Disc Prolapses that Reabsorb

A recent study shown that re-absorption of disc prolapses is higher than previously thought.

Zhong 2017

The Concern and fear that the words “slipped disc” “disc bulge” or “degenerative disc disease” can be worse than the actual symptoms of pain. The image of being broken and not being able to recover. But as previously noted in another blog about MRI scans, a large number of the general public suffer with a disc prolapse without symptoms. They manage to carry out a normal fulfilled life.

This new study of pooled data from the UK and Japan showed a significantly high number of lumbar disc re-absorption. To be precise it was 66.6% (82.94% in the UK I might add!!). All patients received conservative treatment, there was no invasive treatments like surgery or steroid injections.

This goes to show that with patience in your recovery and the right guidance, spinal problems will resolve without being too hasty for surgery.

 

Original Abstract

BACKGROUND: Lumbar disc herniation (LDH), a common disease, is often treated conservatively, frequently resulting in spontaneous resorption of the herniated disc. The incidence of this phenomenon, however, remains unknown.

OBJECTIVE: To analyze the incidence of spontaneous resorption after conservative treatment of LDH using computed tomography and magnetic resonance imaging.

STUDY DESIGN: Meta-analysis and systematic review of cohort studies.

SETTING: The work was performed at The Suzhou Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine.

METHODS: We initiated a search for the period from January 1990 to December 2015 using PubMed, Embase, and the Cochrane Library. Two independent reviewers examined the relevant reports. The references from these reports were also searched for additional trials using the criteria established in the PRISMA statement.

RESULTS: Our results represent the pooled results from 11 cohort studies. The overall incidence of spontaneous resorption after LDH was 66.66% (95% CI 51% – 69%). The incidence in the United Kingdom was 82.94% (95% CI 63.77% – 102.11%). The incidence in Japan was 62.58% (95% CI 55.71% – 69.46%).

LIMITATIONS: Our study was limited because there were few sources from which to extract data, either in abstracts or published studies. There were no randomized, controlled trials that met our criteria.

CONCLUSIONS: The phenomenon of LDH reabsorption is well recognized. Because its overall incidence is now 66.66% according to our results, conservative treatment may become the first choice of treatment for LDH. More large-scale, double-blinded, randomized, controlled trials are necessary to study the phenomenon of spontaneous resorption of LDH.

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Reference

Zhong et al, (2017) Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician

Ligament Sprains & Timeframes

Ligament sprains are one of the most common injuries, as their main role is to support the
joint. If poorly managed there is a risk of further injury.

Patience is not about doing nothing. Patience is about doing everything you can. But being patient about Results

What are ligaments?

Ligaments are fibrous tissues that attach from one bone to another across a joint. The tissue is very strong, varies in thickness and is dense with nerve receptors. Its role is to provide stability, guide movement, maintain joint shape and act as position sensors for the joint.

Previously ligaments were thought of as inactive structures, they are in fact complex structures that influence the localised joint and the entire body once injured (1).

How are ligaments injured?

Ligament sprains are the result of loads exceeding the maximum strength of the ligament with little/no time to recover. This force causes acute tears of the ligament fibres.

These structures can be damaged through several mechanisms, like contact or direct trauma, dynamic loading, repetitive overuse, structural vulnerability and muscle imbalance (2). A sprain of ligaments usually affect the following joints:

How does it affect us?

As with most soft tissue damage there will be the typical acute pain and swelling. Injury to a ligament will compromise joint stability and ability to control movement. It can also reduce our balance, proprioception and muscle reflex time (3). With poor joint position comes restriction in movement and weakness of the surrounding muscles.

What types of ligament sprains are there?

The severity of ligament injury is graded using various clinical classifications. The most common is a three-level system that determines structural involvement.

Grade 1 Grade 1 sprain1

  • Slight stretching and microscopic tearing of the ligament fibres
  • Mild tenderness and swelling around the ankle
  • Heals within 1-2 weeks 

Grade 2

  • Partial tearing of 10-90% of the ligament fibresGrade 2 sprain1.jpg
  • Moderate tenderness and swelling around the ankle
  • Partial structural instability when tested by Physio or doctor
  • Healing takes up to 6 weeks

Grade 3

  • Complete tear of the ligamentGrade 3 sprain1
  • Significant tenderness and swelling around the ankle
  • Complete instability when put under stress
  • Poor weight bearing
  • Conservative treatment can take 12-16 weeks
  • Potential reconstructive surgery is required

*Timeframes are based upon the guidance of a professional. Treating injuries on your own poses a risk of not fully recovering and a greater chance of re-injury.

For an appointment, call on 095290990 

  1. Frank, (2004) Ligament structure, physiology and function. J Musculoskelet Neuronal Interact
  2. Gabriel (2002) Ligament injury and Repair: Current concepts. Hong Kong Physiotherapy J
  3. Hauser (2013) Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics. The Open Rehabilitation Journal

Recovering from an ankle injury

Ankle sprains are a common injury in sport. If not assessed by the physio and guided correctly through the recovery they often struggle to get back to normal levels and are more likely to re-injure the joint.

Ankle sprains

Ankle sprains account for up to 30% of all sports injuries (1). When the ankle joint is put under strain from sudden twisting forces or landing in an uneven position it causes too much stress on the supportive ligaments, resulting in a tear. More commonly seen in sports with lateral movement and jumping, such as basketball or volleyball. But everyday life, misjudging steps or walking on uneven ground.

Symptoms:

  • Severe pain
  • Swelling
  • Bruising
  • Difficulty walking
  • Stiffness
  • Weakness
  • Loss of balance

What structures get damaged?

Fractures

The ankle consists of 3 bones, the Tibia,ankle fractures Fibula and Talus. Depending on the force from the injury we can have fractures of the tibia and fibula. 25% of ankle sprains could have some form of fracture (2), whether it be a complete break, a chip of the bone or the ligament pulling the bone from its attachment. An Xray would help eliminate this diagnosis and help guide your rehab.

Ligaments sprains

The ankle is the pivot point for the foot and the leg, it gives us a range of different movements. We have ligaments aligning in various directions to provide support for the ankle. When movement is taken too far ligaments can be damaged. On the outer part of the ankle we have 3 ligaments, the inner part has a large dense ligament and the tibia and fibula have connecting ligaments.

An ankle sprain can have more than one ligament involved, but the most common ligament to get strained is the Anterior Talo-Fibila Ligament (ATFL), affected by up to 73% of ligament injuries (3). Most commonly brought on from rolling the ankle.

The degree of damage to ligaments is classified by grades 1-3. Grade 1 meaning small tears of the ligament fibers, Grade 2 a partial tear of the ligament between 10-90% and grade 3 being a complete rupture. All grades have different recovery times and need to be guided appropriately for the best outcome.

Management of my ankle sprain

In the first 72 hours you will go through the first stage of healing. During this time you want to move the ankle within your comfort level, don’t push into sharpness. Compress and elevate the joint to manage the swelling. If you wish to use ice (5 minutes minimum) and NSAID’s, use it sparingly only to control the pain. See my blog about ice for more info.

Diagnosing an ankle sprain and rehab

If you have sprained an ankle it’s important that you are assessed by a Dr or Physiotherapist. Taking a detailed history and clinically assessing your ankle will help us come to a clear diagnosis of your injury. Xrays and ultrasound scans may also be required.

Someone that sprains their ankle is 5 times more likely to sprain their ankle again (4)

Once we understand the severity of the injury, treatment can be more specific to achieve the quickest recovery. Physio can assist in number of ways:

  • Education – Understanding the tissue recovery, the mechanics of the ankle, knowing your treatment plan and the stages of your rehab.
  • Gait re-training – You may start off on crutches or a moonboot, but then weaned off and guided to walk normally.
  • Exercise prescription including sport specific training – As you improved you will be provided the appropriate exercises. Including exercises relating you your sport to make a better transition.
  • Balance exercises – Progressing balance is essential to preventing further ankle sprains.
  • Taping – There are a number of strapping techniques for swelling/bruising in the initial stage. Strapping can ease you back safely into sport.
  • Soft tissue massage – This helps stimulate blood flow and encourage healing. Also, helps desensitise the nervous system to encourage better movement.
  • Mobilisations – to assist in better movement of the joint and gives you more confidence to use it.

For an appointment, call on 095290990 

  1. Fong et al, (2007)A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007
  2. Luciano et al, (2012) Epidemiological study of foot and ankle injuries in recreational sports. Acta Ortop Bras
  3. Woods et al, (2003) The Football Association Medical Research Programme: an audit of injuries in professional football: an analysis of ankle sprains. A Br J Sports Med.
  4. McKay et al, (2001) Ankle injuries in basketball: injury rate and risk factors. Br J of Sports Med.

Coping with Stress – Part 1

We all suffer with stress and it’s becoming a growing problem where people struggle to cope and burnout. Stress impacts my patients on a number of levels, mainly with pain perception. When under control we have better recoveries from injury.

The Greatest weapon against stress is our ability to choose one thought over another.

Everyone can recognise stress in their daily life. Some people seem to have more stress than others, or is it simply their reaction to events that creates stress? What is stress? And why is a physio talking about stress?

What is stress?

Fight or flight is stress at its very basic. It’s an important mechanism our brain has to cope and be ready for any perceived threat. This causes many bodily changes to prepare us for action, such as increased neural activity, muscle tone, heart rate, breathing pattern disrupted sleep etc. But stress is also emotional and responds with the same physical response. There are two forms of stress positive and negative. It helps to have a balance of both to make logical decisions.

Positive: It can motivate us into action and achieve our goals.

Negative: Too much causes anxiety and other health issues.

There are many forms of emotional stress. Everyone manages stress differently, making it easier for some people to cope with than others. Below are the leading causes of negative stress.

  • Workplace environment, too many emails, phone calls, long hours
  • Divorce/breakups/relationship difficulties
  • Demands of family/children (sleep patterns, household duties, balancing activities)
  • Car accidents. Being stuck in traffic
  • Theft, burglary, loss of personal property
  • Loss of employment or business
  • Death of a family member or close friend
  • Cash flow problems
  • Poor academic performance/work overload

How can stress impact my injury?

When we’re injured we have the mechanical pain from the damaged structures. But carrying negative stress causes increased sensitivity of our pain receptors and decreases the inhibitory interneurones in the central nervous system that regulate how much pain we feel (1,2). If we find ways to channel our stress better the pains we feel from injury become more tolerable.

  1. Donello et al, (2011) A peripheral adrenoceptor-mediated sympathetic mechanism can transform stress-induced analgesia into hyperalgesia.
  2. Corcoran et al, (2015) The Role of the Brain’s Endocannabinoid System in Pain and Its Modulation by Stress.

Improving press position

The final part to the 4 shoulder positions that give us stability. The press position is used in so many ways, failing to find a good press shape can produce poor results and pose a risk to injury.

This is the final part of the 4 shoulder shapes we should all be able to achieve. Creating these shapes provides more efficient transitions when under load, making it easier and posing less risk to the shoulder.

So we’ve opened up the over head, front rack and hang shape. The last position is a press. Think of so many positions, bench press, rowing, burpee, chest to bar pull up, muscle up, ring dip….. If we create a poor, unstable position from this point it will make the movement much more difficult.

With the press we need to achieve full shoulder extension without the elbows flaring. Rarely do we get full extension in the shoulder. Even when sat at a desk typing were put in a perfect opportunity to hold the press position, but we get too flexed through the spine and the keyboard is placed to far away.

The other movement is internal rotation, which was part of our hang position. Good internal rotation at the shoulder will stop the elbows from flaring.

The last part being the lack of mobility of our lower cervical and upper thoracic spine. Which when stiff takes us into a rounded shoulder position. Trying to mobilise this area will help improve shoulder and head position.

Below are a series of mobility exercises to help with these directions.


Barbell hold – With the bar racked up to shoulder level and secure in the rack. Reach back with both hands, hold onto the bar and gentle lean forwards till you feel a stretch in the front of the chest and shoulders. Hold for 2 minutes. Gradually work your hands closer together.

Peanut lower cervical – This one you’ll have to get hold of a peanut (two lacrosse balls stuck together). Place the peanut at the base of the neck. Lift the hips to the ceiling. Some gentle rocking or arm movements through flexion or behind the back will help mobilise this point. 2 minutes

Lats smash with LaX ball – Take the ball under the arm pit into the meaty portion at the back, which is your lats. Roll into the lats with the arm in over head position lying on your side. 2 minutes.

Band hold – The other alternative to the bar hold is a band hold. Same position but hold the band behind you. Hold the stretch for 2 minutes.

CrossFit – How can Physio help?

CrossFit has its share of injuries like any sport. An experienced physio with knowledge of the training can get an athlete functioning pain free quickly and performing back to their best.

To perform at your best you need a strong mindset, great coaching staff that are strict with your technique and an experienced physio to prevent aches and pains

Most Kiwi’s are pretty tough, with a ‘she’ll be right” mentality when it comes to injury. You’d think that would be a perfect combination with the image CrossFit portrays. But when you’ve been carrying that niggle for so long and it starts getting worse, it could shut you down completely from training.

Physio and CrossFit work well together

Physio’s are specialists in movement analysis and CrossFit itself is a training regime that goes through gross fundamental movement patterns. So putting yourself through these movements and identifying your weakness’ gives me a lot more insight into where your problem could be coming from.

What are the common complaints?

There have been interesting studies done over the last few years into injuries within CrossFit. Interestingly the studies correlated similar with the same common areas being involved:

  • Shoulder
  • Lower back
  • Knee

Some injuries being severe enough to stop some from working, training and competing. These are the most common areas of injury I see come into the clinic from CrossFit, but I also see others suffering from:

  • Neck and thoracic strains
  • Ankle sprains and hypomobility
  • Hip impingement
  • Patella dysfunction from quad heavy squats
  • Wrist strains

How can Physiotherapy help?

As a physio it’s my job to get you functioning pain free as quickly as possible. Being a Crossfitter myself, who performs daily and understands the training styles, philosophy and terminology I can relate to the frustrations that you may face with limitations in training. Also working on site I can take you into the gym, look at techniques of different movements and provide you with additional drills to perform before your WOD.

What do I offer a CrossFit athlete?

  • An assessment of your movement patterns looking for weakness, asymmetry and any underlying mobility issues.
  • Hands on therapy for immediate pain relief, this may involve soft tissue massage, joint mobilisations and dry needling.
  • Localised taping of problem areas to assist you during your next training session
  • Diagnosis and ongoing management for acute or severe injuries, including referrals for further tests such as x-rays/ultrasounds, scans or to a specialist.
  • Educating you on what caused your injury or pain and steps to prevent further problems.
  • A personalised rehabilitation program – listing corrective, strengthening and stretching exercises to assist your recovery.
  • Liaising with and providing regular updates of your progress directly to your coach or trainer to ensure you get a coordinated approach to your rehabilitation. This also ensures that you are scaling or modifying WOD’s as required.

For an appointment, call on 095290990 

Montalvo et al (2017) Retrospective Injury Epidemiology and Risk Factors for Injury in CrossFit. Journal of Sports Science and Medicine

Keogh et al (2016) The Epidemiology of Injuries Across the Weight-Training Sports. Sports Medicine

Weisenthal et al (2014) Injury rate and patterns among CrossFit athletes. Journal of Orthopaedic Sports Medicine, Arthroscopy, and Knee Athroplasty

Improving front rack position

Improving the front rack position can help us in so many movements. This page shows a number of stretches that will improve shoulder mobility. and help prevent injury.

This is the second part of the shoulder, expanding on a previous post about 4 important shoulder positions that we should all be aiming to achieve. It’s quite important that you can find these positions comfortably, especially under load, as it will help to limit the risk of injury but also make it easier for you to transition out of it.

So, we’re all now great with our over head position. Can you now transition back down to a front rack? à la thrusters, hand stand push ups or catching the wall ball into the squat. Front rack is the most complexed out of the 4 positions as there are so many structures feeding into that position.

With Front rack most of us struggle with finding that shoulder external rotation to get the hands outside of the shoulders while keeping the elbows high. This helps line the hands into a stable platform for the bar.

The forearms are often tight making it hard for the wrists to fully extend. How many of us get achy wrists after front squats? Create that stable platform with good wrist extension.

Our triceps can also restrict the elbow from going into full flexion. And finally good Thoracic mobility as mentioned in the over head position. It will impact achieving extension and getting the maximum lift through the elbows.

Below are a series of mobility exercises to improve that Front Rack position.


Stick external rotation stretch – Grab a stick, hold it outside the arm. Lift your elbow and pull the stick from underneath your arm, across the body. This will pull your hand out further and you will feel the shoulder wind up. Hold for 1 minute. To take this further by repeating a hold-relax method, pulling the stick inwards for 5 seconds then relaxing further into external rotation .

Banded External rotation – Put the elbow into the band, take the hand on the inside of the band and hold on. Keep the elbow close to your head and drive the arm pit forwards. Hold the stretch for 2 minutes.

Wrist Flexor stretch – Kneeling on the floor, with palms facing away, put your hands down on the floor and take the wrists into extension, moving your body backwards. Hold for 2 minutes. Next get the band and place the hand in the same position. Have the band pull away while doing small oscillating wrist extensions into the stretch. Repeat for 1-2 minutes.

Triceps smash – Excuse the facial expressions in this video, I don’t always look that way! Resting the tricep on the bar while flexing and extending the elbow. Start at the triceps tendon (above the elbow) repeat 10-12 reps then move higher up the muscle. To increase the pain….I mean load, use the band to get fascia tacked down to the bar.

Thoracic Mobility as mentioned above it’s important to extend at the Thoracic below are two basics.

Improving overhead position

Often we are restricted with overhead movements as it is an action we don’t use often enough. Try these exercises to increase movement if your tight reaching above your head.

So from the last blog we’ve learnt there are 4 positions of high torque when we wind up the shoulder capsule and surrounding muscles. By utilising these positions they will produce better pathways to move from and minimise the risk of injury.

We’ll start off with the over head positions. In every day life we don’t take our hands above our shoulders often enough. It’s understandable the shoulder will feel tight in these positions. But with a little regular mobilising we should be able to feel more comfortable holding our arms up there.

In the shoulder we have big internal rotators and some small external rotators which can cause a bit of an imbalance. Both internal and external rotation needs to be stretched to achieve full over head movement.

The other thing restricting our overhead movements is thoracic mobility. Another area that often gets stiff with a sedentary life. Additional extension at the Thoracic region without hyper extending at the lower back will give us better shoulder flexion.

Below are some basic mobility drills to improve Thoracic extension.

Foam Roller – Slowly moving over the foam roller, trying to extend over the top, keeping steady breathing throughout. Try to keep the neck in a stable position avoiding hyper-extending, also avoid rolling into the Lumbar spine.  Try this for up to 2 minutes. Once you find some stiffness, stay on that point and lift your arms straight above your head. 1 minute.

https://www.instagram.com/p/BT2yyupFzCP/?taken-by=fundamentalphysio

T spine extension – Kneeling, put both elbows up on the step/box. Drop the chest down to the ground. Feeling a stretch at the Thoracic spine and lats. Hold the stretch for 2 minutes. Try to stay strong at the lumbar spine avoiding extending.

https://www.instagram.com/p/BT2zxQgFaYu/?taken-by=fundamentalphysio

Below are just some stretches you can do to access both the internal and external rotation restrictions at the shoulder.

Pec major stretch – Using a resistance band, taking up the slack with the hand behind, turn your body away, producing a large stretch in the chest. Hold for 2 minutes.

https://www.instagram.com/p/BT20WulFJyD/?taken-by=fundamentalphysio

Under arm stretch – Attach a light resistance band to the opposite frame. Hold the other end with your hand behind the neck, pull into the opposite rack and drive the armpit into the poll. You’ll get a good triceps and lats stretch. 2 minutes.

https://www.instagram.com/p/BT20x4YFGYp/?taken-by=fundamentalphysio

Infraspinatus LaX ball smash – Direct the ball into the shoulder blade. With the pressure, take the hand across the body and over head. 1 minute each direction.

Trigger points – what are they?

Trigger points are the most common source of muscle pain. There are many factors that affect a trigger point and for best results they should all be identified.

I’m going to put a wild bet out there that everyone has a trigger point in at least one muscle of their body. Some have more than others. Who of you are regularly rubbing their shoulders or elbows? More and more we are sitting at the computer or looking down at our phones (sorry for writing this blog) causing prolonged tension on muscles around the neck and shoulder, resulting in the development of trigger points.

What is a Trigger point?

It is defined as a hypersensitive palpable nodule in taut bands of muscle fibers. Meaning very small bundles of muscle fiber have become contracted/”knotted” due to a chemical imbalance within the tissue.  The area is very painful and can cause you to jump or cramp on palpation. It can cause referred pain, weakness and restriction through movement. Which makes doing normal activities and training difficult.

Triger Point diagram
Diagram of trigger points within a muscle

Trigger points of individual muscles have a very specific referred pain pattern and can mimic other problems. For example pain in the forearm and wrist can be referred from Infraspinatus, a shoulder muscle. Without a detailed assessment and clearing other areas this could be misconceived as a tennis elbow.

What causes a trigger point?

A TP can be brought on in a number of ways. 

  • Poor postures held for a prolonged period, causing certain muscles to work harder while trying to support structures like the head, eventually causing TP’s.
  • Repetitive strain on muscles from overuse over multiple days, weeks and months. How many clicks of the mouse or typing are your doing? How much swiping of the smartphone? These repetitive movements take their toll.
  • Emotional stress and poor sleep can cause muscle tension. Particularly the neck and shoulder muscles.
  • A lack of movement will develop TP’s when sitting or on bed rest for a prolonged time.
  • Heavy lifting can cause the development of TP’s when the muscle is placed under excessive loads which it is not familiar with.
  • Trauma to a muscle, either as a reflex to pain or overcompensating for the weak and injured structure. This is quite common with car accidents or sports injuries.

Our muscles sit within a biochemical “soup” of  hormones, nerve transmitters and chemicals, all affecting the PH and Oxygen levels of the tissue. Your body knows the perfect recipe to keep everything balanced, but when we overload it with one or more of the above, it causes changes to the recipe, resulting in a drop in PH (becoming more acidic) and reduces the oxygen supply. This leads to the development of TP’s.

How do we treat a trigger point?

Your desire to change must be greater than your desire to stay the same. 

The following treatments for trigger points will help settle them down, but if we provide the same environment they will return.

  • Trigger point release – sustained manual pressure applied to the trigger point causes increased blood flow to remove toxins from the area, interrupts the pattern of pain and spasm and encourages the production of natural pain relieving endorphin’s.
  • Trigger point dry needling – There is a growing evidence base for trigger point dry needling. The needling causes local twitch responses which are a central nervous system reflex. This helps disrupt the pain feedback loop but also reset the acidic biochemical “soup” the muscle is sitting in, back to its normal levels.
  • Myofascial release – the surrounding tight myofascial tissue that feeds into and over the trigger points could also be restricted, causing further exacerbation of the area. Using this technique will give some length back to these structures and can alleviate the trigger point.

Once the hands on therapy has been applied it is not the end of treatment. The muscles with the TP’s will need to be stretched to help prevent their return. Postural correction and stability exercises for surrounding muscles may need to be followed. Changes ergonomically may need to be enforced to prevent falling back into poor habits. Also looking at ways of alleviating stress through improved sleep, meditation, breathing techniques and increase of general exercise.

All of these factors will need to be considered to provide long lasting benefit and avoid their return.

  1. Travell & Simon (1999). Myofascial Pain and Dysfunction: The Trigger Point Manual
  2. Shah et al (2008) Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: An application of muscle pain concepts to myofascial pain syndrome. Journal of Bodywork and Movement Therapies
  3. Simons, (2008), New Views of Myofascial Trigger Points: Etiology and Diagnosis, Archives of Physical Medicine and Rehabilitation

Does your shoulder get the green light?

Are you able to achieve full shoulder range and move efficiently with speed and load. Essential to preventing injury and getting the most out of your training.

The shoulder is such an interesting part of the body. It’s a joint that’s suspended by muscles and fascia and its only point of contact with the rest of the skeletal system is a dinky little joint at the collar bone. Which means that our musculature is doing all the work to maintain stability while moving through huge ranges.

Underneath the layers of muscle, the shoulder has a capsule and it has four positions where it winds up and reaches its highest levels of tension and stability. If we can achieve these positions from start to finish when transitioning through movement, particularly under load we’ll have less chance of injury.


  1. The first movement being overhead a combination of external rotation and flexion at the shoulder and protraction of the scapula (moving forward around the rib cage). Examples of this being the start position of chest to bar pull up or end position of push press. Our arms should get past our ears with the elbow pits facing each other.
  1. Next the front rack position is also flexion and external rotation of the shoulder. Obvious examples are a front squat or the bottom of a hand stand push up. This is elbows up to shoulder level, with the hands outside the shoulders and palms turned up.
  1. Hang position is a full internal rotation of the shoulder. This can be seen when we clean or Snatch. Elbows out to the side at shoulder level and hands down to floor, aiming for the forearms to be in line with the body.
  1. The press position consists of internal rotation and extension. Seen with the start of a bench press or bottom of a ring dip. The elbows are taken past the body as far as possible with hands at chest level.

Failing to maintain shapes of stability becomes more difficult to transition and finish safely to the next position. Make sure you have competency in all 4 positions. If you’re struggling with a position you need to be mobilising. If you’re having pain with these positions you should have it assessed to avoid being side lined.