Kettlebell Leg Training

The other day I was having a discussion with one of my favorite athletes of all-time, the incomparable Danny O’Rourke.

Every off-season, DO comes in and we put together a program to help him take his game to the next level, as well as prepare him for the rigors of a 9-month MLS season.

He is a very thoughtful and intelligent guy, and over the course of our discussion he asked a very simple question:

“Are you doing anything new or different from what you did last year?”

While I like to think that I’m fairly vanilla in my approach, is question got me thinking about things that I have changed, tweaked or improved over the last year.

One of the biggest changes I’ve made is trying to get even more focused and specific with regards to my exercise selection with my athletes. Quite simply, I want to choose exercises that give them maximum carryover, either with regards to sport-performance, movement quality, and ideally, both!

And one thing I’ve found myself using more and more of are anterior-loaded kettlebell exercises.

Let’s discuss why you might want to consider using these exercises in your program, and then I’ll finish up with a few of my favorite kettlebell leg training exercises.

Why Kettlebell Leg Training?

Before I get into why I love these exercises so much, let me make one thing abundantly clear:

Yes, I know the kettlebell purists are going to hate me for writing this.

I’m not going to write about cleans, snatches, long cycle or the like.

Instead, the exercises I’m going to depict are actually very standard exercises, but we use a kettlebell to modify and improve how they are loaded.

So while I’m obviously a huge fan of the traditional kettlebell exercises, all that I ask is that you be open-minded about how you can use these tools to get more out of your average, everyday lifts.

And with that being said, here are three reasons I feel as though you should give these exercises a shot!

1. Trains ‘dem quads.

Look, I know everyone wants to talk about the posterior chain (or P-chain, for short), but that’s soooooo 2008.

Nowadays, all the cool kids are bringing their training back to the middle and doing some serious anterior chain (or A-chain) training as well.

In all seriousness, the quads are a key muscle group, whether your goal is athletic development or more physique focused. I wrote an entire article called The Case for Big Quads, which is definitely worth a read.

2. Increases anterior core involvement.

When evaluating most of our clients, it’s obvious that there are serious imbalances between the muscles of the anterior core versus the posterior core.

Getting even more specific, we see these imbalances between the muscles of inhalation, versus the muscles of exhalation.

And there’s no shame in my game here – I’ve been heavily influenced by the Postural Restoration Institute, and their methodology has changed how I coach my clients and athletes.

With that being said, I really feel as though everyone needs a ton of anterior core training. When you use the exercises below, not only do you develop the legs to a high degree, but the core as well.

3. Decreases lat recruitment.

This jumps off the previous point, but if we can agree that most of us live in a position of extension, or inhalation, then we need to choose exercises that allow us to train our legs without moving into excessive extension.

The lats are a muscle group we have to keep an eye on here. While we know they play a role at the shoulder, they often get pulled into the mix at the lumbar spine and low back as well.

If your lats are stiff, they can yank you into an anterior pelvic tilt/increased lumbar lordosis, so working around them can be critical in our program design. Again, I wrote an entire article the lats (Lats: Friend or Foe?), so definitely check that out when you have some free time.

But the cool thing here is that anterior loaded kettlebell exercises reduce the need for external rotation at the shoulder, which decreases the likelihood that the lats will kick on and yank you into a bad position.

My Favorite Kettlebell Leg Exercises

Whether it’s reducing the influence of the lats as a spinal stabilizer, or strengthening the quads and core, I’m a huge fan of anterior-loaded kettlebell leg training.

Now I’m sure there are 1,000 derivatives of the exercises below, but here are my three go-to exercises, along with some coaching cues that I think will help you get more out of your training.

2-KB Front Squat

I first used a 2-KB front squat years ago while taking the Russian Kettlebell Challenge (RKC) instructors course.

At the time I was still very powerlifting dominant in my training, so I’m not sure I really respected the movement at the time.

However, as my focus has shifted more towards training athletes, and thus developing more well-rounded athletes, this is now one of my go-to exercises, especially early-on in a training program.

Set-up with 2-KB’s in front of the body. I like to keep the elbows down to a degree, and interlock the fingertips.

The feet should be placed about hip/shoulder-width apart, with a small degree of toe flare. From this position, simply sit down/back, making sure the feet, knees and hips are in a straight line throughout.

Squat as low as you can without losing your lower back position, and think about “feeling” your entire foot while squatting down. Stay in control, and then think about using the quads and glutes to drive out of the bottom.

At the top, finish tall and reset before squatting again.

2-KB Split-Squats and Reverse Lunges

I’m obviously a huge believer in single-leg and split-stance work (which is why I create the Single-Leg Solution in the first place!), but the 2-KB variations take this stuff to the next level.

I always liked using anterior loaded variations of split-squats and lunges, but the barbell wasn’t ideal for two reasons:

1. It’s cumbersome and takes up a ton of space, especially in a busy gym.
2. Driving the elbows up (as you would in a front-squat) can yank on the lats and pull you into an increased lumbar lordosis/anterior pelvic tilt.

Enter the Kettlebell. (See what I did there?!?!?!)

The 2-KB version of the split-squat and lunge keeps you in a great torso position, loads the anterior core, and builds the quads to boot.

Set-up with 2-KB’s in front of the body, interlocking the fingertips to improve stability and control.

If you’re performing a split-squat, set-up in the 90-90 position outlined here. Exhale to get your abs/core turned on, and then think about dropping straight down.

Keep the entire foot on the floor, and then think about pushing through the foot to drive back up to the starting position.

For the reverse lunge, the goal is to step back into that 90-90 position. It’s obviously a bit more dynamic and prone to error, but if you’re in the ballpark of the 90-90 position then you’re doing just fine.

2-KB Step-ups

Last but not least we have the 2-KB step-up.

Much like the lunge/split-squat, I always liked anterior-loaded step-up variations, but they feel prey to the same issues.

Again, when swapping out a kettlebell for a barbell, you eliminate those issues and really get a ton out of the movement.

Performance on the step-up is pretty simple to coach, but definitely not easy to perform. Start by racking 2-KB’s in front of the body and interlocking the fingertips. One foot should be on the box with the foot/knee/hip in alignment.

From this position, think about feeling the whole foot and then driving through the midfoot to stand up onto the box.

Lower under control, again feeling the whole foot, and lowering back down the foot/knee/hip staying in alignment throughout.

One Final Cue/Technique Tip

There are obviously a million or more cues I can use here, but I really like to keep things simple.

Up to this point, we’ve assumed that the kettlebells themselves are enough to get you into a good core and pelvic position, but unfortunately, that’s not always the case.

What you may need to do is exhale to restore core and pelvic position first, and then inhale slightly (while keeping the proper position!) to improve stability.

And if that doesn’t make sense, here’s a quick video to better explain how to do this:

Summary

Kettlebell leg training isn’t the be-all, end-all of training, and I will never tell you that it is. The powerlifter/meathead that lives deep in my soul still loves the big, basic squatting and deadlifting variations, and I don’t think that will ever change.

However, I think there is definitely merit in using these kettlebell variations for specific clients, to get a specific training effect.

If you haven’t tried them in the past, give them a go next time you’re in the gym, as I think they can make a profound difference in your training!

- See more at: http://robertsontrainingsystems.com/blog/kettlebell-leg-training/#sthash.UeU4yNvi.dpuf

Sprinting for Muscle

by Travis Hansen

 http://www.t-nation.com/training/sprinting-for-muscle

Here's what you need to know...

•  Sprinting isn't the primary method for muscle growth, but like all speed work, it can quickly get you bigger.

•  A few sprint workouts during mass phases can greatly reduce bodyfat accumulation and also increase insulin sensitivity so you get even leaner in the process.

•  Doing some speed work immediately after your warm-up will potentiate the CNS, thereby increasing force output.

Sprinting has typically been associated with athletic development rather than as a way to acquire quality muscle mass. However, while in many ways sprinters and bodybuilders couldn't be more different, the fact is there's considerable overlap between the two disciplines and you can exploit this overlap in your pursuit of bigger, stronger legs.

Speed work such as sprinting isn't the primary method for muscle growth, but it does "speed up" the hypertrophy process. So think of sprinting as a secondary technique for size, one that can get us to our size destination much faster.

Here's how specific speed work and sprinting can help you with your physique.

1. Speed Work Prevents Fat Gain

Speed training creates a huge metabolic disturbance and is one of the best methods for losing or maintaining fat stores. According to the many DEXA scans I've run on athletes and clients, body fat stores rapidly decrease and muscle size increases once sprinting is employed. One reason is the effect (and after-effect) sprinting has on our underlying physiology. Sprinting significantly increases EPOC, or post-exercise oxygen consumption, which sucks up calories like a sponge for hours after high intensity training.

This can really assist your efforts during mass phases by limiting unwanted fat gain. Keep in mind that you only need a few hundred calories to pack on a single pound of muscle, while any extra will be diverted to fat stores. Sprinting effectively establishes a safeguard against this all too common bulking pitfall.

Additionally, since a leaner body is more insulin sensitive and has less aromatase (estrogenic) activity, it's in your best interest to keep body fat to a reasonable level – even while adding size.

2. Speed Work Improves Anaerobic Conditioning Levels

The more work we do in the hypertrophy training zones (70-85% of 1RM), the better we can grow. Sprinting can ensure that the specific energy support systems (alactic and lactic) that fuel performance in these zones are performing at optimal levels. This will generate greater rep work output, resulting in more muscle growth.

3. Speed Work Potentiates the CNS

By sequencing some speed work immediately after your warm-up or movement prep but before strength work, your CNS and force output will be far greater, resulting in more growth.

Furthermore, even general speed training will induce specific adaptations in the neuromuscular system (i.e., rate of motor unit recruitment, synchronization, etc.) that will allow the body to generate force faster. The faster you can summon force, the more total force you can generate during a rep attempt. This allows you to lift more weight and complete more volume, two of the most important variables for building muscle mass.

4. Speed Work is a Form of Progressive Overload

Barbells, dumbbells, and kettlebells are forms of external resistance. However, sprinting offers a not-so-common form of resistance by way of the momentum of our body mass, which creates another essential source of overload.

Studies show that the landing impact during sprinting can exceed three times bodyweight. Multiply this across several foot contacts during a sprint and you can see both the challenge and benefit that this type of training can bring for promoting tissue growth.

5. Speed Work Functions as Supplemental Hip Training

Sprinting is a good general test for hamstring strength, since the hamstrings are the dominant muscle group in sprinting. The specific joint angles that occur during a sprint mimic a reverse hyper, a staple supplemental exercise for people looking to get strong or big. Integrating some speed work into your training helps address weaknesses at the posterior chain and ensures that this area is contributing maximally during your lifts.

Real World Evidence

Powerlifters are very big and strong. They also do a form of direct speed work in their training programming called Dynamic Effort work, which is markedly similar to sprinting. Their speed work helps recruit more mass, increase force production, drive through sticking points, and provide a new source of stimulus to prevent stagnancy – not to mention putting on size!

Another example of individuals who do speed work, obviously, is sprinters. Many are very muscular and extremely lean, often without doing much resistance training work. Of course, the best of the best have genetic advantages that influence their results, but clearly sprinting helps accentuate their genetic gifts.

These sprinters are generally very muscular because the conditions required for growth are all present during sprinting – general overload, volume-fatigue, and high eccentric contractions.

The Plan

Note: You must start with an Acceleration/Speed Prep Phase. This is designed to increase specific strength of the sprinting musculature and improve coordination, flexibility, and mobility. It also helps prevent the initial muscle strain that often occurs when someone integrates standard sprinting into his program without preparing for it.

The Program

Week 1: 5 x 5-second sprints on treadmill at an incline.
Week 2: 5 x 20-yard sled sprints using bodyweight + bodyweight as external load.
Week 3: 5-10 x 10-yard sprints
Week 4: 5 x 20-yard sprints

If you're an athlete, you could expand this to 40 yards x 3 reps in week #5, but there's no need to train at a greater distance if you're just looking to get big and strong. Twenty yards is sufficient and safer, too.

The progressions provided will still enable you to build speed and power, groove your sprint pattern, limit fatigue, and reduce the rate by which the limbs have to react – all of which can be a source of sprinting injury. By the fourth week you should be ready to go with standard sprint training.

Here's how to apply your sprint work into a 3-day "modified" Westside Barbell template. If you prefer to train 4 days a week, make sure to sprint every other training day on lower body days only, so you enable full recovery and limit both local neural fatigue and lower body muscular fatigue.

3 Day Template 

Day #1
Sprints
Max Effort Lower
Supplemental Work

Day #2
Max Effort Upper
Supplemental Work

Day #3
Sprints
Dynamic Effort Lower
Supplemental Work

Squat Like a Champion

by Martin Rooney 

 http://www.t-nation.com/training/squat-like-a-champion

Here's what you need to know...

• The squat is a highly functional exercise that every athlete should be doing, or working their way up to doing.

• The biggest obstacle lifters face when squatting is their mobility. And with mobility, you either move it or lose it.

• Squatting ability should be assessed on a continuum. Find the movements that you can do well and gradually work up in difficulty as your mobility improves.

I love to squat. The unmistakable feeling of heavy weight on my back and the sound of clanging 45's always clears my mind like nothing else.

However, the barbell back squat is under fire from the same "experts" who want to abolish gym class and make overhead pressing an indictable offense.

Yes, squatting can be "dangerous" for the lower back when mobility is an issue, and certainly there are other "functional" single-leg activities you can perform in place of the squat.

But just because you might not be ready to squat today doesn't mean it'll be off the table forever. There's a way to systematically progress to performing solid squats.

That's right, like a martial artist moving from white belt to yellow and beyond, you can earn the right to squat.

But is it Functional?

Some experts say the squat isn't functional. Really? Well, unless you take a dump by doing a single-leg pistol squat to the bowl, or put a foot up on the tank to drop a Bulgarian-inspired deuce, a two-footed squat still takes place every day.

And why doesn't anyone call out the chin-up for functionality? It's not like people are doing that motion on a daily basis.

Anyway, here are four "functions" of the squat that make it worth keeping in your program:

1. The squat functions to improve athleticism. In my 20 years of training and coaching, I've seen a lot fewer people get hurt squatting than those dropping weights on their toes. I have, however, seen thousands of athletes lower their 40 times and increase their vertical jumps by squatting.
2. The squat functions to improve cardio. Most people think cardio involves elliptical machines, leotards, and aerobics class. Do some sets of 15-20 squats and see if your heart rate doesn't spike. Squats will improve your cardiac capacity and mental toughness.
3. The squat functions to add muscle mass. The squat is the absolute best exercise for adding functional bodyweight. If your goal is to weigh more than people think, the squat will pack on muscle in places people can't even see.
4. The squat functions to get athletes ready for future programming. If you're a trainer and you have to get athletes ready for college, squatting should be a staple. Single-leg dumbbell crossover step-ups might earn you points for creativity, but if you aren't making your athletes squat you aren't doing all you can to prep them.

What about all the single-leg exercises like step-ups and lunges? Are they useless? No way! I've successfully performed and programmed single-leg exercises with squats for years. I'm not sure where this "one or the other" attitude came from.

Mobility: The Real Problem

The big issue with the back squat isn't weakness – it's mobility.

Contrary to what you might hear, mobility isn't age dependent; it's movement dependent. Stop moving for an extended period of time and don't be surprised when the back squat folds you in half like a cheap lawn chair.

We all saw that photo of the one-year-old sitting in the hole of a perfect squat. Heck, some of you might've posted it on your Facebook page and commented on his "ass to grass" form.

Newsflash: Not many 30-60 year-olds have that level of mobility. Maybe that's what's supposed to happen with mobility. Fail to maintain it and you lose it.

If that's what happens, you turn the barbell squat into a "bad morning exercise," both during the workout and the next day when you hobble out of bed.

But if you keep moving and maintain or even enhance your mobility as you age, the squat doesn't have to go. You can greatly improve your mobility for squatting if you work at it.

Below is my mobility routine that I perform before every squat workout.

Squat Mobility Progression

1. Shoulder Wall Slides

Begin seated or standing against a wall with the arms held overhead. Slide the elbows, wrists, and hands down the wall to the "W" position shown. Hold for 5 seconds and repeat for 10 reps.

2. Soleus and Hip Flexor

Begin half-kneeling with the front foot a few inches from the wall. Lean forward to touch the knee to the wall while stretching the opposite hip. Hold for 5 seconds and repeat for 5 reps on each side.

3. Seated Glute and Ankle

Begin sitting with one leg crossed over the other and the hands supporting the body at the end of the chair. Lower yourself down to bring the forehead toward the knee. Hold for 5 seconds and repeat for 5 reps on each side.

Want Even More Depth? Change Your Shoes

Ankle mobility is the biggest limiter with the squat. Chuck Taylors might be the rage, but if ankle mobility is the limiting factor you'd be better off investing in a pair of Olympic lifting shoes. The higher heel reduces the demand for ankle ROM (range of motion) that you might not have.

Earn Your Squat

Here's a thought: The barbell back squat isn't an introductory exercise as it requires adequate mobility. So, if the back squat is giving you problems, it's better to work up to it.

Here's a 16-exercise continuum I use to help my athletes "earn their squat." The continuum begins with lower load and mobility requirements and gradually progresses to heavier, more challenging movements.

See where you fit and start there. Move up the continuum as your strength and mobility improves.

Low Mobility, Low Load
1. Body Squat, hands held straight out front, heels elevated
2. Body Squat, hands held straight out front, feet turned out
3. Body Squat, hands behind head, feet turned out

Low/Moderate Load, Average Mobility
4. Single Kettlebell Goblet Squat
5. Single Dumbbell Goblet Squat
6. Dumbbell/Kettlebell Squat, held at side

Moderate/ High Load, Average Mobility
7. Double Dumbbell Front Squat
8. Double Kettlebell Front Squat
9. Barbell Front Squat
10. Barbell Zercher Squat (see below)
11. Dumbbell/Kettlebell held-at-side Squat
12. Barbell Back Box Squat

High Load, High Mobility
13. Barbell Back Squat, heels elevated (shoe or plate)
14. Barbell Back Squat
15. Dumbbell Overhead Squat
16. Barbell Overhead Squat

As you can see, apart from the overhead barbell squat, the back squat is near the top of the squat food chain. In my TFW System, you don't just do it – you have to earn it.

So work up to it just like you would with other lifts. You wouldn't do full cleans from the floor without a progression right? Why should the squat be any different?

On to the Next One

Hey, if you don't like squatting, don't do it. If you don't have the mobility, don't do it (at least not yet). But trying to remove it from everyone's training is weak and totally unnecessary, not to mention counter-productive.

And unless everyone starts doing single-leg step-ups onto the toilet, I still think the squat is very "functional" too.

STEEL CLUB EXERCISE: 2-HAND SIDE PRESS

 John Wolf   

Summary

The 2-Hand Side Press will take the attributes of the 2-Hand Front Press and add the additional challenge of torso rotation. The addition of this rotation will make the obliques fire to create the movement and then to stabilize the load. It is an awkward movement for most so the most common mistake is to attempt to move through the range too quickly, which will destabilize the Steel Club as well as the shoulder girdle. This is a high tension movement that should be performed in a controlled fashion.

Exercise Steps

Step 1: Clean the Steel Club into the Ready Position aligned with the shoulder of the top hand

Step 2: Tuck your pelvis and brace your core

Step 3: Turn your torso 90 degrees away from top hand and press the Steel Club towards your mid-line while keeping your shoulders back. The hips may turn but should turn less than 45 degrees.

Step 4: Maintain tension in core and lats as you pull the Steel Club back into rack facing forward. Repeat.

STEEL CLUB PROGRESSIVE CHALLENGE SERIES #1

 John Wolf   

Workout Summary

Learning new Steel Club skills should always be built on progressions. If you have developed proficiency in the individual components that make up a complex skill and teach your nervous system how to properly sequence the skills then you will be able to perform the complex skill well. It has been made to seem much more complicated than it is by some. In this 4-part series you will be introduced to a no nonsense approach to building complex skills.

This first Steel Club workout in the Progressive Challenge series will focus on transitioning into and out of the basic Steel Club Pullover exercises in combination with either a Steel Club Squat or Steel Club Clean.

Workout Instructions

This program is to be done in a circuit format performing each drill in the workset for the prescribed number of repetitions with one grip before changing grips. This will allow the progressions to build naturally by grooving the techniques on one side without having to stop and change grips on each exercise. For example…you will perform A1-A3 continuously with a right hand over grip before changing grips to left hand over and going back through A1-A3 to complete one round.

A1: Steel Club 2-Hand Pullover to Ready – 4 rounds x 5 reps each side
A2: Steel Club 2-Hand Front Press Squat – 4 rounds x 5 reps each side
A3: Steel Club 2-Hand Barbarian Squat – 4 rounds x 5 reps each side

B1: Steel Club 2-Hand Side Clean – 4 rounds x 5 reps each side
B2: Steel Club 2-Hand Side Pullover – 4 rounds x 5 reps each side
B3: Steel Club 2-Hand Side Clean to Pullover – 4 rounds x 5 reps each side

Импиджмент синдром и разрыв «вращательной манжеты»

Автор: Олег Н. Миленин, Москва

 

Импиджмент синдром и разрыв «вращательной манжеты» . 

  

Что такое вращательная манжета плеча? 

Под вращательной манжетой плечевого сустава понимают сухожильное образование состоящее из сухожилий надостной. подостной и подлопаточной мышц. Основная функция этого анатомического образования – стабилизация и удержание головки плеча в суставной впадине лопатки при отведении верхней конечности. 

  

Как повреждается вращательная манжета и что такое импиджимент синдром? 

Наиболее уязвимым местом вращательной манжеты является сухожилие надостной мышцы, так как оно находится прямо под акромиальным отростком лопатки и может при неловком движении об него повреждаться. Но чаще всего вследствие возрастных или посттравматических изменений происходит заострение акромиального отростка с отложением на нижней, обращенной к вращательной манжете поверхности, солей кальция в виде шипов-остеофитов приводящее к истиранию вращательной манжеты - это так называемый импиджмент синдром. 

Как диагностировать Импиджмент синдром и разрыв «вращательной манжеты»? 

На ранних стадиях развития импинджмент-синдрома основной жалобой пациентов является разлитая тупая боль в плече. Боль усиливается при подъёме руки вверх. Многие пациенты отмечают, что боль мешает им уснуть, особенно если лежать на стороне пораженного плечевого сустава. Характерным симптомом импинджмент-синдрома является возникновение острой боли у пациента при попытке достать до заднего кармана брюк. В более поздних стадиях боль усиливается, возможно появление тугоподвижности сустава. Иногда в суставе отмечается пощелкивание в момент опускания руки. Слабость и затруднение при поднятии руки вверх может свидетельствовать о разрыве сухожилий вращательной манжеты. 

Наиболее информативным методом для диагностики разрывов вращательной манжеты это – Магнито-резонансная томография (МРТ), исследование позволяющие качественно и количественно определить повреждения мягких тканей. 

т консервативное лечение импиджимент синдрома ? 

  При отсутствии на МРТ повреждения вращательной манжеты, лечение импиджимент синдрома начинают терапевтическими методами : 

•  ограничение активности 

•  противовоспалительная терапия 

•  введение стероидных препаратов 

•  различные виды и методы физиотерапии. 

Терапевтическое лечение может занять от нескольких недель до месяцев, и если заболевание не запущено, то этих методов, как правило достаточно. 

  Когда необходима операция ? 

  В том случае, когда терапевтическое лечение не дало результатов, когда боль является острой, либо повреждена доминирующая рука, без которой страдает качество жизни пациента, применяют хирургическое лечение - артроскопическую субакромиальную декомпрессию. 

В чем заключается операция? 

  В большинстве случаев операцию проводят артроскопически – через проколы кожи, без разреза. В полость плечевого сустава через прокол вводится специальный оптический прибор – артроскоп, позволяющий осмотреть сустав, выявить повреждение вращательной манжеты и установить причину болей. Через второй прокол вводится специальный инструмент шейвер, удаляющий костные шипы с акромиального отростка лопатки, сдавливающие вращательную манжету и вызывающие боль. 

Какова тактика лечения при обнаружении разрыва сухожилий вращательной манжеты? 

В связи с особенностями кровоснабжения, самостоятельно без операции полнослойный разрыв вращательной манжеты зажить не может. Операцию можно выполнить артоскопически через проколы, либо через небольшой разрез. Тип операции зависит от размера, расположения разрыва. Частичные разрывы требуют, только сглаживания краев повреждения во время операции. Полные разрывы, вовлекающие всю толщу связочного аппарата требуют сшивания, если же разрыв произошел в месте прикрепления сухожилия к кости, то это требует «подшивания» его к кости при помощи рассасывающихся якорных фиксаторов. 

Как происходит реабилитация после операции? 

  Если вращательная манжета не повреждена, то со второго дня назначаются активные движения в плечевом суставе. Спортом можно заниматься через 4 недели после операции.

Нестабильность и привычный вывих плечевого сустава

Автор: Олег Н. Миленин, Москва

  Плечевой сустав – самый подвижный в теле человека. Устроен он таким образом, чтобы позволять осуществить движение любого объема во всех плоскостях. Обратная сторона повышенной подвижности плечевого сустава – предрасположенность к повреждениям. Плечевой пояс прикрепляется к грудной клетке спереди в грудино-ключичном суставе, а сзади лопатка соединяется с грудной клеткой только с помощью мышц. Особенностью плечевого сустава является значительная роль мышц не только в генерации движения, но и в динамической стабилизации плечевого сустава. Например, движение броска мяча невозможно осуществить безопасно и правильно без первоначальной стабилизации лопатки зубчатыми, трапециевидными, ромбовидными мышцами, а плеча – мышцами манжеты ротаторов. Между тем, очень часто, патология этих мышц в силу постепенного развития симптомов, принимается как просто «артроз» или даже «остеохондроз». В результате пациент с болями в плече приходит к спортивному травматологу с уже массивным разрывом манжеты ротаторов, который требует длительного восстановления после уже давно показанной операции на сухожилиях этих мышц. Не менее актуальная проблема – нестабильность плечевого сустава, 

возникшая после вывиха (и его вправления) . 

Кратко приведем терминологию возможных повреждений плечевого сустава при нестабильности плеча после его вывиха. 

•  повреждение Банкарта – обозначает отрыв капсулы и суставной губы от суставной впадины плеча. 

•  повреждение Хилл - Сакса – костное повреждение задненаружной части головки плеча при ударе о край суставной впадины после вывиха. 

•  повреждение SLAP – места повреждения суставной впадины плеча. 

•  манжета ротаторов (вращательная манжета) – сухожилия группы мышц (надостной, подостной, круглых, подлопаточной), которые вращают и стабилизируют плечевой кости. 

Как происходит вывих плечевого сустава и почему развивается его нестабильность? 

Плечевой сустав составляет головка плечевой кости и гленоид (суставная впадина лопатки). По краю суставной впадины располагается менископодобная структура - суставная губа, которая выполняет роль стабилизатора (присоски). Капсула плечевого сустава в свою очередь плотно фиксируется к краю суставной губы, осуществляя стабилизирующую функцию. 

Вывих плеча происходит в случае, если происходит разрыв суставной капсулы или суставная губа (лябрум) вместе со связками отрывается от костного края суставной впадины лопатки. Это так называемое повреждение Банкарта. 

Если отрыв суставной губы происходит на ограниченном участке, то возникает чрезмерное смещение плечевой кости в зоне отрыва и пациент ощущает нестабильность - подвывих плечевого сустава. Чаще всего это происходит при вращении отведённого плеча кнаружи. Если отрыв суставной губы происходит на значительном участке (сравнимым по диаметру с головкой плечевой кости), то происходит полный вывих плеча – головка плеча полностью соскальзывает с суставной впадины лопатки и уходит в пространство между шейкой лопатки и мышцами. В ряде случаев после полного вывиха плечо вправляется самостоятельно, в других это можно сделать только с помощью врача. 

Каков прогноз после первого вывиха плеча? 

После первичного вывиха и его вправления дальнейший прогноз зависит от возраста пациента. Статистика свидетельствует о том что, у пациентов моложе 30 лет в 80 % случаев после первичного вывиха следует повторный, то есть без операции оторванная суставная губа не может самостоятельно прирасти на место. Для лечения пациента старше 30 лет со свежим первичным вывихом требуется обездвиживание руки в специальной шине до 6 недель, либо оперативное вмешательство. 

Как лечить повторяющийся (привычный) вывих плеча и нестабильность плечевого сустава? 

  

Для лечения этого состояния используется артроскопический способ, то есть операция проводится без разрезов, через проколы. В полость плечевого сустава через прокол вводится специальный оптический прибор – артроскоп, позволяющий осмотреть сустав, выявить повреждение связочного аппарата плечевого сустава и установить причину нестабильности. 

Через другой прокол в полость сустава вводятся специальные инструменты позволяющие прикрепить оторванную суставную губу. Фиксацию суставной губы осуществляют при помощи рассасывающихся фиксаторов – якорей. 

При правильном выполнении данной операции успех достигается в 95 % случаев. 

Всегда ли удается выполнить операцию артроскопическим способом? 

В случае застарелого повреждения или отрыва суставной губы с костным фрагментом, производится операция малоинвазивным способом через небольшой разрез 4 см, фиксируя костный фрагмент на место. Кроме того, преимуществом открытой техники является возможность ушивания растянутой капсулы сустава. 

  

Какова тактика реабилитационного лечения? 

  Плечо фиксируют в специальной шине в положении отведения и наружной ротации на 3-6 недель. Несколько раз в день шину снимают для выполнения упражнений, направленных на увеличение силы и объема движений. Занятия спортом разрешаются через 3-4 месяца после операции. 

  

Протокол реабилитации после оперативной реконструкции капсулы и суставной губы ( Bankart ).* 

* Внимание! Требуется консультация врача, специалиста в реабилитации по данному направлению. 

I фаза – острая, немедленная. 

Неделя 0-2. 

1) 1 неделя комфорта. 

2) Иммобилизация в брейсе 4 недели. 

3) Мягкие активно-ассистированные упражнения объема движений с L -образным бруском ( L - bar ). Все до болевого порога. 

А. Сгибание плеча 0-120 ° 

Б. Абдукция 20 ° , наружная ротация до 20 ° . 

В. Абдукция 20 ° , внутренняя ротация 45 ° 

•  Упражнения с веревкой, прыгалками. 

•  Объем движений локтя и кисти. 

•  Изометрия наружной и внутренней ротации, абдукция, бицепс. 

•  Разгибание, сгибание локтя. 

•  Упражнения на сжатие меча. 

•  Холод. Противовоспалительные мероприятия. 

  

Неделя 3-4. 

Холод. Противовоспалительные мероприятия. Магнитотерапия. 

1. Активно-ассистированные упражнения объема движений с L - bar . 

А. Сгибание 120-140 ° . 

Б. Отведение 45 ° , наружная ротация 20-30 ° . 

В. Отведение 45 ° , внутренняя ротация 45-60 ° . 

2. Начало легких изотонических упражнений для мускулатуры плеча в отведении – внешняя и внутренняя ротация, надостная мышца и бицепс. 

3. Начало упражнений усиливающих стабилизаторы лопатки – ромбовидные, трапециевидные, передние зубчатые мышцы. 

  

Неделя 5-6. 

1. Прогрессия всех активно - ассистированных упражнений объема движения с L - bar . 

А. Флексия 160 ° 

Б. Абдукция 90 ° , наружная ротация 45-60 ° . 

В. Абдукция 90 ° , внутренняя ротация 65-90 ° . 

2. Эргометр для верхней конечности на 90 ° абдукции. 

3. Упражнения с мануальным сопротивлением на диагональные паттерны движения. 

4. Прогрессия всех силовых упражнений. 

  

II фаза, промежуточная (8-14 недель). 

Неделя 8-10. 

1. Прогрессия к полному объему движения. 

А. Флексия 180 ° 

Б. Наружная ротация 90 ° . 

В. Внутренняя ротация 85 ° . 

2. Изокинетические упражнения в нейтральной позиции. 

3. Продолжить все упражнения на усиление силы. 

4. Начать упражнения усиливающие мышцы, стабилизирующие лопатку. 

  

Неделя 10-14. 

1. Продолжить все упражнения на мобилизации капсулы. 

2. Начать программу из 10 упражнений для “бросковых” видов спорта. 

3. Абдукция 90 ° , эргометр для верхней конечности. 

4. Упражнения с мануальным сопротивлением на диагональные паттерны движения. 

  

III фаза, продвинутая (4-6 месяцев ). 

1. Продолжить все упражнения на подвижность. 

Стречинг наружной ротации, внутренней ротации, сгибания, на капсулу плечевого сустава. 

2. Продолжить 10 упражнений для “бросковых” видов спорта. 

3. Изокинетическая наружная - внутренняя ротация. 

4. Тестирование изокинетики. 

5. Плиометрические упражнения. 

6. Интервальная тренировочная программа с одобрения врача. 

  

IV фаза возврата к функциональной активности. 

•  Продолжить все усиливающие упражнения. 

2. Продолжить 10 упражнений для “бросковых” видов спорта. 

3. Продолжить стречинг. 

4. Функциональная спортивная нагрузка