side plank position, reach up and then under and behind the body with the top hand.  This will induce trunk rotation and challenge the oblique abdominal muscles.  Hold this position for several seconds before reversing the movement back to the starting position.

Half-Kneeling Cable Chop

Assume a half-kneeling position next to a cable column or anchored resistance band.  The kneeling position removes contributions from the lower body and increases the demands on the trunk, pelvis and hip musculature.  From a balanced and upright kneeling position, pull the cable or band diagonally across the body towards the opposite hip.  Maintain a neutral spine and trunk position throughout the exercise.  Avoid rotating the body as your arms pull across the body.  Resisting this movement is what activates the abdominal muscles.  Hold this position for several seconds before reversing the movement back to the starting position.

Lateral Lunge with Press and Reach

This advanced exercise starts from a standing position next to a cable column or anchored resistance band.   Holding the handle or band close to the body; initiate the exercise with a lateral lunge.  Once the lunge position is attained, slowly press the arms straight out in front of the body.  The band or weight will induce a rotational challenge to the trunk muscles.  Resisting this movement is what activates the abdominal muscles.  Next, slowly raise the arms straight overhead while maintaining the lunge position.  Maintain a neutral spine and trunk position throughout the exercise.  Hold this position for several seconds before reversing the movement sequentially back to the starting position.

Closing Thoughts on Abdominal Exercises

Abdominal exercises are one component of a comprehensive exercise program targeting total body muscular strength and physical performance.  Abdominal exercises performed in isolation are rarely successful for improving performance or decreasing pain.  When developing your program, consider these five trunk muscle exercises.   Performing each exercise in a controlled fashion, with a focus on proper technique and muscular endurance will elicit the best results for the long-term.

References

  1. Chaudhari AMW, Mckenzie CS, Pan X, Onate JA. Lumbopelvic control and days missed because of injury in professional baseball pitchers.  Am J Sports Med. 2014;42(11):2734-2740. doi:10.1177/0363546514545861.
  2. Granacher U, Gollhofer A, Hortoba T, Kressig RW, Muehlbauer T. The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: A systematic review. Sports Med. 2013;43:627-641. doi:10.1007/s40279-013-0041-1.
  3. Reed CA, Ford KR, Myer GD, Hewett TE. The Effects of isolated and integrated “core stability” training on athletic performance measures: A systematic review. Sports Med. 2012;42(8):697-706.

Abdominal Oblique Injuries in Rotational Sports

Abdominal oblique injuries, also known as side strains, are common in rotational sports such as baseball, tennis, golf, and track and field.  These injuries are characterized by a sudden, sharp onset of pain near or on the side of the rib cage.  The injury usually occurs during some type of rotational sports movement such as swinging a bat, club or racket; or throwing a ball.

Trunk rotation plays an important role in generating and transferring power during sport.  It is through the trunk or core, that forces are transferred from the lower body to the shoulder and arms. Activities such as throwing and swinging require the core muscles to both stabilize the trunk and create force in order to transfer power to the upper body.

Anatomy of the Abdominal Oblique Muscles

The core includes the thoracolumbar, abdominal, pelvic, and hip musculature.  These muscle groups provide trunk stability to allow integrated limb movements, such as throwing and swinging, to occur. The abdominal core muscles include the rectus abdominis, transversus abdominis, internal oblique and external oblique.  Most abdominal injuries occur in the internal and external oblique muscles.  Less commonly, injuries can occur to the intercostal muscles between the ribs themselves.

The Role of the Oblique Muscles in Sport

The internal and external oblique muscles are responsible for flexion and rotation of the trunk, as well as providing trunk stabilization during complex sports movements.    Poor mobility of the hips or thoracic spine can contribute to excessive stress and compensation through the trunk musculature during swinging or throwing.  Rehabilitation often addresses hip mobility with manual therapy techniques performed by the physical therapist.  An imbalance between right and left side oblique muscles are also common is in sports such as golf and baseball.  This may place excessive forces through the lead side oblique musculature.  Finally, the large forces generated by lower body muscles (quadriceps and hamstrings) may overpower the weaker core musculature leading to injury during explosive sports movements.

The incidence of Abdominal Oblique Injuries in Baseball

A 2010 study in the American Journal of Sports Medicine investigated the incidence and trends of abdominal injuries in professional baseball players.  From 1991 through 2010, abdominal strains accounted for approximately 5% of all injuries in Major League Baseball.   Nearly half of these injuries occurred in pitchers.   These injuries occurred most often during the early part of the season.

In both pitchers and position players, the majority of injuries occurred on the side opposite to their throwing arm.  Pitchers missed, on average 35 days on the disabled list, while position players missed 26 days on average.  Players who receive steroid or PRP injections have been shown to miss more time from injury.   More than 1 out of every 10 sustained a re-injury during their career.  Most of these re-injuries occurred during the same or the following season.   As a result of these injury trends, many MLB teams have increased their focus on preemptive core and trunk strengthening exercises for all players.

Closing Thoughts

The incidence of abdominal oblique injuries is on the rise in rotational sports such as baseball and golf.   These injuries can result in substantial loss of playing time.  Proper training can prevent abdominal oblique injuries from occurring.  In a few weeks, I will post an article describing exercises which can help reduce the risk of sustaining an injury.  These exercises can also be part of a comprehensive rehabilitation program to safely return an injured athlete back to sport.

References

  1. Camp CL, Conte S, Cohen SB, et al. Epidemiology and impact of abdominal oblique injuries in major and minor league baseball. Orthop J Sport Med. 2015;5(3):1-8. doi:10.1177/2325967117694025.
  2. Conte SA, Thompson MM, Marks MA, Dines JS. Abdominal muscle strains in professional baseball. Am J Sports Med. 2010;40(3):650-656. doi:10.1177/0363546511433030.
  3. Nealon AR, Kountouris A, Cook JL. Side strain in sport: A narrative review of pathomechanics, diagnosis, imaging and management for the clinician. J Sci Med Sport. 2017;20:261-266.

Baseball Stretching Drill to Restore Range of Motion between Innings

Baseball players will lose range of motion in their throwing shoulder and elbow following a pitching session.  This loss of range of motion becomes cumulative over the course of a season.   Range of motion deficits have been shown to increase the risk of arm injury in baseball players.  Baseball stretching routines performed over the course of a season can help reduce this risk.  Also, stretching drills during baseball games, or between innings, is another method to combat muscle tightness and loss of range of motion in baseball pitchers.

The two-out drill has been developed by researchers from the California State University in Sacramento, and world-renowned orthopaedic surgeon Dr. James Andrews.   These seven baseball stretching exercises can be performed in approximately one minute between innings.  During game situations, the drill is initiated after two outs have been recorded and prior to the pitcher taking the mound each inning.   Performing this drill has been shown to restore professional baseball pitchers shoulder range of motion back to pre-pitching levels.   The seven baseball stretching exercises are described below with a video to follow.

Baseball Stretching: The Two-Out Drill

  1. Internal rotation stretch. Place the non-throwing hand on top of the throwing elbow with the non- throwing forearm resting on top of the throwing forearm. The non-throwing arm is then used to produce an internal rotation stretch in the throwing shoulder by rotating the forearms down towards the ground. This stretch is held for 3 seconds and is repeated twice with approximately 1 to 2 seconds of rest between stretches.  Be sure to stay tall during the stretch and avoid holding your breath.
  2. Elbow extension stretch. Extend the throwing elbow with the forearm tuned up. With the opposite hand, pull the throwing hand so that the wrist is extended back. This stretch is held for 3 seconds and is repeated twice with approximately 1 to 2 seconds of rest between stretches.  Be sure to stay tall during the stretch and avoid holding your breath.
  3. Big arm circles. Perform big arm circles clockwise and counterclockwise for 5 repetitions each way.  Make the circles as big and fast but comfortable, with an emphasis on increasing range of motion.  Be sure to stay tall during the exercise.
  4. Small arm circles. Perform small, tight arm circles clockwise and counterclockwise. Movement is fast but at a comfortable pace.  Perform 5 circles forward, and 5 circles in reverse.
  5. Forearm touch. With the arms up out to the side and elbows bent, move the elbows in so the elbows and forearms touch.  Next, move the arms in the opposite direction until a mild stretch is felt in the front of the shoulders or chest.  Repeat 5 times continuously.
  6. 90/90 IR and ER. Begin with the arms up out to the side and elbows bent. Internally and externally rotate the shoulders as far as possible at a fast but comfortable pace. Repeat 5 times continuously.  Be sure to stay tall and breathe during the exercise.
  7. Trunk Rotation. Begin with the arms fully extended and out to the side.  Rotate your arms and trunk from side to side, through a full range of motion, to the left and then back to the right. Movement is fast but at a comfortable pace.  Repeat 5 times continuously.

Closing Thoughts

Performing the two-out drill with two outs will allow adequate time to prepare the throwing shoulder for the subsequent inning.  This may be a practical and effective means to preserve shoulder range of motion throughout the course of a baseball game.  Rest and avoiding excessive throwing is undoubtedly the most important factor related to reducing risk for arm injuries in baseball players.  However, the two-out drill may help maintain shoulder flexibility during a game, and perhaps over the course of a season.  Maintaining shoulder range of motion is just one small piece to minimizing risk for injury in baseball players.

References

  1. Escamilla RF, Yamashiro K, Mikla T, Collins J, Lieppman K, Andrews JR. Effects of a short-duration stretching drill after pitching on elbow and shoulder range of motion in professional baseball pitchers. Am J Sports Med. 2016;45(3):692-700. doi:10.1177/0363546516671943.
  2. Reinold MM, Wilk KE, Macrina LC, et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008;36(3):523-527. doi:10.1177/0363546507308935.
  3. Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39(2):329-335. doi:10.1177/0363546510384223.
  4. Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers: A prospective study. Am J Sports Med. 2014;42(9):2075-2081. doi:10.1177/0363546514538

 

 

5 Arm Care Stretching Exercises for Baseball Players

The unique demand of throwing a baseball places a great deal of stress on the bones, muscles, and soft tissues of the arm.  Therefore, shoulder and elbow injuries are common amongst baseball players of all ages.  Repetitive throwing leads to adaptations in the bony structure and muscles around the shoulder.  Some of these adaptations are believed to be necessary in order to perform at a high level.  Other changes, specifically those related to muscle tightness, can increase the risk of sustaining an elbow or shoulder injury.   Therefore, it is important for baseball players, coaches, and parents to understand the rationale and best methods for stretching the muscles of the arm in overhead athletes.

Range of Motion in the Baseball Pitcher

The amount of shoulder external and internal rotation range of motion receives a great deal of attention in overhead athletes.  Repetitive throwing during a youth athlete’s period of peak growth induces adaptive changes to the structure of the upper arm bone.  The middle portion of the arm bone actually rotates backward in relation to the upper end of the bone or head of the humerus.  This is termed retroversion and it is believed to be a necessary and beneficial adaptation.  Retroversion of the humerus allows the baseball player to achieve greater amounts of shoulder external rotation, or layback, during the arm cocking phase of throwing.

Retroversion of the humerus will cause an increase in the amount of shoulder external rotation but a decrease in the amount of available internal rotation.  Again, this is believed to be a necessary adaption to improve performance.  Research suggests that the total arc of internal and external rotation range of motion is what becomes important.  The total arc of motion between the throwing and non-throwing shoulder should be within 5 degrees of each other (shown in the illustration below).  When greater discrepancies in the total arc of motion are present, stretching exercises should be performed to improve symmetry between sides.

Image result for total arc motion

The Basics of Stretching for Baseball Players

Baseball players have been shown to lose range of motion throughout the course of a single game and over the course of a season.  This loss of range of motion and flexibility typically occurs in the shoulder and elbow musculature.  Common muscles prone to tightness in baseball players include the rotator cuff, lattisimus dorsi, pectoralis major and minor, biceps, and triceps.  A regular stretching routine, performed 3-5 times per week, can help restore lost range of motion.  Also, a basic 10-minute stretching routine may potentially improve performance and decrease risk for an arm injury.  The stretching exercises presented here are a few baseball players should be familiar with.

Five Arm Stretching Exercises for Baseball Players

  1.  Cross-Body Stretch: This stretch addresses the posterior shoulder muscles which are prone tightness in overhead athletes.  The infraspinatus, teres major, and teres minor muscles can become shortened from repetitive throwing.  This stretch is performed lying on the involved side with hips and knees bent.  The involved shoulder and elbow are positioned in 90 degrees of flexion.  The hand of the uninvolved arm grasps the elbow of the involved arm and gently pulls it across the body.  Once a mild stretch is felt on the outside or back of the shoulder, this position is held for approximately 30 seconds.  The stretch is typically performed 2-3 times each session.

  1. Sleeper Stretch: The cross-body stretch has been shown to be superior to the sleeper stretch for improving shoulder range of motion in young baseball players.  However, the sleeper stretch is probably the more popular of the two stretches.  For this stretch, the same starting position as the cross body stretch is assumed.  However, with the sleeper stretch, the wrist and forearm of the involved arm are gently moved down towards the table.  Once a mild stretch is felt on the outside or back of the shoulder, this position is held for approximately 30 seconds.  The stretch is typically performed 2-3 times each session.   For most athletes, both the sleeper and cross-body stretch do not need to be performed.  My personal experience, and the best available evidence, suggests the cross-body stretch is the most beneficial for improving range of motion.

  1. Bench T-Spine Mobilization: Extension of the upper back is necessary to achieve the arm cocking position needed for throwing.  Without adequate extension of the spine, unnecessary stress will be placed on the shoulder or elbow.  This stretch also provides a nice stretch to the lattisimus dorsi and triceps muscles which can also limit overhead mobility. The exercise begins by assuming a kneeling position facing a bench.  Place your elbows on the bench in front of you holding a PVC pipe or dowel with the palms facing up.  Sit back, pushing your buttocks towards your heels, keeping your spine relaxed, until you feel a stretch in your upper back.  Be sure to engage your abdominal muscles to prevent excessive arching of the low back.  (I could have done a better job of this in the video below).  For an added stretch you can bend your elbows further past your head.  Hold this position briefly, and exhale fully.  Reverse the motion to return to the start and repeat 6-8 repetitins.

  1. Thoracic Spine Windmill: This is a great dynamic mobility drill to restore thoracic spine rotation and improve the flexibility of the lattisimus and pectoral muscles.  Begin on your side with both arms outstretched in front of you.  Place a foam roll under your top leg with the knee and hip bent to 90 degrees.  The bottom knee and hip remain extended throughout the exercise.   Reach forward with your top hand and then complete a large circular windmill motion as you rotate your entire upper body.  Keep reaching as if you were attempting to lengthen your entire arm.  Follow your hand with your eyes to ensure proper thoracic spine and rib cage movement.  The top knee and leg should remain in contact with the foam roll throughout the exercise.  We generally perform 6-8 repetitions on each side.

  1. Side-Lying IR/ER: This is a more advanced dynamic mobility exercise targeting the thoracic spine, rib cage, lattisimus dorsi, and pectoral muscles.  Start in a side-lying position with the arm to be stretched on top.  Place a foam roll under your top leg with the knee and hip bent to 90 degrees.  The bottom knee and hip remain extended throughout the exercise.  Initiate the movement by reaching with the lower arm up towards the sky.  Hold this position, reaching upwards, throughout the drill.  The arm to be stretched is then placed overhead with the thumb pointing down towards the floor.  Exhale fully at the top and then reverse the movement by bringing the arm down to the side.  As the arm is lowered the thumb position changes so it is pointing down towards the back pocket.  It is important that both elbows remain fully straight during the drill.  We generally perform 6-8 repetitions on each side.

Closing Thoughts

These five stretching and mobility drills address typical muscle flexibility problems baseball players present with.  As always, an individualized approach is always superior to ready-made one-size fits all programs.  Building arm strength through resistance training is also important for improved performance and resiliency in the baseball player.   Before engaging in any exercise program, those with a history of arm problems or those currently experiencing pain should first be evaluated by a physician, physical therapist, or athletic trainer.  Some players may require additional arm care strategies such as passive stretching and soft tissue mobilization techniques.

 References

  1. Bailey LB, Thigpen CA, Hawkins RJ, Beattie PF, Shanley E. Effectiveness of manual therapy and stretching for baseball players with shoulder range of motion deficits. Sport Heal A Multidiscip Approach. 2017;9(3):230-237. doi:10.1177/1941738117702835.
  2. Hibberd EE, Oyama S, Myers JB. Increase in humeral retrotorsion accounts for age-related increase in glenohumeral internal rotation deficit in youth and adolescent baseball players. Am J Sports Med. 2014;42(4):851-858. doi:10.1177/0363546513519325.
  3. Keller RA, De Giacomo AF, Neumann JA, Limpisvasti O, Tibone JE. Glenohumeral internal rotation deficit and risk of upper extremity injury in overhead athletes: A meta-analysis and systematic review. Sport Heal A Multidiscip Approach. 2018;Online:1-8. doi:10.1177/1941738118756577.
  4. Mine K, Nakayama T, Milanese S, Grimmer K. Effectiveness of stretching on posterior shoulder tightness and glenohumeral internal-rotation deficit: A systematic review of randomized controlled trials. J Sport Rehabil. 2017;26:294-305.

Try These 5 Row Variations to Strengthen the Shoulders and Core

Anyone interested in strengthening the core and shoulder musculature should be performing some type of row variation as part of their workouts.  The row is a pulling movement which involves flexing the elbow, extending the shoulder, and pulling the shoulder blade back, also known as retraction.  The row challenges the muscles of the upper back (trapezius, rhomboids, and erector spinae) as well as muscles of the core and low back.  Also, when performed in various standing positions, this exercise can train the entire kinetic chain from the lower body, through the trunk, to the upper body.

It is common for the row to be performed seated with the use of exercise machines.  This is fine for those first learning the movement pattern.  However, seated machine rows do little to challenge the core or lower body musculature.  There are much better options for athletes, those with a history of injury, and those looking to take their workouts to the next level.

If absolute strength is the goal, heavy barbell or dumbbell bent over rows are the best options.  However, these row variations require coaching and practice to perfect proper technique.  Performing heavy rows with improper technique makes one susceptible to low back or shoulder injury.  Again, there are better options, especially for those with a history of injury and looks to train in a more specific fashion.  Try the following five row variations and see which ones work best for you.

Standing 1-Arm High Cable Row

Set up a cable system with the cable positioned slightly above the level of the head.  Stand in a lunge position with the left foot in front of the right.  The majority of body weight should be on the front leg with the knee bent approximately 45 degrees.  Start with a palm down grip with the right arm extended out in front.  To begin the movement, pull the cable, bending at the elbow, straight back towards the trunk while maintaining a neutral spine.  Be sure to emphasize scapular retraction which refers to pulling the shoulder blade back and slightly down.  Also, avoid shrugging the shoulders or arching the low back.

This exercise challenges the core by activating the trunk musculature to resist rotation as the arm and scapula produce the row movement.  This makes the 1-arm high cable row a good option for those who are looking to train anti-rotational trunk muscle endurance.  This high-cable position and lunge stance set-up have also been shown to result in favorable muscle activation patterns of the lower and upper trapezius.  This is important for overhead athletes or those with a history of shoulder problems.

Cable Lawnmower Pull

This exercise begins with the trunk flexed and rotated to the opposite side of the exercising arm.  The hand of the exercising arm starts at the level of the opposite knee. To begin the movement, the trunk is rotated toward the exercising arm while extending the hip and trunk to a vertical position.  The exercise ends with the arm at waist level with the shoulder blade retracted as if placing the elbow in the back pocket.  Pause for 1 or 2 seconds then slowly reverse the movement returning to the starting position.

The lawnmower pull is a multi-joint functional exercise performed in a diagonal pattern replicating many movements in sport.  The exercise incorporates the transfer of force from the lower body through the trunk to the upper body.  It has been shown to activate the trapezius and serratus anterior muscles at low to moderate levels.  These muscles are important for maintaining shoulder health in overhead athletes (i.e., baseball players) and those with a history of shoulder pain.  The exercise can be performed with a cable system, resistance band, or dumbbell.

1-Arm Band Rotational Row

Set up a resistance band anchored at approximately waist to belly button level.  Position the front leg with the foot facing towards the anchored band.  The rear leg will begin facing the same direction but must be free to pivot once the exercise commences.  The right arm begins extended and the majority of body weight begins on the left leg.  The movement occurs with the simultaneous coordination of an upper-body row, trunk rotation, and weight shift to the rear leg.  Pause in the end position for  1 to 2 seconds before reversing the movement in a slow and controlled fashion.

This row variation is ideal for rotational athletes such as baseball players.  It incorporates the coordinated activity of the lower body, trunk, and upper body.  Controlling the eccentric, or negative, part of the exercise is important.  This exercise also teaches weight transfer and weight acceptable from the rear to lead leg and vice versa.  Be sure to perform the exercise from both sides to avoid reinforcing any side to side asymmetries which are common in athletes.

Suspension Trainer Row

Anchor a suspension trainer, such as a TRX, in an overhead position.  Grasp both handles with the arms extended.  Position the feet in front of the body spread slightly wider than shoulder-width apart.  Your body should be maintained in a neutral position with your head, trunk,  and legs forming a straight line.  Perform the row movement and pause at the top position for 1 to 2 seconds before returning to the start position in a slow and controlled fashion.  Maintain the trunk in a rigid position throughout the exercise. To increase the challenge of this exercise position your feet further away from your upper body to assume a more inverted position.

The inverted position assumed in the suspension trainer row elicits high activation of the abdominals,  latissimus dorsi, upper back muscles, and hip extensor muscles (glutes and hamstrings). This exercise produces lower levels of lumbar spine muscle activity due to lower spine loads incurred from the suspended position.  These factors make the suspension trainer or inverted row a good option for patients with a history of low back pain.

Dumbbell Renegade Row

Hold two dumbbells and assume a push-up position with the feet spread slightly wider than shoulder-width apart.  Align the head, trunk, and lower body in a straight line and maintain this position throughout the exercise.  Initiate a row with one arm while maintaining stability through the trunk and lower body.   Control the descent of the load back to the floor.  Be sure to alternate sides with each repetition.  Light loads are recommended when first learning this exercise.

The push-up position utilized in the renegade row increases challenges to the abdominal musculature.   Furthermore, 1-arm row variations have been shown to elicit great oblique abdominal muscle activity compared to rows performed with both arms simultaneously.   This is a more advanced row variation so it may be best to start with cable or suspension rows before embarking on the renegade row.

Closing Thoughts

There are many variations to the row exercise and I have described only five.  For beginners, it is best to start with cable row variations and suspension trainer rows.  The lawnmower pull and rotational row are more complex movements which require total body coordination.  Thus, these exercises are more challenging to master.  To really challenge the core and shoulder stability, the renegade row is a higher level option.  The most important points are that you choose the most appropriate variation for your level of training and that your technique is as close to perfect as possible.

References

  1. De Mey K, Danneels L, Cagnie B, Lotte VDB, Johan F, Cools AM. Kinetic chain influences on upper and lower trapezius muscle activation during eight variations of a scapular retraction exercise in overhead athletes. J Sci Med Sport. May 2012:6-11. doi:10.1016/j.jsams.2012.04.008.
  2. Fenwick CM, Brown SH, McGill SM. Comparison of different rowing exercises: Trunk muscle activation and lumbar spine motion, load, and stiffness. J Strength Cond Res. 2009;23(5):1408-1417.
  3. Harris S, Ruffi E, Brewer W, Ortiz A. Muscle activation patterns during suspension training exercises. Int J Sport Phyiscal Ther. 2017;12(1):42-52.
  4. Saeterbakken A, Andersen V, Brudeseth A, Lund H, Fimland MS. The effect of performing bi- and unilateral row exercises on core muscle activation. Int J Sports Med. 2015;36:900-905.
  5. Wattanaprakornkul D, Halaki M, Cathers I, Ginn KA. Direction-specific recruitment of rotator cuff muscles during bench press and row. J Electromyogr Kinesiol. 2011;21:1041-1049. doi:10.1016/j.jelekin.2011.09.002.
  6. Youdas J, Keith J, Nonn D, Squires A, Hollman J. Activation of spinal stabilizers and shoulder complex muscles during an inverted row using a portable pull-up device and body weight resistance. J Strength Cond Res. 2016;30(7):1933-1941.

5 Thoracic Mobilization Drills to Improve Overhead Mobility

The position and mobility of the thoracic spine directly affects the amount of overhead shoulder movement available.   A more erect and mobile thoracic spine and rib cage will result in greater overhead range of motion.  A slouched posture or stiffness in the thoracic spine and rib cage will result in a loss of range of motion reaching overhead.   Excessive thoracic kyphosis, or a slouched posture, may alter the position of the shoulder blade and impair muscle activation patterns both of which contribute to limited overhead function and shoulder pain.

Approximately 15 degrees of thoracic spine extension mobility is required for full overhead motion when lifting both arms such as when performing a barbell overhead press. Full 1-arm elevation requires approximately 9 degrees of thoracic extension.  Thoracic spine rotation is also crucial for rotational sports such as baseball where a large amount of power is transferred through the trunk.   A baseball pitcher who lacks thoracic spine rotation will compensate by increasing movement and stress through the shoulder and elbow joints.

Strength is foundational for optimal shoulder health but thoracic spine mobility is often a neglected area when athletes attempt to maximize their overhead shoulder function.  Therefore, exercises targeting thoracic spine extension and rotation mobility should be included in any rehabilitation or performance enhancement program seeking to optimize shoulder function.  Instead of jumping to restore shoulder mobility with bands and balls, try these thoracic spine mobility exercises first.

Bench T-Spine Mobilization

This is my favorite exercise for restoring thoracic spine extension.  It also provides a nice stretch to the lattisimus dorsi muscle which can also limit overhead mobility. The exercise begins by assuming a kneeling position facing a bench.  Place your elbows on the bench in front of you holding a PVC pipe or dowel with the palms facing up.  Sit back, pushing your buttocks towards your heels, keeping your spine relaxed, until you feel a stretch in your upper back.  For an added stretch you can bend your elbows further past your head.  Hold this position, and exhale fully.  Reverse the motion to return to the start and repeat the desired number of repetitions.

Thoracic Extension + Rotation (Reach Backs)

Begin this exercise by sitting back on your heels, face down, with one hand behind your head and the opposite forearm resting on the ground in front of you.  This position minimizes available movement in the low back and maximizes movement to the upper back.   From this position rotate your elbow up to the sky while exhaling.   The opposite forearm remains in contact with the ground.  Return to the starting position and repeat for the desired number of repetitions before switching to the opposite side.

Foam Roll Thoracic Extension Mobilization

This exercise can be a challenge to perform correctly.  Most end up extending through the lumbar spine and not the thoracic spine.  Begin in a lying position over a foam roll.  Place the hands behind the neck supporting, but not pulling on, the neck.  Raise the buttocks off the ground and roll the upper back up and down the foam roll.  Identify a sensitive, stiff, or tender area and then drop the buttocks down to the ground.  From this position perform small extension movements by lifting the elbows up towards the ceiling.  Be careful not to overextend at the lower back.

Thoracic Spine Windmill

This is my “go to” exercise to restore thoracic spine rotation.  Begin on your side with both arms outstretched in front of you.  Place a foam roll under your top leg with the knee and hip bent to 90 degrees.  The bottom knee and hip remain extended throughout the exercise.   Reach forward with your top hand and then complete a large circular windmill motion as you rotate your entire upper body.  Keep reaching as if you were attempting to lengthen your entire arm.  Follow your hand with your eyes to ensure proper thoracic spine and rib cage movement.  The top knee and leg should remain in contact with the foam roll throughout the exercise.  Perform the desired number of repetitions and then repeat on the opposite side.

Standing Thoracic Rotation Mobilization

The standing rotation exercise is ideal to incorporate into a pre-workout dynamic warm-up.  From a standing semi-squat position place one arm between your thighs just above the knees.  This position will block unwanted hip and pelvic movement.  Next, rotate the body upwards towards the sky by following your open hand with your eyes.  At the top of the movement, exhale before returning to the starting position.  Perform the desired number of reps and then repeat on the opposite side.

Closing Thoughts

After performing these mobility drills it is important to work on strength and endurance of the thoracic muscles.  Also, manual therapy to the thoracic spine and rib cage has been shown to accelerate recovery and reduce shoulder pain immediately and for up to 1 year.  Maintaining or improving thoracic spine mobility is imperative for any active individual who regularly functions overhead.  Manual therapy, mobility drills, and strength/endurance exercise targeting the thoracic spine can lead to significant gains in overhead function for athletes and the general population.  These 5 mobility drills can be easily integrated into any pre-workout warm-up routine or as part of a home exercise program.