#675: Eric Cressey, Cressey Sports Performance — Tactical Deep Dive on Back Pain, Movement Diagnosis, Training Principles, Developing Mobility, Building Power, Fascial Manipulation, and Rules for Athletes

Systemic issues like vitamin D affect back pain

Medications, nutrient deficiencies, and under-reported injuries often contribute to back pain more than structural issues on imaging.

"Do you know if this person is wildly deficient in vitamin D or they have adequate magnesium levels? There can be so many different places where things can kind of go off the rails systemically that I think it's just so important to always start with a conversation and also get a feel for their history with exercise and in some cases, rehabilitation. What's worked, what hasn't, what's made you feel better. All right, you felt great with dry needling, but not with something else. Those are all things that can kind of give you a clue into the clinical puzzle, so to speak. Yeah, totally. If somebody is, let's just say a jujitsu player and they're constantly in guard, that's going to be very different from say a surfer who spends 90% of their time paddling in that extension. So you have the conversation. What happens after that? I always go to a static postural assessment and there's a lot of, I guess, debate over posture and it doesn't perfectly predict injury or lack thereof, but it does give us some clues into where people at least start. And then there are schools of thought that are heavily focused on alignment. The idea being if you're in a good alignment, it's going to increase the likelihood that you're going to be in a better position once you actually wind up somewhere else. I look at it much more as how's gravity working on this body? What are the shapes that they're in? And it starts to give me some clues on, hey, if you've got really, really low shoulders, you got this downslope shoulder blade like crazy and you have anterior shoulder pain, I'm probably thinking that when we get to movement, your scapular upper rotation, what's taking place when you take your arms overhead, probably is going to be less than ideal just because you're starting 10 yards behind the starting race. The other fly in the ointment for me is that I have congenital transitional vertebra. Well, I should say vertebrae. What is the plural? Vertebra is the singular, I guess. So I have one transitional segment, which means for people who may wonder, if you're looking at my lumbar spine, so my lower back on an MRI from the side, the segments of the spine should, and I'm simplifying here, but look kind of rectangular. And in my case, I have one vertebra in the lower back that is more like a wedge. It's like a door wedge. So I have a lot of lower back lordosis, right? I have sway back, basically. I used to have kyphosis, which was that hunchback look. Thankfully, fixed that. But that is also another aspect to this whole thing, which has led it to be a problem for decades. It's true for my brother as well. But then, whatever it was, 12 weeks ago, suddenly everything just got put into acceleration mode from a pain perspective. and it's really been mystifying. And it's made me really sympathize for people in chronic pain because it seems to be such an elusive problem for so many people. So you look at the static posture. What comes next? I mean, to your point, everybody's invincible until they're not, right? And I think that's a line I tend to use quite a bit. But you might have that conversation about, hey, I have a congenital variant in some way. Some people we see in the structure of their hips or could be a number of different things, but what you also have to do is you have conversations with doctors, with physical therapists to see if their symptoms actually correlate with where that may take place. And that's something I should emphasize is that I work as part of a comprehensive team. I have physical therapists one door down and massage therapists. And we refer out to a lot of orthos on the regular. But once we've done that postural screen, you know, for me, I will go into a collection of like, I guess, classic orthopedic range of motion tests. We may do some manual muscle testing. And then we actually get them up and move them around in more general screens. Things like overhead squats, overhead lunge walks, pushups, toe touches, shoulder abduction, slash flexion, all these different screens that are, I guess, collectively general screens. So you want a collection of both general and specific screens that you're not necessarily missing things. I got it. So general screen, but you're also doing specific screens that might relate to the lower back assessment. Yeah. And those are your gateways, right? In my world, those are sometimes just the things that I need to know on whether, hey, we need to refer this out. Because you're going to have people that walk in with low back pain that just, they trained like idiots. They either choose the wrong exercises. Who are you calling an idiot? Or they go in the wrong patterns or whatever it is. So some people just need good coaching and maybe a little break. Maybe they need a discussion about like, hey, the volume in your program is just inappropriate. We need to find some different kind of variability for you. And then other people, they kind of scream, this is something much more clinical. We need to escalate this. We need to get it to the hands of somebody who could do some imaging for it and maybe get a better diagnosis. Or we may in-house do some kind of test retest where it's, Hey, let's do some manual therapy here and let's see if they get some symptomatic resolution. And if we do create some kind of a transient change, whether it's in the context of their range of motion or in their reduction of symptoms, what are some things on the exercise side of things that we can do to follow it up to make those changes stick? Is there a resource or a book, anything that people could check out to become familiar with some of these movement screens? Long time ago, I talked about FMS in the four-hour body. There are probably many other variants of that type of screen. With the understanding that you should work with a professional, are there any other resources you might recommend? Yeah, for sure. And I think the crew at FMS has done a good job. And the selective functional movement assessment is kind of a little bit more of a clinical add-on to that, that I think they've done a good job with that. If you walk in and look at our screen, it's really a collection of different philosophies all melded together. So I think my response would probably be very different for people in the health and human performance industries asking versus like a general population folk. With that said, I know Kelly and Juliet Starrett in their new book have kind of talked about some stuff. He was a recent guest, just things that people should be able to accomplish in terms of activities of day living and tasks. I do think that's a little maybe a good proactive screen that people could use. Built to move for people. Great read. Just finished it. So people could start there. Let's continue to go down the rabbit hole of lower back pain. So I'm looking at some research that I gathered for this conversation. Could you speak to maybe some of the ingredients in the cocktail that can produce lower back pain or exacerbate lower back pain? So I have a number of things here. I didn't want to read them in depth. maybe you have revised your thinking on this, but I have a whole list of things here. Left AIC, right BC patterning. No idea what that is. Poor motor control and strength of the glutes, poor hip rotation and mobility in general, thoracic spine mobility, et cetera. Are there any usual suspects that in, not necessarily sedentary folks, but let's just make this personal because that's the easiest way to have a conversation. You have a former competitive athlete, me, and I've done a fair amount of extension and flexion, but I'd say probably more flexion just from wrestling and so on. And I have not competed in a long time, but I've continued with the weight training and sometimes more methodical than other times. What are some of the ingredients that you would want to consider as part of the cocktail that is producing the lower back pain? I can't remember when I wrote that, but it's a good find in the archives. I think the big things that I would say is all those things come back to probably two things. It's loading aberrant patterns. So, you know, an example of the left AIC, right BC patterning, that speaks to the Posture Restoration Institute. And they talk about a very predictable pattern of asymmetry, you know, right hips that are shifted out, low right shoulders. And so there can be some compensatory things when we start to load that. What does that mean? Left AIC? It's just an abbreviation for the pattern that they talk about. I see. But basically that's the way they define it. And you will see it very commonly. If you go to any major league baseball game, you'll see every shortstop standing between pitches, like in the exact same position, they'll be stuck in their right hip with a low right shoulder. And their mindset has always been that we'd rather breathe well and move poorly than move well and not be able to breathe. It's a survival instinct. And to some degree, these patterns that we account for are how we maintain our line of sight and our ability to breathe the way that we want to. So these are normal asymmetries, right? We have a heart and we have a vena cave on one side and a liver on the other side. But when we get into trouble is where these things may become excessive and we load on top of them and we lose the variability that we count on to have long-term successful movement."

MRI findings often don't correlate with back pain

82% of asymptomatic people show disc abnormalities on MRI. Cressey emphasizes movement diagnosis over imaging alone.

"What do you mean by that? So if you look at how your spine is constructed, as an example, look at your lumbar spine. They're very big vertebral segments. They're really conditioned much more for handling compression. They don't rotate nearly as much. And as you go further up your spine, you have substantially smaller segments that are way more equipped for rotational capacity. And I think that just speaks to our body's wonderful design, is that we need to get a lot of rotation through our hips and a lot of rotation through our mid-back arthacic spine, and certainly our cervical spine as well. And we don't necessarily have it. Sometimes we go to the wrong places to get it. And that's why some people wind up with back pain. What would be some of the wrong places? The lumbar spine in particular. Oh, I see. Rotating at the lumbar. Correct. Basically using the molars of the back to rotate. That's exactly it. You get into trouble when you bang those big segments off of one another. you can wind up with a collection of different issues. And, you know, Stu McGill has done some great stuff in his research where he's talked about spine range of motion, particularly lumbar spine range of motion being positively correlated with injury risk. It has to move, but it just can't move to an excessive amount. There is such a thing as hypermobility. Exactly. And I think the challenge that we see sometimes is how people change over the course of time. So, you know, I talked in that article about poor hip mobility and we know that some athletes over the course of time will develop reactive changes in their hip. Now, does poor hip mobility in this context mean hip extension, sort of the freeze frame of the sprinter with one leg behind them, or does it mean something else? I think it can be all the above. You you look at a lack of hip internal rotation, it seems to be associated with low back pain in golfers. So I think it depends on what your activity is. But I would argue that not having sufficient hip flexion can create problems too. I think it's a joint that obviously has evolved from an evolutionary standpoint from being very, very mobile to being a little bit more stable to support weight bearing. But where we get into trouble as we start to lay down a lot of bony overgrowth on the acetabulum, so the socket, or on the head of the femur. And those can create a collection of challenges because you have stiffness that you have a hard time working around. So at the end of the day, it all comes back to we lose variability over the course of time. We lose the ability to go back to what's very foundational for us. So I'd love to chat maybe about thoracic mobility in a second, just to do a deep dive on one of these. First, I want to say, and you can fact check me on this, just for people listening who may suffer from low back pain or back pain, or actually it's a question, what percentage of your super high performing players, if you were to take an MRI of their back, have what would be viewed as something pathological or deterioration? 100%. 100%. And the best example I can give you, this is with knees."

Push-ups and landmine presses protect the spine

Cressey favors push-ups, cable presses, and landmine presses as spine-friendly alternatives to heavy barbell pressing.

"Whenever possible, I try to emphasize things like push-ups, cable presses. I love landmine presses."

Hinge patterns are safest for back pain rehab

Hinge-based movements like deadlift variations are generally safer for back pain than squats due to biomechanical advantages.

"But in general, these are high cross-sectional area muscles that probably have a lot more of an ability to help us. And most people are going to be stronger in a hinge pattern than they are in a squat pattern. So it's probably the most biomechanically efficient way for most people to accomplish Thank you. to help us. And most people are going to be stronger in a hinge pattern than they are in a squat pattern. So it's probably the most biomechanically efficient way for most people to accomplish various lifting tasks, whether it's something that's significant in the gym or something that's as simple as picking up a bag of groceries or a kid. What are your go-to exercises? If you could only pick two or three, let's just say, for the strengthening of the posterior chain and that hinging action, where would you go? Without a failure, looking at a deadlift. And deadlift is a broad categorization. You might have a trap bar deadlift or a kettlebell deadlift, something that in those realms are going to be a little bit easier to teach. A lot of people go right to the straight bar and some people just are not biomechanically set up to be successful with that. So we don't necessarily go to that. Things like kettlebell swings, if you're ready for the patterning and the higher velocity, I think a lot of people need to train power as much as they need to train strength, particularly as we age. And that's a low impact alternative to going out and sprinting or jumping that isn't going to leave an Achilles on the floor. So I think kettlebell swings probably have some merit in that discussion. Certainly various hip thrust opportunities have come about in the industry from a wide variety of exercise selections there. I think some people probably do better with them than others, but I do think there's a place for it. Anything in those worlds are good. Single leg RDLs as well. It's kind of like a- Romanian deadlift. Yeah, something underneath that deadlift umbrella. But at the end of the day, most of them are going to be deadlift derivatives. Same thing with a kettlebell swing. It's a deadlift that you just execute quickly. Why is power important as we age in addition to strength? And maybe you could differentiate the two. So really think of power as just strength with a time component. It's how quickly we can apply force. And you'll see powerlifting is really not powerful. It's slow movement. Yeah. Most of the athletes you see on TV are really, really powerful. The guys that are running fast and jumping high, that's kind of a in-person demonstration of power. But I think where power is tricky, we do know that it tends to detrain fastest. Strength, aerobic capacity, they actually stick around pretty well. Assuming you're not like a crazy high level of those things, you can probably train it if you're in an intermediate to slightly advanced stage, you can probably train it once every 30 days and it's going to power. No, I'm talking about strength and aerobic capacity. On the power side of things, it seems like it starts to detrain in as little as five to seven days. So it's very important to actually challenge it. And where it becomes vitally important as we age is, this is the stuff that protects you when you're older and you want to avoid falls. And we know that you fracture your hip. For a lot of people, it's honestly a death sentence, as terrible as it sounds, because it markedly impacts your mobility. We know that the cognitive decline after a loss of ambulation is really substantial. So we see a lot of people that just tend to spiral after falls. Being honest, my own father passed away a couple of years ago after he fell down our cellar steps and fractured his clavicle. And it was very interesting, maybe in the context of the orthopedic relationship to systemic factors, he kind of went through multi-system failure. He was unhealthy, but a clavicle fracture on a fall really kind of like pushed him over the edge on it."

How to find good orthopedic practitioners

Ask local sports teams for referrals to their preferred orthopedic specialists rather than searching blindly.

"If you're in any decent-sized city, you don't have to find someone from the Yankees. Any sports team can give you a referral to their favorite ortho."