Thinking out loud about prehab and injury prevention

[Garrett Smith]

Okay, so in the comments today I said I was going to be thinking about my prehab and other topics.

So, I figured I'd start this thread and let others join in as they choose. Or not.

First article I wanted to re-examine was this one by Boyle:
http://www.t-nation.com/readArticle.do?id=1618485&cr=

The best part of the article for me is here:
One of the beauties of the Functional Movement Screen is that the screen allows us to distinguish between issues of stability and issues of mobility. Cook's thoughts were simple and led me to realize that the future of training and of corrective exercise may be on a joint-by-joint approach rather than a movement-based approach.

Cook's analysis of the body was a straightforward one. In his mind, the body is just a stack of joints. Each joint or series of joints has a specific function and is prone to specific, predictable levels of dysfunction. As a result, each joint has specific training needs. The table below looks at the body on a joint-by-joint basis from the bottom up:

Joint + Primary Training Needs
Ankle mobility (particularly sagittal)
Knee stability
Hip mobility (multi-planar)
Lumbar Spine stability
T-Spine mobility
Gleno-humeral stability

Everything that I've learned to this point, along with what I've watched and experienced, leads me to believe the above is true. So, first things first. Training ankle mobility is an absolute must for me before any workout.

Some days, when I have a good long stretch to walk barefoot on, I do the foot drills:
http://wellness.ndsu.nodak.edu/fitness/Events/marathon/footDrills.pdf
Great drills, quick, easy, and simple to share as they are pretty hard to screw up.

If I'm in a tight space (like at my gym) and I don't want to take off my shoes, I do some Z-Health drills plus some others from Coach Boyle. Anywhere from 3-5 reps each. Z-Health drills include ankle circles and ball-of-foot circles, drills from Coach Boyle include the "Ankle mobility" and the "Leg swings" from this article:
http://www.t-nation.com/readArticle.do?id=1778726&cr=

I think I'm covered with the ankle mobility. On to knee stability. This one is nice and easy to cover.

So, another quote from the first link:
Knees need stability. They are hinges with minimal rotary components. Think squats and straight leg deadlifts.

Makes sense. I'm pretty sure the CA WOD covers the two-leg versions of squats and DL variations. :) I want to add in some one-leg versions of squats and straight-leg DLs, so I do that on my once-weekly each gymnastics "moves" and "holds" workouts. These include:
Pistols
One-leg straight leg DLs (see in here http://www.t-nation.com/readArticle.do?id=1543621&cr=)
Pistol bottom position holds
Wall sits

OK. Knee stability covered. Easy peezy. On to hip mobility. This one is a bit tougher.

Typically for me, I do Z-Health hip int/ext swings both in front and to the sides, I also count the leg swings mentioned previously, and then I do either open-chain hip circles or closed-chain hip circles from Z-Health (trying to alternate days).

While it could be argued that multi-direction lunges are more "functional", I also believe they allow for too many other joints to compensate and hide poor hip mobility, so they aren't a great choice in my book. If I add them after this thought process, I'll definitely do them after my (more) isolated hip mobility drills. I'd also add crossover lunges. I probably wouldn't do any more than 2 reps of any lunge direction/version if I include them.

Also, I do like the Cossack squat + lunge + hip turn drill (see http://www.bodybuilding.com/fun/henkin27.htm under "Range of Motion" heading) and Pavel's "pump" from ETK (think down dog + upward dog + some twisting motions). I have the hurdles to do Coach Davies' hip mobility drills, and I love them (even with the same drawbacks as directional lunges, easy to compensate/cheat), I just never seem to get around to them these days (it's cold and I'm not warmed up yet, so outside just isn't happening).

I'm also going to try to remember my hip flexor stretch in the mobility/warmup segment, to "turn off the brakes" for the OL/squats sure to follow!

Hip mobility, check. On to lumbar stability.

Other than all the weighted posterior chain work Coach Greg has us do, I really like the stuff I do in my gymnastics workouts for this area. Front/side/back planks, lever progressions, hollow rocks, Supermans, back and/or hip extensions, GHD situps, reverse hypers, etc. I think that one is covered. I also do Z-Health pelvic & lumbar circles, just to keep everything moving well down there.

Lunchtime. To be continued...

[Garrett Smith]

Thoracic mobility. Anterior-to-posterior, especially (and vice-versa, of course!). Huge, huge deal.

I typically do Z-Health thoracic glides and circles. Those are a staple for my personal mid-back issues. I have recently added in the three basic moves from Robb Wolf's latest article in the PMenu on kyphosis--glide kips, shoulder dislocates, and overhead squats. Brilliant in both its scope and simplicity--including both closed-chain (kips), open chain (dislocates) and active mobility (OHS). I do five reps of each of those movements, including both supinated and pronated grips on the kips. Okay, got that. On to scapular/shoulder stability.

Scapular/shoulder stability. Probably the whole reason I'm writing this right now, due to recent irritation of my A/C joints from improper positioning during overhead lifts. As I have a really long torso, I tend to slouch when seated, which likely leads to my mid-back issue and also weakness in the scapular retractors. This combined with the fact that recent re-testing has shown a loss of my previous ability to touch fingers together in the over & under behind-the-back-touch-your-fingers-together test (see http://www.t-nation.com/readArticle.do?id=818555&cr=) has prompted me to do more work for my shoulder complex. BTW, my "active impingement" test was negative.

Recently I have re-added three movements to my prehab warm-up to prevent this issue from happening again. The Reach-Roll-and-Lift (see above link), wall slides, and face pulls.

In my OHS, I'm now concentrating on retracting the scapula before elevating them, and pullups/chinups/commando chins are included often for their depression movement to the scapula. In my pushups, I always do depth style, and I always add the "plus" at the top, and do the opposite in my body rows. L-sits for the active depression movement, and shrugs and OL for the elevation movement of the scapula with the arms in the down position. I believe the major scapular movements are each covered.

Oh, I always do neck mobility. Last thing I want is a bad neck. I do want to figure out some very simple neck stability exercises as well.

I think that covers everything Boyle talked about.

Did my first session of self myofascial release + stretching this morning. It was okay, I'd much rather get Thai massage...:D

[Eric Kerr]

Garrett,

Roughly how long does it take you to do a typical pre-hab session?

I've looked into this type of thing a little myself due to some shoulder issues.

But, my attention wandered over after I started doing some mental math and decided that I'd likely never get to my workout for all the pre-hab/warm-up exercises. Getting an hour a day to pre-hab/warm-up + workout + shower + stretch these days is tricky with two little ones under three at home.

I do think part of the key is getting an accurate assessment of potential issues that you may be suffering from in order to efficiently address these types of issues. The problem is as suggested by that Cook/Boyle reference, that each joint is a separate unit. Inferred is most Dr's will specialize in one joint. That is a lot of doctor visits to get a complete picture. Then there is the matter of simple efficiency.

Posture Alignment by Paul D'Arezzo is an interesting read in this vein. It basically recommends addressing any issues prior to engaging in another type of exercise program so that movements in the program and not compromised, exacerbating existing problems. The whole start with a solid (or at least a re-properly aligned foundation) type approach.

I'm sure most of the hard working individuals around here appreciate it when they see things like. "Want to enhance your knee stability? Do your squats and straight leg deadlifts". Scheeww, I don't have to give up every heavy lift!

I guess my point is where can I find super trainer that knows all this stuff like the back of their hand rather that fumbling inefficiently around in the semi-dark? I guessing I'm not going to find exactly that person, but posts like yours help by going through the thought process. So thanks. :)

Eric

[Derek Simonds]

Did my first session of self myofascial release + stretching this morning. It was okay, I'd much rather get Thai massage...:D

I am trying to convince my wife we should spend a couple of years in Thailand so she can become a specialist. I don't think she is biting.

[Derek Simonds]

Seriously great post. I think that this is a great thought starter for a lot of us.

I am going to reread before bed and think over everything you laid out.

[Garrett Smith]

Eric,
My prehab + warm-up (including 3' on the x-country skier and a slightly extended Burgener warm-up) takes 30 minutes at the very most, and I chop it down to 15-20 minutes when I need to. I leave myself ~80 minutes or slightly less to train (depending on the WOD, of course), and that doesn't include shower time. That includes all prehab, warm-up, heavy training (I take relatively few warm-up sets after all the other intro activities, I'm not a big believer in a whole lot of warm-up sets, ie. squats at 75% x 3 x 5 get at most for a warm-up 5 reps with bar and 3 reps at around maybe 50-60%, sometimes I just jump to the 75%), and the daily three stretches (front shoulders, hip flexors, hamstrings). With only an hour to train including shower, that's tough, you really have to pick and choose. I'd say maybe figure out one mobility drill from each of the major areas and do one per workout day, rotating through different mobility drills. Working out is my hobby and I don't have kids yet, so I have more time. Also, note that I don't do all the exercises I mentioned up there every day. I pick and choose based on the day and I really try not to overlap too much if pressed for time.

You may want to look for a Z-Health trainer (www.zhealth.net) in your area, one who is hopefully at least I-Phase (intermediate) certified. I've spent something like $2700 on Z-Health training, so I feel pretty comfortable with teaching and doing joint mobility, and believe me when I say that a lot of people know about joint mobility concept-wise yet don't do it right in practice at all.

Derek, glad you liked it.

For both of you guys, I'll post what I would typically do in a prehab session tomorrow to pull it together better.

[Sam Cannons]

Garrett,

Excellent post, I am loving all the mobility stuff out there at the moment. My warm-up consist of a similar style. I will usually start from the top down and do 10-12 reps -

start with a bit of foam rolling for Thorasic Mobility
shoulder dislocates
shoulder circles
hip circles
forwards and backwards scorpions (MM)
the Pavel pump
cossacks
OHS
hand stands
kip swings
some pullups and dips and kettlebells swings/snatches, sometimes some bridges

usually run through the following complex to finish the warmup start with an empty bar and do 1-3 sets adding a little bit of weight.
muscle snatch
snatch balance
ohs
sotts press

I vary it up and add in others like 1 legged walking RDL, dynamic good morning, cossacks, skin the cats and band face pulls, frog swims, windmills. Depending on what i feel is tight or lacking at the time.

[Garrett Smith]

Dang. I just typed in a bunch of stuff and lost it. I'll try again.

Here was my mobility work for today, it took me less than 15 minutes, all exercises done standing, 3 reps of each exercise in each direction unless otherwise noted:
Ankle circles
Ball-of-foot circles
Leg swings
Ankle dorsiflexion, straight, inside, outside
Cossack + lunge + hip turn, 2 reps
Experimented with some directional lunges incorporating cossack finishes
"Hula hoop" 5 reps
Pelvic tilts, ant.-post., lateral, and full circles
Experimented with open-chain lateral pelvic tilts (balancing on one leg, using the quadratus lumborum on the opposite side to lift the other leg off the ground by attempting to close the space between the lateral ribcage and pelvis)
Lumbar lateral glides
Lumbar half circles, front, back, left, right, 1 rep each
Thoracic glides, ant.-post., lateral, and full circles
Glide kips, overhand, underhand, 5 reps each
Overhead pass-throughs aka shoulder dislocates w/ dowel 5 reps
OHS w/ dowel
Reach-roll-and-lift 5 reps
Wall slides 5 reps
Band face pulls 5 reps
Neck ant.-post. & lateral flexion, and full circles (done carefully!)

Covered pretty much everything I wanted to do.

Warm-up for today's WOD consisted of my extended Burgener warmup, 3 reps of each, done first with a pipe dowel and second with the empty bar, all with a snatch grip:
High hang jumping shrugs
Hang high pulls
Muscle snatch
Power snatch land
OHS
Pressing snatch balance
Heaving snatch balance
Snatch balance
Tall snatch

Sometimes I'll add some full snatches at the end as well.

[Scotty Hagnas]

Excellent posts!

My routine is very similar, and this is what I do with all of my clients here at CrossFit Portland. I have a standard framework of movements that I work thru regularly, then I cycle in drills to improve certain areas or movements. This way, I don't have a huge list of warmup drills to hit every session.

On off days, and later on training days if I'm feeling beat up, I'll do a full session of SMR, joint mobility, and stretches/RMAX Body Flow chains. This will take 30' to 1 hour. Pre workout, I do a much shorter ~15' or so warmup - depending on how I feel.

The more that you incorporate this type of work, the less time it takes to warm up. Occasionally, I dive straight in with almost no warm up. Keeping an optimal length/tension relationship in the muscles will keep you in a state of readiness all of the time.

[Garrett Smith]

Thanks, Scotty! We seem to be on the same page about most things, it seems.

I agree about the need for less warm-up after doing a lot of joint mobility training. If you're wondering what I mean by "a lot" of mobility training, I specifically did 8-weeks of the Z-Health R-Phase (basic) exercises (in a program laid out by Dr. Cobb covering different areas and at different speeds) and 12-weeks of the I-Phase (intermediate) program. Nearly 5 months of working on prescribed joint mobility drills has really benefitted me in many ways.

I do want to learn more Body Flow chains. That being said, any compound movement (even those designed to increase mobility) has WAY more room for compensatory movements to take place that the practitioner has no idea are happening (to hide or "work around" immobile joints). There is a place for everything, including compound joint mobilizations, and I know Scotty has also had a ton of training in joint mobility.

I often tell people that if there was only one "form" of exercise I could do, it would be joint mobility training. It's the stuff that will still be with me when the amount of weights I'm lifting have dwindled to very little. I also believe that many of the health benefits of things like tai chi, qigong, and the "flow-ier" styles of yoga comes from the joint mobilizing movements that they do.

[Allen Yeh]

Good post, while it does seem like a lot, it really doesn't add that much more time onto the workout I'd say 10-15 minutes. I do something similiar to what Garrett has outlined and I can usually cap most of my workouts in about an hour. The difference is I typically will do less exercises but do more sets and/or reps and switch my exercises around day to day. My log has a few examples of what I'll do prehab/warmup/mobility wise. This doesn't count getting dressed and showering but all warmup stuff/skill work/WOD. I personally don't foam roll until at home later simply becasue the gym doesn't have one.

[Chuck Kechter]

This is 2/3 of my training... Mobility before -- compensation after. WIth (whatever) training (MMA, Met-con, or strength work) as the meat in the sandwich.

Good stuff!

[Garrett Smith]

New article on T-Nation, to get you thinking more on this topic:
The Mobility--Stability Continuum (http://www.t-nation.com/readArticle.do?id=1865219)

Nothing ground-breaking, but a good thought starter as well.

The concept of "stiffness" is introduced. From how I understand it being used in the article (as it is simply "introduced", not elaborated upon), I'm not so sure that I think it is the best word for the concept they are trying to get across.

See various definitions of "stiffness (http://www.google.com/search?hl=en&client=safari&rls=en&defl=en&q=define:stiffness&sa=X&oi=glossary_definition&ct=title)".

There is one definition in there, towards the bottom, that just fits in too well with double-entendre-rich OL:

Determined primarily by the number and size of balls in engagement and, to a certain extent, by the preload and type of nut mounting.

But I digress.