There are a lot of exercises used in training that can have a very dramatic effect in a clinical cissoretting. The scale of the exercise may be different depending on the population, but the principles remain. Many times in the clinical world, clinicians get caught up in doing the same exercises they were taught in school that may be effective in the beginning of recovery from an injury but do not elicit enough of a stress to really drive adaptation when thinking about creating optimal function for a patient (or athlete).
First, a mention of the farmer’s walk and suitcase carry
One of the most under utilized exercises in clinical work is a properly coached, executed, and appropriately heavy carry. Most do not understand how a sufficiently challenging farmer’s walk or suitcase carry can force a patient to create appropriate levels of trunk stiffness and loading of a single leg stance. You can replace many correlate exercises for “core activation” (one of Pavel’s favorite terms!) with a variety of carries. Do not get me wrong, everything has its place depending on the person you are working with, but eventually you have to create enough of a stress to drive an adaptation.
The farmer’s carry and suitcase carry are terrific examples of exercises that are missing in the training of most patients and athletes. They provide an excellent training stimulus for the frontal plane and can help correct a variety of compensations and imbalances around the trunk.You likely plan them in your training and the training of others already so I am doing to discuss two other carries that are favorites of mine. These two carries tackle a lot of the same trunk stability issues we see but in a slightly different way. We will discuss the use of the kettlebell front rack and overhead carries.
I have personally come back from four major upper extremity surgeries and have an affinity for working with shoulders at my clinic. While some of the things I do are outside of the scope of practice of the strength coach (manual work to help a person reclaim position) the simple strategies I use to help people learn (or re-learn) positions of the shoulder are fair game. My intent is to give you an understanding of why I do certain things and how they can be applied in a clinical or coaching setting. While the farmers carry is important in the beginning stages of recovering from a shoulder injury, the rotator cuff is reflexive to distraction and compression to keep the head of the humerus centered in the socket, it does not take into account organization of the trunk and pelvis while holding your arm in different positions.
Carry No 1: Front Rack
For a shoulder to be considered healthy, (at least in my book), it needs to be able to move from a front rack position to an overhead position with control, strength, and without pain. If you are familiar with the principles of StrongFirst, pressing big weight overhead is a staple of our big six of training. Pavel even wrote a book, you may remember Enter the Kettlebell, with one arm pressing and swings as the main training objective.
We will start with the front rack carry. To me, it is the most underutilized of the carries I typically see performed with a kettlebell. Your press is only as good as your clean (that is an old StrongFirst saying that is still very true) and the front rack carry is an extended version of that moment after a heavy clean before you press the weight overhead. If you do not have a solid front rack with all the proper muscles firing to position the kettlebell and shoulder in the correct position for a smooth and efficient press, you will be asking for trouble when it comes to getting and keeping a big weight overhead.
A lot of the issues with the overhead position can be traced back to a lack of strength and endurance in the rack position. From proper breathing and bracing to proper rib cage position and movement of the scapula, it all starts from the rack. You can do front rack carries with single or double kettlebells depending on what you are trying to accomplish and I would suggest you mix in a healthy dose of both.
When you hold a kettlebell properly in the rack, you get an isometric contraction of the muscles of the shoulder girdle (pecs, lats, serratus, teres major, etc). Long holds in this position with some cuing are a great way to get the muscles around the shoulder blade active and can help someone learn better control of the position of their shoulder blade on their rib cage. Work in some deep, focused breathing and you have a tremendous exercise as the placement of the kettlebell will help self-correct people away from accessory breathing patterns (what many of you refer to as chest breathing). This can be a great way to start helping someone with shoulder impingement.
When pulling down hard with the lats and keeping the elbow down and against the rib cage, you also start getting activation of the quadratus lumborum, transverse abodominus, and internal and external obliques. Pair a long hold in the rack with an effective rooting and bracing strategy and we are starting some powerful lower back training. Add in some deliberate walking while maintaining proper posture and position and have the person breathe through the nose with their cadence and magic for the shoulder and spine will start to happen. I could have spent a long time teaching that person a whole bunch of different exercises or I can work with one well-executed exercise. The body does not really work in parts. It works in movements and the more you can make something appear like something a person will actually do, the better.
Carry No. 2: Overhead
This brings us to my other favorite, the overhead carry. Unfortunately, I typically see overhead carries performed very poorly as part of a “met-con.” The person is internally rotated with shrugged shoulders and a bent elbow; wandering around suffering. They are not receiving any benefit from the activity and are likely just cementing in a bad habit and potentially injuring themselves down the road. When performed correctly, the overhead carry is a very powerful tool in restoring proper function of the shoulder girdle. Just like the front rack carry, if it is executed with intention, proper coaching, and appropriate loading, you can replace a lot of exercises.
There are many ways to perform overhead carries but I really prefer using the kettlebell for the majority of the work. Yokes make for great variety when you want to have a person do a carry but stay connected across one implement. There is a time and a place for both in training. I am not as fond of barbell overhead carries because you can’t fail as safely as you can with a kettlebell or yoke. I also like the kettlebell because the way the weight is distributed also acts as a bit of a loaded stretch. You can certainly use dumbbells, but they require an extra degree of difficulty beyond the kettlebell. You have to fully create rotation at the shoulder to stabilize them as the weight is distributed differently. This makes the kettlebell the most utilitarian variety because you can cover the needs with most of the population you work with and easily meet them where they currently are.
When properly executed, the overhead carry will help a person with proper shoulder mechanics to stabilize a load. If loaded appropriately, you can spend a lot of time in the overhead position and teach the person, through effective cuing, to have the proper muscles engaged (elbow locked out, shoulder slightly externally rotated, lat and pec slightly engaged, arm fairly close to the ear with no shrugging). Time is a key component in this exercise so you don’t want the load to be so heavy that the person can’t keep total focus on the task for an extended period of time. You need to be able to see if the person can maintain proper relaxed breathing, a strong and stable trunk, and support the load with their entire torso, not just their shoulder girdle. This makes the overhead carry much more than a shoulder exercise as it challenges the entire body to work together to perform an extremely demanding task. If you can master the positions of the rack carry and the overhead carry, filling in the middle becomes much simpler when people understand where to start and where to finish.
Breathing and Rib Cage Position
Before I wrap this up, I want to go back to the importance of breathing and rib cage position during both carries. I think these are often overlooked pieces when evaluating how an athlete is performing either exercise. Breathing is a very popular topic these days in the world of strength and conditioning and you can certainly dive deep into the rabbit hole of breathing assessment and training. Like many things, people will get too far one way or the other and not see the forest for the trees. What is important to understand in the context of these carries and training of the shoulder is the position of your rib cage and how it can be manipulated with your breathing can have a major impact on the function and, eventually, health of the shoulder girdle.
This is why spending a few minutes discussing efficient breathing mechanics and how to maintain them under load and the challenges of different positions is important before you start. It is beyond the scope of this article to dive too deep into breathing mechanics but understanding how to show a person to pull air into their lungs with efficient use of the diaphragm instead of lifting their rib cage actively to fill their lungs to create intra-abdominal pressure and stiffness. Tilting the bottom of the rib cage up (this is called an open scissor between the rib cage and the pelvis) will change how the shoulder blade can move in relationship to the rib cage and throw off the normal scapulohumeral rhythm that is essential for proper overhead lifting.
If you break overhead shoulder motion into thirds, roughly one third should come from scapulothoracic motion and two thirds should come from glenohumeral motion. If we put the shoulder in the plane of scaption, which is having the scapula in 30 degrees of abduction from the frontal plane, the first thirty degrees or so of abduction of the shoulder in the sagittal plane should be coming from glenohumeral motion. After the initial 30 degrees, the shoulder blade will start to upwardly rotate and eventually the motion at the shoulder blade will account for about 50-60 degrees of the 150-180 degrees of total shoulder motion.
Here are some images of the plane of scaption. The first image is from www.rehabtrainer.com.au and the second image is from www.yogaetcstudio.com.
When people tilt the rib cage, they will not have as smooth and full motion through the scapula and glenohumeral joint and the overhead position will not feel strong and stable. Tilting the rib cage allows the person to appear to have full overhead motion but it is simply because they have changed the angle of their rib cage instead of fully flexed the shoulder. By coaching proper breathing and bracing during these static holds and carries, you can safely begin to teach and reinforce sound shoulder mechanics. Here is a video showing the carries with some explanations.
I will be discussing these and many other lifts and their applications in a clinical setting in the new StrongFirst for Clinicians course coming February 17-18 in Atlanta, GA. For more information at the link.