Training & Conditioning 19.6

Examining Sports DrinksEastern Sports Medicine Philosophy
Complex Forces
The mechanics of shoulder function and dysfunction
September 2009 Vol. XIX, No. 6, $7.00

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Nutrition
13 Fluid DynamicsFrom low cal to high sodium, todays sports drink market is more diverse than ever. Are you prepared to help athletes navigate the sea of options and find the best product for their individual needs? By Michelle Rockwell
Treating the Athlete
22 Complex ForcesA comprehensive shoulder training program can address key deficiencies and provide targeted treatment for a wide range of dysfunctions.By B.J. Baker
Optimum Performance
31 An Alternate RouteIf traditional training methods leave your teams wanting more, maybe its time to consider another approach. At Northwestern University, some athletes look to Eastern sports medicine philosophy to gain an edge.By Darryl Aiken-Afam
Leadership
39 In the Right PlaceAt the University of Vermont, athletic trainers are hired and overseen by the campus health center, not the athletic department. Heres an inside look at this organizational trend and the many benefits it offers.
By Allison Shepherd
Sport Specific
45 On the Way UpThe University of Louisville womens basketball team sees its conditioning program as a pyramid. After developing a strong foundation, they keep working until they reach the top.By Teena Murray
Bulletin Boards
5 NCAA recommends sickle cell trait testing Study explores female hormone cycle and joint laxity Warning about doping with nitrites Helping a school in financial need.
Q&A
8 Tony Cox Henry County (Ind.) Sports Medicine
Sponsored Pages
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Product News
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58 Advertisers Directory
CEU Quiz
65 For NATA and NSCA Members
68 Next Stop: Web Site
Cover Photo Getty Images.
September 2009, Vol. XIX, No. 6
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September 2009 Vol. XIX, No. 6
Marjorie Albohm, MS, ATC/L Director of Sports Medicine and Orthopaedic Research, Orthopaedics Indianapolis
Jon Almquist, ATC Specialist, Fairfax County (Va.) Pub. Schools Athletic Training Program
Brian Awbrey, MD Dept. of Orthopaedic Surgery, Massachusetts General Hospital, and Instructor in Orthopaedics, Harvard Medical School
Jim Berry, MEd, ATC, SCAT/EMT-B Director of Sports Medicine and Head Athletic Trainer, Myrtle Beach (S.C.) High School
Leslie Bonci, MPH, RD Director, Sports Medicine Nutrition Program, University of Pittsburgh Medical Ctr. Health System
Christine Bonci, MS, ATC Co-Director of Athletic Training/Sports Medicine, Intercollegiate Athletics, University of Texas
Cynthia Sam Booth, ATC, PhD Manager, Outpatient Therapy and Sportsmedicine, MeritCare Health System
Debra Brooks, CNMT, LMT, PhD CEO, Iowa NeuroMuscular Therapy Center
Cindy Chang, MD Head Team Physician, University of California-Berkeley
Dan Cipriani, PhD, PT Assistant Professor Dept. of Exercise and Nutritional Sciences, San Diego State Univ.
Gray Cook, MSPT, OCS, CSCS Clinic Director Orthopedic & Sports Phys. Ther. Dunn, Cook, and Assoc.
Keith DAmelio, ATC, PES, CSCS Head Strength & Conditioning Coach/Assistant Athletic Trainer, Toronto Raptors
Bernie DePalma, MEd, PT, ATC Head Athl. Trainer/Phys. Therapist, Cornell University
Lori Dewald, EdD, ATC, CHES Health Education Program Director, Salisbury University
Jeff Dilts, Director, Business Development & Marketing, National Academy of Sports Medicine
David Ellis, RD, LMNT, CSCS Sports Alliance, Inc.
Boyd Epley, MEd, CSCS Director of Coaching Performance, National Strength & Conditioning Association
Peter Friesen, ATC, NSCA-CPT, CSCS, CAT, Head Ath. Trainer/ Cond. Coach, Carolina Hurricanes
Lance Fujiwara, MEd, ATC, EMT Director of Sports Medicine, Virginia Military Institute
Vern Gambetta, MA, President, Gambetta Sports Training Systems
P.J. Gardner, MS, ATC, CSCS, PES, Athletic Trainer, Colorado Sports & Spine Centers
Joe Gieck, EdD, ATR, PT Director of Sports Medicine and Prof., Clinical Orthopaedic Surgery, University of Virginia (retired)
Brian Goodstein, MS, ATC, CSCS, Head Athletic Trainer, DC United
Gary Gray, PT, President, CEO, Functional Design Systems
Maria Hutsick, MS, ATC/L, CSCS Head Athletic Trainer, Medfield (Mass.) High School
Christopher Ingersoll, PhD, ATC, FACSM Director, Graduate Programs in Sports Medicine/Athletic Training University of Virginia
Allan Johnson, MS, MSCC, CSCS Sports Performance Director Velocity Sports Performance
Tim McClellan, MS, CSCS Director of Perf. Enhancement, Makeplays.com Center for Human Performance
Michael Merk, MEd, CSCS Director of Health & Fitness, YMCA of Greater Cleveland
Jenny Moshak, MS, ATC, CSCS Asst. A.D. for Sports Medicine, University of Tennessee
Steve Myrland, CSCS Owner, Manager, Perf. Coach, Myrland Sports Training, LLC, Instructor and Consultant, University of Wisconsin Sports Medicine
Mike Nitka, MS, CSCS Director of Human Performance, Muskego (Wis.) High School
Bruno Pauletto, MS, CSCS President, Power Systems, Inc.
Stephen Perle, DC, CCSP Associate Prof. of Clin. Sciences, University of Bridgeport College of Chiropractic
Brian Roberts, MS, ATC, Director, Sport Performance & Rehab. Ctr.
Ellyn Robinson, DPE, CSCS, CPT Assistant Professor, Exercise Science Program, Bridgewater State College
Kent Scriber, EdD, ATC, PT Professor/Supervisor of Athletic Training, Ithaca College
Chip Sigmon, CSCS Strength and Conditioning Coach, Carolina Medical Center
Bonnie J. Siple, MS, ATC Coordinator, Athletic Training Education Program & Services, Slippery Rock University
Chad Starkey, PhD, ATC Visiting Professor, Athletic Training Education Program, Ohio University
Ralph Stephens, LMT, NCTMB Sports Massage Therapist, Ralph Stephens Seminars
Fred Tedeschi, ATC Head Athletic Trainer, Chicago Bulls
Terrence Todd, PhD, Co-Director, Todd-McLean Physical Culture Collection, Dept. of Kinesiology & Health Ed., University of Texas-Austin
Training & Conditioning (ISSN 1058-3548) is published monthly except in January and February, May and June, and July and August, which are bimonthly issues, for a total of nine times a year, by MAG, Inc., 31 Dutch Mill Rd., Ithaca, NY 14850. T&C is distributed without charge to qualified professionals involved with competitive athletes. The subscription rate is $24 for one year and $48 for two years in the United States, and $30 for one year and $60 for two years in Canada. The single copy price is $7. Copyright 2009 by MAG, Inc. All rights reserved. Text may not be reproduced in any manner, in whole or in part, without the permission of the publisher. Unsolicited materials will not be returned unless accompanied by a self-addressed, stamped envelope. Periodicals postage paid at Ithaca, N.Y. and additional mailing offices. POSTMASTER: Send address changes to Training & Conditioning, P.O. Box 4806, Ithaca, NY 14852-4806. Printed in the U.S.A.
Editorial Board
2 TRAINING-CONDITIONING.COMT&C SEPTEMBER 2009
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BoardBulletin
NCAA Recommends Sickle Cell TestingIs a Mandate On the Way?In June, the NCAA released a new recommendation calling on member schools that dont already test athletes for sickle cell trait to begin doing so. And if the association adopts proposed legislation, that testing could soon become mandatory.
The recommendation was handed down by the NCAAs Committee on Competitive safeguards and medical As-pects of sports, and follows similar calls for more testing from the NATA and the College of American pathologists. To help programs understand sickle cell trait and the dan-ger it poses to athletes, the NCAA will also produce a video about the condition, which will be posted online and made available to all member institutions.
The recommendation will help because it gives us a very important point of information, scott Anderson, ATC, Head Athletic Trainer at the University of Oklahoma and co-chair of the NATAs sickle cell task force, told the Orlando Sentinel. Certainly from my perspective and my role in raising awareness toward sickle cell trait in the athlete, it makes absolute sense that we would have this [recommendation].
While the NCAA hopes its latest step will spur more schools to begin testing voluntarily (a recent NATA survey found that 36 percent of Division I Football bowl subdivi-sion members still dont test), a proposal from rice Univer-sity is aiming to force their hand. rice will soon introduce legislation that would make testing mandatory for NCAA institutions, and it could be voted on as early as next year.
both the NCAAs recommendation and rices forthcom-ing proposal are part of the settlement in a wrongful death lawsuit brought by the family of rice football player Dale Lloyd II, who died in sept. 2006 following a team workout. The medical examiners report linked Lloyds death to sickle cell trait, which rice did not test for at the time.
sickle cell trait testing is inexpensivetypically around $5 for an initial test and $35 for a confirmation. Athletes found to have the condition can still participate in any sport, but extra safeguards are recommended, such as special emphasis on hydration, progressive acclimatization, and adequate rest and recovery between bouts of effort. The NATA released a consensus statement on sickle cell trait in 2007, identifying it as the third-leading cause of non- traumatic sports deaths in high school and college athletes.
To download the NATAs sickle cell trait consensus statement, which contains information and advice on managing the condition, go to:www.nata.org/statements/consensus/sicklecell.pdf.
Menstrual Cycle Affects Knee Joint LaxityA recent study from kinesiology researchers at the Univer-sity of Calgary found that a relationship does exist between a womans monthly hormone cycle and the laxity of her knee joints. However, this laxity occurs at different points in the cycle for different women, which may be why earlier research found little evidence of such a link.
In the study, published as a series of papers in the Brit-ish Journal of Sports Medicine and the American Journal of Sports Medicine, 26 women were monitored through the entire course of their monthly cycles. At each phase, the women performed a battery of athletic movements, such as quick jumps and sharp cuts. The researchers found that 14 subjects exhibited the greatest amount of laxity during ovu-lation, 10 showed it during the follicular phase (the roughly eight days immediately before ovulation), and two others had laxest joints in the luteal phase (the roughly 11 days immediately after ovulation). based on these results, the researchers concluded there is a direct (though inconsis-tent) relationship between increased knee laxity and hor-monal phase, suggesting that women are at greater risk for knee injuries at certain times during their monthly cycle.
What this shows us is that the connection between the hormonal cycle and knee laxity is not a cookie-cutter rela-tionship, Darren stefanyshyn, phD, professor of Kinesiol-ogy at Calgary and one of the studys lead authors, said in a statement. Individuals have significant differences and I think that finding out why these differences occur could go a long way to helping athletes understand if they are more at risk and perhaps designing interventions to help prevent injury.
A New Warning About Nitrite Dopingsports medicine professionals can add yet another drug to the list of potentially harmful performance-enhancing sub-stances. Designed to treat heart and blood disorders, ni-trites are also found in prescription drugs that treat erectile dysfunction, and according to several recent reports, they are fast gaining favor in the sports world as a performance enhancer.
Currently, nitrites are not on the list of substances banned by the NCAA or any international athletic governing body, so they arent looked for in doping tests. but Declan Naugh-ton, phD, professor of biomolecular sciences at Kingston University in england, warns that nitrite usewhich some athletes believe improves blood flow to muscles during activitycould prove dangerous and even fatal.
Nitrite has enormous potential as a treatment for diseas-es characterized by inadequate blood supply, but if taken

BoardBulletin
T&C sepTember 20096 TrAINING-CONDITIONING.COm
BoardBulletin
in supplement form without clinical supervision, nitrite may lead to a number of serious side effects, including cardio-vascular collapse, coma, convulsions, and death, Naugh-ton told attendees during a may conference at Kingston called The Dark side of sport: Chemical enhancement of Athletic performance. based on current research on the levels of abuse of performance enhancing drugs by ath-letes, the future uptake of this drug by the athletic commu-nity is of real concern.
Andrea petroczi, phD, a public health researcher at Kingston, backed up Naughtons concerns about ath-letes using nitrites. she recently examined the UK sport Drug Information Database, a system that gives athletes, coaches, and team physicians access to information on pharmaceutical use, and found that in the months leading up to the 2008 beijing Olympics, checks on medication for erectile dysfunction nearly doubled compared to the previous two years.
The take-home message from this latest warning is simple: Athletes should be cautioned about the dangers of seeking performance enhancement through pharma-ceuticals. In addition, they should be reminded that just because a substance is not banned by their sports gov-erning body, that does not mean its safe for unsuper-vised experimentation.
Sports Med Group Returning Fees, Working Pro BonoIn these tough economic times, many schools could use a helping hand. Thats exactly what Delaware Valley High school in philadelphia recently received from the group that provides its athletic training coverage. recognizing that the school is facing financial troubles, Orthopedic Associates of the Greater Lehigh Valley, based in phillipsburg, N.J., and easton, pa., decided to work for free.
In addition to waiving its coverage fee for the upcoming year, Orthopedic Associates also donated $6,000 to the schoola figure that represents what Delaware Valley had paid for services during the 2008-09 school year. Nicholas Avallone, mD, an orthopedic surgeon at the clinic who pro-vides game coverage to the schools football team, present-ed a check to the Delaware Valley school board in June.
Avallone, who played football at princeton University, told the Hunterdon County Democrat that when schools are struggling to pay their bills, he considers pro bono work to be part of his duty to the community. Taking care of the kids is a top priority for us as physicians, he said. Were fortunate to be a busy practice and can give back to the community were serving. I enjoy doing this very much Its a passion of mine to take care of athletes. n
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T&C SEPTEMBER 2009 TRAINING-CONDITIONING.COM8
Tony CoxHenry County (Ind.) Sports Medicine
here, most kids were doing performance enhancement in the summer only, and they wanted to know, Do I have to stop when school starts? The answer, of course, is no, so now were working with them all the time, which is a big im-provement.
Howwasthetransitionfromcollegetoclinic?Ive really enjoyed it. Ive watched this clinic grow over the last 15 years, and a lot of the athletic trainers whove worked here were students of mine at Ball State, so I knew I would fit in.
Before I came here, I thought that working with 13-year-olds would be very different from working with college stu-dent-athletes, but its not. The kids who seek performance enhancement here want to be just like the student-athletes I worked with at Ball State. So I nurture them, instill a work ethic, and focus them on their goals. I find that I get a really good effort without much prodding.
Whereareyouachievingthemostsuccessinperformanceenhancement?Basketball and volleyball are huge in East Central Indiana, so when kids first come here, theyre usually hoping to jump higher. They also say they want to get stronger. So we focus on those two areas, but really, were working to develop good, functional movement. If they cant move their bodies correct-
Former longtime Ball State athletic trainer Tony Cox now works at a private clinic, where he helps athletes in their teens and early 20s improve balance, flexibility, and strength.
For more than 20 years, Tony Cox, MA, ATC, LAT, loved his job at Ball State University. As an instructor in the School of Physical Education, Sport, and Exercise Science, hed taught hundreds of athletic training education students. As Head Mens Basketball Athletic Trainer, hed built great working relationships with five head coaches, helped the team reach the NCAA Division I tournament, and traveled as far as Alaska and Hawaii.
But in the fall of 2006, Cox decided to make a change. He found it increasingly difficult to work with new Head Coach Ronny Thompson, who had been hired six months earlier. So Cox left Ball State, retiring at 55 as an Associate Athletic Trainer Emeritus, and moved to the clinical setting at Henry County Sports Medicine in New Castle, Ind., an affiliate of Henry County Memorial Hospital.
As the Director of Performance Enhancement and Ath-letic Training Programs at Henry County, today Cox enjoys the new challenges of working with athletes as young as 13. Along with training athletes in the clinics performance gym, he provides coverage for basketball and volleyball games at Winchester (Ind.) Community High School. Hes also spending more time with his family, including his son, Kyle, who is pursuing a career as a basketball coach after playing on the Ball State team during Coxs tenure, and his daughter, Caitlin, a sophomore volleyball player at Indiana University.
In 2004, the Indiana Athletic Trainers Association named Cox Collegiate Athletic Trainer of the Year, and earlier this year he was honored as a Mid-American Conference Athlet-ic Trainer Emeritus. In this interview, Cox talks about leaving Ball State, the transition to clinical work, and new trends in performance enhancement.
T&C:Whatdoesyourcurrentjobentail?Cox: As the Director of Performance Enhancement and Athletic Training Programs, I oversee a staff of two athletic trainers. During the school year, we provide game coverage to five local high schools. Year-round, we offer injury evalu-ation, rehabilitation, and performance enhancement, primar-ily for student-athletes but also for older folks who want to stay active.
We work with some of the best athletes in East Central Indiana, ranging from 13 to 22 years old. When I first came
Q&A

T&C SEPTEMBER 2009 9 TRAINING-CONDITIONING.COM
Q&Aly, making them stronger isnt going to help them much.
We incorporate a lot of core strength, hip movement, and flexibility work. Once those areas have been developed, their jumping improves because they can use their hips to incor-porate more powertheyre not just jumping with their legs.
The word Im getting from their coaches is that their movements are quicker and their jumps are higher. And be-cause theyre moving more effectively through the different planes of the body, theyre not getting injured as often. To me, thats success.
My first few weeks at the clinic, I did more observing and studying than anything else. I wanted to discover how these kids moved, and what their strengths and weaknesses were. I realized a lot of them hadnt worked on balance, so we focus on that. I tell them that if their feet arent in good balance, that deficiency transfers up to their shins, knees, hips, and lower back.
I also explain that if they dont work on balance now, they may face problems later on. Because of my years at Ball State, I can foresee the stresses and strains these kids are going to encounter once they get to college. When they get to that next level, we want them to be ready.
WasithardtoleaveBallState?I was miserable about it. Id graduated from Ball State and been there my whole professional life. But I felt I was fight-ing a losing battle with Coach Thompson, and I was get-
ting no assistance from my administration on the issue. So I thought, Im going to move on.
For 23 years, I taught athletic training students how to deal with difficult coaches, but I couldnt solve the problems that arose in this situation. Athletic training has come a long way over the years, and we deserve to be respected, because weve become an integral part of coaches success. But if coaches dont understand that, its tough.
The relationship between a coach and an athletic trainer is like a marriageyou give and take. But if a coach doesnt
want you to be a part of what hes doing, theres not much you can do. I really wanted it to work out, but it didnt.
I was fortunate to work with five coachesAl Brown, Rick Majerus, Dick Hunsaker, Ray McCallum, and Tim Buck-leywho welcomed me into their lives, both as a friend and a teammate. They let me do my job, and Im still close with all of them. But no matter how hard I worked, Ronny Thompson didnt seem to want any part of me. So when this opportu-
For 23 years, I taught athletic training stu-dents how to deal with difficult coaches, but I couldnt solve the problems that arose in this situation. We deserve to be respected ... But if coaches dont understand that, its tough.
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Q&Anity came up at the clinic, I decided it was time to start a new chapter of my life.
I retired from Ball State, which named me a Ball State University Omegathats the most prestigious honor the school can give youand became an Associate Athletic Trainer Emeritus. That was a good feeling. And after Ronny
Thompson resigned the following summer, the new basket-ball coach, Billy Taylor, invited me to meet with him. He said, I know what you meant to this program for all those years, and I want you to always feel welcome here. I thought that was extremely classy.
Whatwerethehighlightsofyour23yearsatBallState?Watching the mens basketball team beat UCLA and Kan-sas in 2001 and getting publicity as giant killers. Going to bowl games with our football team and to the NCAA tournament with our womens volleyball team were really
gratifying, too, and I still have pictures in my office of all those things.
Theres nothing better than being part of something big-ger than yourself, and when I look back on those years that were so successful, two things were always present: Every-body got along, and apart from some bumps and bruises, everybody stayed injury free. We worked hard, and when all was said and done, there was this wonderful sense of camaraderie.
Whatsthebestpartofbeinganathletictrainer?Fulfillment. Every time you work with an athlete, you know youre touching his or her life. Its about more than treat-ing an injury. Its about helping athletes become better people, because the way they deal with a setback has a lot to do with how theyll overcome other difficulties down the road.
Someday, theyll call to say, I just got my first job, and youll know you made a difference, because they still want you in their lives. When I left Ball State, I found out I had touched a lot of people, and I felt Id done my job.
Whatsthehardestpartofbeinganathletictrainer?Being away from family. I was fortunate that the coaches I worked with always welcomed my family, and my two kids were always involved in my life as an athletic trainer. But I was not able to spend as much time with them as I
Its about more than treating an injury. Its about helping athletes become better
people, because the way they deal with a setback has a lot to do with how theyll
overcome other difficulties down the road.
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T&C SEPTEMBER 2009 11 TRAINING-CONDITIONING.COM
Q&A
Tony Cox Director of Performance Enhancement and Athletic Training Programs Henry County Sports Medicine, New Castle, Ind.
Previous Positions: Associate Athletic Trainer and Instructor, School of Physical Education, Sport, and Exercise Science, Ball State University, 1983-2006
Education: BS, Ball State University, 1982 MA, Miami University, 1983
Honors: Indiana Athletic Trainers Association Collegiate Athletic Trainer of the Year, 2004
Ball State University Omega, 2007
Mid-American Conference Athletic Trainer Emeritus, 2009
would have liked. My son was one of the better basketball players in the
state of Indianahes still in the national high school record book for career free-throw percentageand my daughter was volleyball player of the year in Indiana. Growing up, they understood when I couldnt go to their games, but that didnt make it any easier. Now I have more time. When I came here to the clinic, I had Thanksgiving with my family for the first time in 23 years.
WhatdoyoumissaboutworkingatBallState?I miss rolling up my sleeves and treating student-athletes three or four times a day. I miss traveling with the team, de-veloping relationships, and sharing a common goal. And I miss the feeling I used to get in my stomach leading up to the tip-off.
One of my former students is the Head Mens Basket-ball Athletic Trainer for the University of Kansas, so when the team came to Indianapolis, he invited me to attend a closed practice. He was paying me back, just like I try to
pay back my mentors, and you wouldnt believe how ap-preciative I was. I got that feeling in my stomach as game time approachedmy heart was racing, because I felt I was part of it. I really miss that.
Being a collegiate athletic trainer was off-the-charts wonderful, both personally and professionally. But I en-joy very much what Im doing now. I have the best of both worlds here, because I can continue working as an athletic trainer while still having some time at home.
DoyouevertalktoyourdaughteraboutthecareshegetsfromtheathletictrainersatIndiana?Yes, we talk a lot. Shes working with Adam Clemens, whos a great athletic trainer, and Josh Eidson, whos a great strength coach. When she talks about what theyre doing to make her a better player, I hear the appreciation in her voice. I met Adam and Josh when we were there on a recruiting visit, and as a parent, I felt very comfort-able leaving my daughter in their hands. On the drive back home, I told my wife, Shes going to be very well taken care of.
BeforegoingtoBallState,whatdidyouthinkyouweregoingtodo?I wanted to be a high school or college basketball coach, and I wanted to teach. But when I was attending school at Indiana University Eastbefore I transferred to Ball
Statea friend of mine suggested I think about athletic training. He said, Its going to be really huge down the road. Well, he was absolutely right. Theres nothing that would have been better for me.
Whatareyourcurrentgoals?I want to continue building my program here. Henry Coun-ty Memorial Hospital gets a lot of recognition in the com-munity, and even though athletic training is only a small part of the hospital, I want people to see it as a strong, positive, productive service we provide to athletes in our area. My goal is to keep giving, finish strongand then play a lot of golf. n
Growing up, [my kids] understood when I couldnt go to their games, but that didnt make it any easier. Now I have more time. When I came here to the clinic, I had Thanksgiving with my family for the first time in 23 years.
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For several years, I have served as Team Sports Nutritionist for a competitive triathlon squad. Historically, each of the 16 athletes has been permitted to request their preferred sports hydration drink, and as recently as just a few years ago, all of the athletes chose one of two brands. The primary variation was simply which flavor they wanted.
However, in the last few years, the requests have changed dramatically. Most re-cently, the athletes asked for nine different brands and countless flavors. Our team administrator responsible for supplying these products officially went on strike! And I realized I needed to become even more well versed on the many new sports drinks on the market.
When I started my career, most athletes still drank the traditional lemon-lime Gatorade. Athletes can now find many different brands, flavors, nutritional compo-nents, and unique features in the sports drink worldand there is heightened com-petition among the various brands for loyal consumers.
Competition often works to everyones benefit, but the vast number of options can be overwhelming to athletes. In todays market-driven world, your athletes need to be sports drink savvy to get the most out of their workouts.
POURING OUT OPTIONSThe household names like Gatorade and Powerade may still be the biggest players in the industry, with the largest percentage of market share overall, but several newer brands are also becoming well-known and gaining a devoted following. In addition, athletes are asking if popular beverages like Vitamin Water can serve as a sports drink.
Several organizations have come up with their own definition for sports drinks, and they dont always agree. But for those of us working with competitive athletes, sports drinks have a very specific need to fill. They must:
Be designed for use during exercise as a way to rehydrate
Fluid Dynamics
By Michelle Rockwell
Michelle Rockwell, MS, RD, CSSD, is a Sports Dietitian based in Raleigh-Durham, N.C., and the former Coordinator of Sports Nutrition at the University of Florida. She offers sports nutrition consulting services in addition to educational products and workshops through RK Team Nutrition: www.rkteamnutrition.com.istock.com
From low cal to high sodium, todays sports drink market is more diverse than ever. Are you prepared to help athletes navigate the sea of options and find the best product for their individual needs?
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Contain electrolytes, which are typ-ically lost via sweat
Contain carbohydrates Be sold in ready-to-drink, powder,
and/or liquid concentrate forms.That means one of the first things
we need to do is teach athletes what is not an appropriate sports drink. For in-stance, beverages like flavored waters, nutritionally enhanced beverages, and energy drinks are booming in popular-ity. There may be a place for these prod-ucts in some athletes diets, but they should not be used for the purpose of hydrating during intense exercise.
Here is how I categorize the ex-panding options in the sports beverage world:
Sports drinks contain carbohydrates, electrolytes, and sometimes other add-ed nutrients. They are appropriate for use before, during, and after intense exercise.
Flavored waters usually contain very few calories (if any) and sometimes in-clude artificial flavoring, vitamins, minerals, and/or herbs. Familiar names include Propel and Powerade Option. These can be used for general hydration in place of water, but not during long or intense exercise.
Nutritionally enhanced beverag-es may contain carbohydrates, artifi-cial flavoring, added protein, vitamins, minerals, and/or herbs. This category includes Vitamin Water, Special K Pro-tein Water, and SoBe Lifewater. Such products do not work well as sports drinks.
Recovery drinks frequently contain a combination of protein and carbohy-drates along with other nutrients de-signed to support post-exercise energy replacement and muscle recovery. We know that consuming 10 to 20 grams of protein along with carbohydrates with-in 60 minutes of exercise completion is beneficial for athletes, and recovery drinks are often a convenient, appeal-ing source. But they should not be con-fused with sports drinks.
Many athletes also ask me about energy drinks. I would not categorize these as sports beverages and rarely rec-ommend them for any athlete in any situation. They usually include caffeine and/or other stimulants, carbohydrates, artificial flavoring, and sometimes in-gredients such as amino acids, vitamins, minerals, or herbs. The level of caffeine and other ingredients in some energy drinks has raised concern among many
health and sports professionals, and its often difficult to determine exactly how much caffeine and other ingredients are in each drink. Energy drinks are defi-nitely not appropriate as a hydration source.
Theres further confusion over prod-ucts that technically fit into multiple cate-gories. For instance, is a traditional sports drink that contains caffeine an energy drink or a sports drink? I would not use it as a sports drink, because the caffeine can be detrimental to hydration.
How about flavored water with elec-trolytes? While this may be good for hydrating the casual athlete, the lack of carbohydrates makes it a poor choice for competitive athletes doing long or intense exercise. With so many choices in the pure sports drink category, there really is no reason to use products that may compromise the proven effects of sports drinks.
MAKING CHOICESWith a firm grasp of what constitutes a sports drink, an athletes choices are certainly narrowed down. But there are still many options available, so how do you know what is the best sports drink for a specific athlete?
As a sports dietitian, I base the prac-tical strategies I provide to athletes on quality science. On the topics of hy-dration, electrolyte replacement, and carbohydrate consumption during ex-ercise, we are fortunate to have a firm scientific platform from which to make recommendations. That science is the basis for all my advice to athletes.
However, the magic of individualized sports nutrition involves taking into ac-count the fact that all athletes are dif-ferent. Each one presents unique goals, taste preferences, belief systems, and rituals. Furthermore, physiology, diges-tion, gastric absorption rate, sweat rate, and sweat composition can differ dra-matically among individuals. Thus, it is important to take all these personal factors into account.
I also believe in the value of experi-mentation with athletes and their nu-trition choices. We start with science, discuss individual differences, and then use trial and error to arrive at the best results.
THE SCIENCEProper use of sports drinks during ex-ercise can increase safety and enhance performance. When the temperature
rises, the risk of heat illness goes up and mental and physical performance deteriorate. Dehydration increases body temperature.
Sports drinks have been shown to enhance hydration status by stimulat-ing thirst, replacing electrolytes, and promoting fluid retention. Carbohy-drates in sports drinks can replace en-ergy stores (blood glucose and liver and muscle glycogen) and supply fuel to maintain intense, high-level exercise for extended periods.
In general, sports drinks should be chosen over water for any exercise event lasting longer than one hour. I use the 3-H Rule as a guideline: It simply says to use sports drinks whenever exercise is Hard, Hot, or at least an Hour long.
What the drink contains is also part of the science of sports drinks. The two major ingredients to understand are elec-trolytes and carbohydrates. In addition, we need to be well versed on the pros and cons of other added ingredients.
Electrolytes. An effective sports drink should replace electrolytes lost in sweatnamely sodium, potassium, and chloride. Sodium is lost at the high-est rate, with an average of one gram lost per liter of sweat. Considering that many athletes lose a few liters of sweat during a hard, hot exercise session, so-dium replacement is obviously critical to preventing heat-related problems.
The American College of Sports Medicine (ACSM) recommends that sports drinks contain 110 to 220 milli-grams of sodium per eight ounces, and roughly 30 milligrams of potassium. There are no formal recommendations for chloride lost in sweat, as it is almost always paired with sodium in the form of sodium chloride. In other words, if you have enough sodium, you are also getting enough chloride.
However, its important to recognize the extreme variations in individual sweat rates and the concentration of sodium and other electrolytes in each persons sweat. Some athletes are salty sweaters, while others may not lose nearly as much sodium in their sweat, but tend to lose higher concentrations of other electrolytes.
How do you measure an individual athletes electrolyte losses? Some com-panies have developed technology that can quantify sodium loss during ex-ercise. A less scientific way is through trial and error.
You can tell that an athlete is a salty
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2009 Am
ericas Milk Processors. got m
ilk? is a registered tradem
ark of the California Milk Processor Board.
Coaching ManagementFull Page Non-Bleed 7-5/8"W x 10-3/8"H
Full Page Bleed 8-3/8"W x 11-1/8"HFull Page Trim 8-1/8"W x 10-7/8"HLive Area 7-3/8"W x 10-1/8"H
Diedra Harkenrider, Sales AssociateAthletic Management, Coaching Man-agement and Training & Conditioning31 Dutch Mill Road, Ithaca, NY 14850Phone 607-257-6970, Ext. 24 . Fax 607-257-7328 . E-mail [email protected]
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sweater if he or she frequently has a white film on his or her face or cloth-ing after exercise. Another good indica-tion is if an athlete has strong cravings for salty foods post-workout. Athletes who are clearly hydrating welllosing minimal weight during exercise sessions and producing pale yellow urinebut still struggling with muscle cramping or heat issues may also be salty sweaters.
For someone known to be a salty
While sodium is the electrolyte most critically in need of replenishment, mag-nesium, calcium, and other minerals are also lost in sweat. Should you look for sports drinks with these ingredients, too? In general, the answer is no. How-ever, if Im working with an athlete who is hydrating well and who Im certain is consuming sufficient sodium, yet theyre struggling with energy levels, I might recommend experimenting with in-
sweater, I encourage a high salt diet and drinking plenty of sports drinks through-out the day. I also tell them to start with an extra one-quarter to one-half tea-spoon of salt in 20 ounces of sports drink about 30 minutes prior to exercise and continue with the same formula during exercise (one teaspoon of salt is roughly 2,400 milligrams). Another solution is to use specialty endurance sports drinks or electrolyte supplements.
COMPARISON SHOPPINGThis table allows you to easily compare the key attributes of various brands of sports drinks and specialized endurance formulas.
Product: Carb Carb Type of Calories Sodium Potassium Protein Caffeine 8 oz content (%) (grams) Carbohydrates (kcals) (mg) (mg) (grams) (or 1 cup/serving)
Sports Drinks
Gatorade 6 14 Sucrose Syrup, 50 110 30 0 No High Fructose Corn Syrup (HFCS)
Gatorade G2 3 7 Sucrose Syrup, HFCS, Sucralose, Acesulfame Potassium
Powerade ION4 5 14 HFCS 50 100 25 0 No Powerade Zero 0 0 N/A 0 55 35 0 No
Accelerade 6 15 Sugar, Trehalose 80 120 15 4 No Amino Vital 3 8 Fructose 35 10 35 0 No
Clif Shot 8 19 Organic Brown Rice Syrup Solids 80 200 50 0 Some flavors
Clif Quench 4 11 Organic Evaporated Cane Juice 45 130 35 0 No
Cytomax 5 13 Fructose, Dextrose, Maltodextrin 50 55 30 0 Some flavors
GU20 5 13 Maltodextrin, Fructose 50 120 20 0 No
Hammer HEED 10 25 Maltodextrin 100 62 16 0 No
Capri Sun Sport 8 19 HFCS, Sugar 72 66 36 0 No
Ultima Replenisher 2 6 Maltodextrin 50 75 150 0 No
CeraSport 3 10 Rice Syrup Solids 38 100 38 0 No
CeraSport EX-1 2 5 Rice Syrup Solids 20 200 100 0 No
GameOn MyoHydration 3 10 Maltodextrin, Fructose 50 110 130 2 No
Carbo-Pro 19 57 Glucose Polymers 224 0 0 0 No
Endurance Formulas
Gatorade Endurance 5 14 Sucrose Syrup, HFCS 50 200 90 0 No
Perpetuem (2 scoops) 23 54 Maltodextrin 260 231 156 6 No
Powerbar Endurance 5 13 Maltodextrose, Fructose, Dextrose 60 165 8 0 No
Hammer Sustained 30 73 Glucose Polymers, Corn Solids 343 112 0 10.5 No Energy (3 scoops)
EnduroxR4 15 35 Dextrose, Fructose, Sucrose 180 140 80 9 No

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of the results.In terms of carbohydrate concen-
tration in sports drinks, professional organizations have slightly different rec-ommendations. The ACSM and Amer-ican Dietetic Association recommend six to eight percent carbohydrate. The NATA recommends four to eight per-cent carbohydrate. And the Institute of Medicine recommends five to 10 per-cent carbohydrate.
For many athletes, a carbohydrate concentration of greater than eight to 10 percent is likely to inhibit fluid ab-sorption, so choosing a sports drink in the lower range and properly diluting powder or liquid concentrates is im-portant. When an exercise event is very long or will require a lot of fluid con-sumption, a lower concentration can help prevent over-consumption of car-bohydrates and gastric intolerance.
To determine the carbohydrate con-centration of a sports drink, divide the amount of carbohydrates per serving (in grams) by the serving size (in milliliters) and multiply by 100. So, if the serving size is 240 milliliters (eight ounces) and total carbs per serving is 11 grams, the
creased consumption of these other min-erals through diet (not sports drinks).
Carbohydrates. Athletes, and partic-ularly parents of younger athletes, often ask me, Do we really need all that sug-ar in sports drinks? If exercise is hard enough and long enough, the answer is definitely yes. Research has shown that carbohydrate beverages consumed during exercise enhance performance. In fact, our bodies respond so well to carbohydrates during exercise that one study found simply rinsing ones mouth with a sport drink (and not swallowing it) enhanced performance in a cycling time trial.
The key to consider is the type and concentration of carbohydrates in a sports drink. Most contain at least one source of simple sugar, such as glu-cose or fructose. Others contain sucrose (table sugar), which is a combination of glucose and fructose. Some contain high fructose corn syrup, which is also a combination of glucose and fructose and is often referred to as sucrose syrup or glucose-fructose syrup on sports drink labels.
Research shows that a combination
of sugars, as opposed to a single sugar, maximizes absorption during exercise. One reason for this is that each sugar utilizes different intestinal transporters. Having more than one sugar enables two transport systems to work at once and decreases the likelihood that one transport system becomes saturated.
Several newer sports drinks have in-corporated some more complex carbo-hydrate sources, such as maltodextrin. The theory behind these is that slower absorption causes energy to be sustained longer during exercise, which would certainly appeal to endurance athletes. However, the slower absorption rate (especially when a more complex sugar is the sole carbohydrate source) may cause gastric upset.
Some sports drinks tout more natu-ral sources of carbohydrates, such as cane juice or brown rice syrup solids. Many athletes whose lifestyles empha-size a natural or organic diet find these options appealing. There is little re-search on how these carbohydrates are absorbed during exercise, so interested athletes should experiment with them during training sessions and take note
T&C sepTember 2009 17 TrAINING-CONDITIONING.COmCircle No. 110
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nutrition
sport drink contains about 4.5 percent carbohydrates.
To figure out which carbohydrate source and concentration is tolerated best by individual athletes, I again use trial and error. To avoid unwanted out-comes, athletes should try different sports drinks during trainingnot dur-ing competition.
Other Ingredients. Sports drinks con-taining protein have become more pop-ular in recent years. Some researchers have shown that a small amount of add-ed protein can improve exercise perfor-mance and speed muscle recovery, but other studies contradict those findings, and more research is still needed.
In practical terms, if an athlete is in-terested in using a sports drink contain-ing protein, my advice is to try it during several different training sessions and
evaluate how it feels. Some athletes find these beverages helpful and appealing. Others find the taste chalky or unpal-atable, or they experience gastrointes-tinal symptoms (likely because protein empties from the stomach more slowly than other substances). In order for a sports drink to aid in hydration and performance, athletes must be able to
consistently drink adequate amounts of it, so taste, appeal, and comfort are im-portant factors.
Some sports drinks are also fortified with vitamins and minerals. There is little evidence that consuming a specific vitamin or mineral during exercise pro-vides any immediate benefit. However, they may contribute to helping an ath-lete meet his or her overall needs for critical vitamins and minerals.
Sports drinks containing specific
amino acids, various herbal ingredients, caffeine, and other additives are also readily available. In many cases, there is too little of these ingredients to have much impact.
HOW MUCH?Once an athlete has decided on which sports drink to use, the final factor to consider is the amount they should con-sume. This depends on several factors, including sport, workout intensity, envi-ronmental conditions, hydration oppor-tunities, sweat rate, age, general diet, and individual habits and preferences.
Starting exercise in a well-hydrated state is critical, because most athletes dont drink enough during exercise. Athletes can pre-hydrate with water, sports drinks, or other non-alcoholic beverages. Many foods, particularly fruits and vegetables, also have a high water content and contribute to over-all hydration. As the start of exercise nears, athletes should use either water or sports drink to pre-hydrate.
According to the NATA, general pre-exercise guidelines are as follows:
Two to three hours before exercise,
If an athlete is interested in using a sports drink containing protein, my advice is to try it during several different
training sessions and evaluate how it feels. Some athletes find these beverages helpful and appealing.
Circle No. 112 Circle No. 113
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BETTER THAN WATERFor the most part, athletes need to use sports drinks instead of water only for very intense workouts and exercise events lasting longer than one hour. But there are other situations when sports drinks may be helpful. For example:
Whenanathleteisstartingexerciseonanemptystomachorhasntingested adequate carbohydrates.
Ifanathleteiscarbohydrate-loadingsportsdrinksconsumedthrough-out the day can provide extra carbs to help boost stores leading up to an important competition.
Ifanathleteseeksweightgaintheextracaloriescanhelpshifttheircalorie count upward.
Ifanathletehaschronicdehydrationorheat-relatedissuestosupportpre-hydrationandelectrolyteintakebeforeexercise.Fortrainingataltitude,whichincreasesfluidloss.Fortrainingduringverycoldweather,whenathletestendtodrinklessand wear clothing with inadequate ventilation.
Whensufferingfromvomitingordiarrheatoreplacelostfluidsandelectrolytes.
Whenwaterwouldbeappropriatebuttheflavor,sodiumcontent,andappeal of sports drinks is the only way an athlete will hydrate properly.
drink 17 to 20 ounces of water or a sports drink.
Ten to 20 minutes before exercise, drink seven to 10 ounces of water or sports drink.
During exercise, sports drink con-sumption should be based on each ath-letes unique sweat rate. Athletes should aim to lose less than two percent of
their body weight via sweat during ex-ercise. A loss greater than two percent has consistently been shown to jeopar-dize safety and performance.
If you dont know an athletes sweat rate, a general guideline is to have them drink seven to 10 ounces of sports drink every 10 to 20 minutes of exercise, for a total of about 24 to 40 ounces (three to five cups) of sports drink every hour. This level of consumption is not only
likely to meet an athletes fluid needs, but their carbohydrate needs as well. Athletes typically utilize 30 to 60 grams of carbohydrate per hour of exercise, but sometimes can use 100 grams or more. Since most sports drinks con-tain about 15 grams of carbohydrate per cup, three to five cups would equal 45 to 75 total grams of carbohydrates
per hour. Note that if an individual requires
more fluid to balance sweat loss, they may benefit from using a mix of sports drinks and water, or a sports drink with a lower carbohydrate concentra-tion. This will help avoid gastric up-set and over-consumption of sugar and calories.
To calculate an athletes sweat rate, you can follow this procedure:
1. Obtain body weight in minimal clothing and without shoes prior to ex-ercise.
2. Record the amount of fluid con-sumed during the exercise session.
3. Obtain body weight in minimal clothing and without shoes after ex-ercise.
4. Subtract the athletes post-exer-cise weight from pre-exercise weight. If the difference is less than two percent, they are consuming enough fluid. If it is greater than two percent, the athlete is not hydrating well enough during ex-ercise. Assuming that one fluid ounce roughly equals one ounce of mass, the athlete should add 16 fluid ounces of sports drink to their hydrating plan for every pound of weight lost.
For example, if Sams pre-practice weight is 175 pounds and his post-prac-tice weight is 170 pounds after consum-ing two cups of sports drink during a two-hour practice, we know that he needs to up his intake. As a goal for the next practice, Sam must replace at least two more pounds of fluid, or about 32 fluid ounces. That should give him a fluid loss of just three pounds, which is less than two percent of his body weight.
Conversely, what if an athlete gains weight during exercise? That means they are drinking too much, which in-creases risk for hyponatremia, a poten-tially fatal condition in which sodium concentration in the blood becomes dangerously low. Athletes also want to avoid the sluggish feeling of carrying around excess fluid. The advice here is simpledrink less during the workout, but not so much less that dehydration comes into play.
I always tell athletes to drink early in their exercise sessions, prior to the on-set of thirst. Drinking small amounts at very frequent intervals is helpful for achieving optimal hydration without impacting comfort level, and it also helps promote a consistent hydration level throughout a workout.
Todays athletes have a daunting ar-ray of sports drinks to choose from. If they understand the science and claims behind the various products on the shelf, and theyre willing to engage in a bit of trial and error, they can find the one that best meets their hydration needs and suits their personal tastes and pref-erences. Once theyve done that, achiev-ing and maintaining optimal hydration is, well, no sweat. n
I always tell athletes to drink early in their exercise sessions, prior to the onset of thirst. Drinking small amounts at very
frequent intervals is helpful for achieving optimal hydration without impacting comfort level, and it also helps promote a
consistent hydration level throughout a workout.
SUSPENSION TRAINING: FUN & FUNCTIONAL FOR YOUTH TRAININGBy Scott MoodyScott Moody founded Centers for Athletic Performance, Inc. (CAP) in 1999. Moody also owns the educational resource site, AthleteFIT.com, and acts as the CEO for the 501c3, not for profit, Soccer FIT Academy.
For years, CAP, Centers for Athletic Performance, has been looking for shoulder, hip and core progressions (done in a group setting) that would work for athletes 10-14 with no prior training experience. For almost 10 years we have been creating progressions off of body weight squats, step ups and lunge exercises, but found that many of our younger athletes had positioning and body control issues that delayed their progression through the program.
Lack of shoulder stability and core strength made it hard to get into good athletic positions with medballs and dumbbells which limited us in our exercise selection. We were desperately searching for something that could lay a foundation in core strength, shoulder stability, postural control, glute and ham-string strength without the use of dumbbells until we discovered TRX Suspension Training.
The TRX makes this all possible, as we have been able to progress (and digress) exercises to add intensity by simply changing their body position. This ability to increase intensity, variety and complexity within a group setting has not only set the athletes up with a stronger foundation, but it has also increased their knowledge of their own body and how to control, balance and stabilize in various positions.
We have selected a few common areas of concern from our youth population, and the table below shows how we have modified some of our standard body weight exercises to incorporate the TRX. The table also refers to the progressions and digressions that can be made off of each exercise within a group setting to progress each individual at their own pace:
The ability to progress and digress these exercises has not only allowed us to train strength with our younger clientele, but it has also added a new found enthusiasm and competition to the training as athletes try to out perform others in the group by doing more reps in the push up, pull up and lunge based activity. The limitations of physical education classes, tumbling and body weight training, in combination with the reduction in unsupervised active play (tree climbing, swimming, jungle gym play, etc) has created a weaker, less coordinated youth population. This fun and simple training solution could be the answer you have been looking for!
Area of Concern
Hip:(knee tracking incorrectly in frontal and sagital plane)
Shoulder:(mobility/stability with arms extended over-head)
Posture:(core and upper back strength and control)
Standard Exercise
Lunge
Military Press or Upright Row
Bent Over Row
TRX Exercise
Suspended Lunge
Rhythmic motion focus on balance
TRX Isolated Ys
No rocking or swinging the hips
Table Top Row
Straight line from knees to shoulder
Progression
Suspended Lunge(dynamic)
Quick eccentric to concentric transition
Kneeling Rollout
Control posture withpelvic tilt
Straight Leg Pull Up
Digression (youth)Suspended Lunge(pause at parallel)
Pause at parallel, thencome up under control
TRX Isolated Is
No rocking or swinging the hips - straight arms
Standing Row
Body at a 45 degreeangle

SUSPENSION TRAINING: FUN & FUNCTIONAL FOR YOUTH TRAININGBy Scott MoodyScott Moody founded Centers for Athletic Performance, Inc. (CAP) in 1999. Moody also owns the educational resource site, AthleteFIT.com, and acts as the CEO for the 501c3, not for profit, Soccer FIT Academy.
For years, CAP, Centers for Athletic Performance, has been looking for shoulder, hip and core progressions (done in a group setting) that would work for athletes 10-14 with no prior training experience. For almost 10 years we have been creating progressions off of body weight squats, step ups and lunge exercises, but found that many of our younger athletes had positioning and body control issues that delayed their progression through the program.
Lack of shoulder stability and core strength made it hard to get into good athletic positions with medballs and dumbbells which limited us in our exercise selection. We were desperately searching for something that could lay a foundation in core strength, shoulder stability, postural control, glute and ham-string strength without the use of dumbbells until we discovered TRX Suspension Training.
The TRX makes this all possible, as we have been able to progress (and digress) exercises to add intensity by simply changing their body position. This ability to increase intensity, variety and complexity within a group setting has not only set the athletes up with a stronger foundation, but it has also increased their knowledge of their own body and how to control, balance and stabilize in various positions.
We have selected a few common areas of concern from our youth population, and the table below shows how we have modified some of our standard body weight exercises to incorporate the TRX. The table also refers to the progressions and digressions that can be made off of each exercise within a group setting to progress each individual at their own pace:
The ability to progress and digress these exercises has not only allowed us to train strength with our younger clientele, but it has also added a new found enthusiasm and competition to the training as athletes try to out perform others in the group by doing more reps in the push up, pull up and lunge based activity. The limitations of physical education classes, tumbling and body weight training, in combination with the reduction in unsupervised active play (tree climbing, swimming, jungle gym play, etc) has created a weaker, less coordinated youth population. This fun and simple training solution could be the answer you have been looking for!
Area of Concern
Hip:(knee tracking incorrectly in frontal and sagital plane)
Shoulder:(mobility/stability with arms extended over-head)
Posture:(core and upper back strength and control)
Standard Exercise
Lunge
Military Press or Upright Row
Bent Over Row
TRX Exercise
Suspended Lunge
Rhythmic motion focus on balance
TRX Isolated Ys
No rocking or swinging the hips
Table Top Row
Progression
Suspended Lunge(dynamic)
Quick eccentric to concentric transition
Kneeling Rollout
Control posture withpelvic tilt
Straight Leg Pull Up
Digression (youth)Suspended Lunge(pause at parallel)
Pause at parallel, thencome up under control
TRX Isolated Is
No rocking or swinging the hips - straight arms
Standing Row
Body at a 45 degreeangle

COMPLEXFORCES
getty images

TREATING THE ATHLETE
By B.J. Baker
B.J. Baker, ATC, CSCS, is Head Athletic Trainer at Train Boston and former Strength and Conditioning Coordinator for the Boston Red Sox. He can be reached at: [email protected]
Is it possible to keep an athletes shouldera joint with great potential for extreme functional ranges of motionmobile, stable, strong, powerful, and healthy? Is
that a realistic goal given the complex demands of sports and the detrimental effects over time of gravity, poor posture, imperfect mechanics, and overuse? Like many sports medicine clinicians who work in performance training, I have been challenged by this shoulder conundrum.
In the past 20 years, Ive worked with many types of shoulder injuriesa Ma-jor League Baseball pitcher with dead arm syndrome, a college swimmer with an impingement syndrome, a middle-aged client with a torn rotator cuff, and countless others. Regardless of the dysfunction, there are common threads in shoulder training programs that pro-duce a complete, speedy recovery. Com-prehensive shoulder assessment and treatment should focus on the thoracic spine, scapula, rotator cuff, and gle-nohumeral joint, while also addressing posture and energy transfer throughout the entire kinetic chain.
By addressing all these components in a progressive manner, I have found success treating a range of simple and
Proper shoulder function depends on intricate relationships between muscle groups, tendons, bone structures, the spinal cord, and more. A comprehensive shoulder training program can address key deficiencies and provide targeted treatment for a wide range of dysfunctions.
complicated shoulder injuries. In this article, Ill provide a detailed look at the main anatomical components of suc-cessful shoulder training, and offer ex-ercise strategies that not only restore full function, but can also help make the shoulder more powerful and injury resistant.
KEYS OF ANATOMYThoracic spine. If an athlete has lim-ited mobility in the middle 12 verte-brae of the spinal column, collectively known as the thoracic spine, the scapu-la wont have a sound foundation from which to operate, increasing risk for a wide variety of shoulder problems. Thoracic extension is critical to ath-letic movement, but in todays seated, backpack-toting, computer-dependent society, a head-forward and kyphot-ic (hunchback) posture has become commonplace. Consistently holding the thoracic spine in this forward po-sition decreases its ability to move ful-ly in other directions, and makes the scapulae much more likely to abduct and tilt anteriorly, closing down on the subacromial space.
That space already offers tight quar-ters for the rotator cuff tendon, biceps tendon, and subacromial bursa to per-
form their intended functions. Further decreasing it can lead to bone spurs on the underside of the acromion (a por-tion of the scapula) due to irritation and pressure from the impinged structures over time. In fact, failure to keep this space open results in some of the more common shoulder pathologies, includ-ing rotator cuff fraying, subacromial bursitis, and impingement syndrome.
To further complicate matters, there are three distinct types of acromi-ons: flat (type one), smoothly curved (type two), and hooked (type three). Each functions a bit differently, and a type three acromion increases the like-lihood of impingement and anterior bone spurs.
The thoracic spine is the most flex-ible spinal region for rotationit has roughly eight degrees of rotation avail-able at each segment. But if that mobil-ity is limited, the body compensates by increasing rotation in the lower lumbar region, producing instability in a seg-ment thats meant to be stable. This is
COMPLEXFORCES

a common reason for low back inju-ries in golfers with inadequate thoracic turning.
Thoracic rotation should be as sym-metrical as possible. Asymmetry can be addressed with corrective exercise, though it may be unrealistic to expect perfect symmetry in athletes whose sport requires unilateral rotation, such as pitchers, golfers, and tennis players. Severely asymmetrical thoracic spine rotation and extension compromise scapular stability and can wreak havoc on the kinetic chain, affecting every-thing from the glenohumeral joint to the subacromial space. Asymmetry also interferes with efficient energy transfer during the throwing motion, and leads to losses in core strength.
Scapula. Ideally, the scapula is posi-tioned on a rib cage thats mounted on a fully functioning, symmetrical thoracic spine. Any scapular dyskinesis, or al-terations of normal position or motion, directly affect the glenohumeral joint
and overall shoulder positioning. Dys-kinesis can be caused by inflexibility, weakness, or muscle imbalances.
Pathologies associated with a poorly functioning scapula include glenohu-meral instability leading to arthritis, impingement, rotator cuff tendonitis or tendinosis, rotator cuff tears, labrum injuries, and medial elbow pain and injury. In fact, studies have shown that poor stability in the scapula is found in 68 percent of athletes with rotator cuff problems, and 100 percent of those with glenohumeral instability.
An athletes scapulae must be profi-cient at protraction, retraction, eleva-tion, depression, upward and downward rotation, and anterior and posterior tilting. No less than 17 muscles affect scapular stability and ability to pro-vide a platform for the rotator cuff and glenohumeral joint. In addition, the glenoid portion of the scapula must be positioned and stabilized in three- dimensional space to act as an appro-priate receptor for the humeral head as it rotates at the high velocities needed for activities like throwing.
Attempting powerful shoulder move-
ments with an unstable scapula is like trying to shoot a large cannon from a small, untethered boatthe lack of a firm base will result in much wasted energy, unwanted movement, and inef-ficiency. Transferring powerful forces up the kinetic chain from the lower extremities through the hips, lumbar fascia, and thoracic spine, only to find a leak in the system at the scapula and glenohumeral joint, is an injury waiting to happen.
Force couples, mobility, and stabil-ity all help maintain the instantaneous center of rotation (ICR) of the humerus in the glenoid. Having an ICR helps ensure proper biomechanical function in the joint, which in turn helps avoid labral fraying and tears. Simply put, when joints are centered, they perform optimally and injury risk is reduced.
Some patterns of dyskinesis related to labral tears in the throwing shoulder are linked to inflexibility of the pecto-ralis major and minor, and weakness of
the lower trapezius and serratus anteri-or. When you examine an athlete, dys-kinesis may present as the inferomedial (lower middle) scapular border being abnormally prominent at rest. Other signs include lack of acromial elevation and lack of full retraction in the throw-ing motion.
Weakness in the upper and lower tra-pezius and rhomboids can also lead to winging of the entire medial border of the scapula at rest. Both patterns cre-ate excessive scapular protraction and decreased scapular retraction and ac-romial elevation during throwing. Dysfunctions like these highlight the importance of activating and properly training the peri-scapular musculature, especially the lower trapezius and ser-ratus anterior.
Glenohumeral joint. Due to the high stresses and forces created by overhead throwing, there are some pathologies and compensations commonly found in throwing populations. The glenohumer-al joint, rotator cuff, and capsule are subjected to tremendous acceleration, deceleration, and distraction forces.
Glenohumeral internal rotation defi-
cit (GIRD) is one of the most common adaptations that can affect throwers. GIRD develops due to the great de-celeration forces placed on the poste-rior capsule and rotator cuff, which cause shortening of the muscles, tight-ness in the posterior-inferior capsule, and a shift of the glenohumeral rotation point. This migration and changing of the posterior capsule contributes to de-centration, or loss of the ICR of the gle-nohumeral joint. For example, research has shown that Major League Baseball pitchers lose internal rotation in their throwing shoulder due to GIRD.
To evaluate the level of GIRD in a throwing athlete, clinicians perform a goniometric measurement of the to-tal range of motion of both shoulders, adding internal and external rotation. Ideally, the values should be the same on both sides, but in most cases, the throwing shoulder lacks internal rota-tion and has greater external rotation.
The greater external rotation capac-ity might be partially explained by ret-roversion, or a bony adaptation of the humerus due to high volumes of throw-ing during the developmental years. However, GIRD is mostly caused by shortening of the posterior capsule and rotator cuff musculature.
The restriction of internal rotation should be roughly equal to the increase in external rotation in the same shoul-der, and the internal rotation deficit should not be greater than 25 degrees when compared to the non-throw-ing shoulder. A GIRD above the 25- degree differential raises the likelihood of elbow pathology, pain, and labral tears. If the total range of motion of the throwing shoulder is lower than that of the non-throwing shoulder, addressing GIRD through stretching the posterior capsule and strengthening the posterior musculature of the rotator cuff is the best way to resolve the dysfunction.
POSTURAL CONCERNSWeve gotten through the tough partthe anatomy lesson. Now, lets explore some specific factors that athletes can address through training and targeted intervention to improve shoulder per-formance and reduce injury risk. One of the biggest of these factors is posture.
Ideal upright posture involves equal co-activation of flexors and extensors, abductors and adductors, and internal and external rotators. In my setting, we have had great success correcting poor
Attempting powerful shoulder movements with an unstable scapula is like trying to shoot a large cannon from a small,
untethered boatthe lack of a firm base will result in much wasted energy, unwanted movement, and inefficiency.
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and simple self-mobilizations using a foam roll. Since the lower trapezius and serratus anterior muscles play a critical role in proper scapular positioning and mobility, exercises to strengthen those muscles should be a top priority when addressing FHP.
A variety of protraction/retraction progressions can successfully activate and strengthen the serratus anterior. Exercise choices include straight-arm punching and retractions, including su-pine on a foam roll and in quadruped and standing positions using gravity, cables, and dumbbells for resistance. Push-ups are also an integral form of serratus work. Whenever you put a hand in contact with the floor in a closed-chain upper-body position, you get optimal activation of the serratus anterior as well as other scapular sta-bilizers and rotator cuff musculature. Lower trapezius activation and strength-ening progressions include such exercis-es as prone Y, W, and I shoulder raises, scapular wall slides, 90/90 scapular re-traction rope pulls (face pulls), lat pulldowns, horizontal rowing, and D2 patterns.
In her text Diagnosis and Treatment of Movement Impairment Syndromes, Shirley Sahrmann discusses a phenom-enon called scapular downward rota-tion syndrome. She argues that frequent exposure to low-amplitude postural loads (in particular the force of gravi-ty) during improper sitting, poorly con-structed training programs, and other negative postural and behavioral influ-ences causes the scapular downward rotator muscles to become short and weak. Thus, one of the most important scapular force couples for improving posture is the upper trapezius, lower trapezius, and serratus anterior, since they are responsible for upward rota-tion of the scapula.
To break the cycle of poor posture, athletes should be encouraged to regu-larly interrupt any long sedentary peri-ods throughout the dayfor instance, to break up long study and computer sessions by simply getting up, moving around, and doing things like stretch-ing their pecs and performing arm cir-cles. Some researchers beli

Training & Conditioning 19.6

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