What is the importance of a movement diagnosis compared to a medical diagnosis?

A medical diagnosis identifies a pathology (e.g., biceps tendonitis), but a movement diagnosis, as described by Shirley Sahrmann, identifies underlying movement issues (e.g., scapular downward rotation syndrome) that could lead to various pathologies. Understanding how one moves and addressing those patterns is crucial for long-term resolution and preventing recurrence, providing a more comprehensive approach to treatment.

Why is isometric training beneficial for tendon health?

Eric Cressey changed his mind about isometrics due to Dr. Keith Barr's research, which shows favorable biochemical responses of tendons (like Achilles and patellar) to isometric loading. Holds of around 30 seconds can significantly improve chronic tendinopathy, suggesting isometrics offer unique benefits not found in concentric or eccentric movements.

What are the common misconceptions about the fascial system?

The biggest misconception is often that fascial manipulation doesn't work. While the exact mechanisms are still being researched, fascia is a critical connective tissue matrix that helps transfer force. Interventions like dry needling, Active Release Technique (ART), and massage likely change fluid dynamics and stimulate the nervous system, offering transient symptom reduction and opportunities for motor learning. It's crucial to follow up manual therapy with appropriate exercises to make changes stick.

What are some practical exercises to improve thoracic mobility for desk-bound individuals?

For those with a rounded upper back (kyphosis), focus on movements that drive rotation and allow the shoulder blade to move freely. Examples include unilateral cable rows with opposite arm reach, 'yoga push-ups' (push-ups to downward dog) for scapular upward rotation, standing cable presses, and landmine presses for a moderated overhead pressing alternative. Incorporating these helps counteract the sustained postures from sitting.

How does specialized care impact athletic injury recovery, especially in baseball?

Highly specialized care, especially from clinicians affiliated with professional sports teams, leads to better outcomes as they understand the unique demands and subtleties of the sport. Generic programs or doctors unfamiliar with sport-specific asymmetries can misdiagnose or prescribe harmful rehab. The goal in competitive athletes is 'return to performance,' not just being asymptomatic, which requires a higher standard of care and an entire team approach.

What is the 'Get Long, Get Strong, Train Hard' philosophy?

This philosophy, attributed to Charlie Weingroff, involves three steps: 'Get long' means creating transient or permanent improvements in range of motion (e.g., positional breathing, soft tissue work). 'Get strong' means performing exercises to solidify those changes under load (e.g., kettlebell arm bar). 'Train hard' means increasing volume and load to make these new patterns feel normal and stick, integrating them into daily movement.

Why is 'Follow Your Passion' potentially bad career advice in strength and conditioning?

Eric Cressey believes 'Follow Your Passion' is problematic because passion doesn't guarantee differentiation. Many in the field are passionate about exercise, but success comes from developing marketable, specialized skills (e.g., language, technology, specific athlete populations) that make you unique. He advocates for building 'career capital' (Cal Newport's term) to later redeem for better compensation, work-life balance, or autonomy.

How important is power training for older individuals?

Power, defined as strength with a time component (how quickly force can be applied), tends to detrain faster than strength or aerobic capacity. It's vitally important as we age because it protects against falls, which can lead to hip fractures, significant mobility loss, and cognitive decline. Low-impact power training options include medicine ball throws, kettlebell swings, and remaining athletic through activities like tennis or golf.

What is the significance of the infrasternal angle in movement assessment?

The infrasternal angle is the angle at the bottom of the rib cage. A wide angle often correlates with individuals who are naturally 'hingy' in squats and good at toe touches, typical of powerlifters. A narrow angle is more common in good squatters who may struggle to hinge, often seen in high jumpers or certain pitchers. This measure provides insight into a person's natural movement biases and can inform exercise selection to avoid reinforcing bad patterns.

What are the key 'upstream' variables people should focus on for long-term health and performance?

Upstream variables include avoiding early sports specialization, maintaining diverse movement patterns into adulthood, prioritizing adequate sleep and nutrition, and ensuring regular, varied movement. Optimizing rotational capacity is particularly crucial, as it's often lost but vital for many activities. Also, being mindful of loading dysfunctional patterns and understanding the true 'why' behind stretching are important for preventing injury.

How has the youth sports landscape, particularly baseball, changed negatively, and what is the impact?

Youth sports have become highly specialized, with kids playing year-round instead of multiple sports, lacking a broad foundation and rich proprioceptive environment. This has led to an 'injury epidemic' in baseball, with many young players experiencing elbow injuries by age 18. The intense specialization and surging fastball velocities are overwhelming sports medicine, creating a generation of highly fragmented athletes who hit a 'wall' at higher levels.

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Eric Cressey — Tactical Deep Dive on Back Pain, Movement Diagnosis, & More | The Tim Ferriss Podcast

Tim Ferriss

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TL;DR

Eric Cressey and Tim Ferriss discuss back pain, movement diagnosis, training, and athletic careers.

Key Insights

Medical imaging often shows abnormalities in asymptomatic individuals, making it crucial to combine imaging with physical exams and patient history.

Low back pain is a non-homogeneous condition, varying significantly between individuals and requiring personalized treatment approaches.

Developing a "movement diagnosis" by assessing how a person moves and performs exercises is as critical as a medical diagnosis for effective treatment.

Improving thoracic spine and hip mobility, as well as strengthening the posterior chain with proper form, are key for preventing and treating back pain.

The fascial system plays a vital role in force transfer and stiffness; interventions like manual therapy and varied movement patterns can positively impact it.

Power training (strength with a time component) is crucial for aging individuals to prevent falls and maintain overall athleticism.

Avoid early sports specialization in youth to foster a broad foundation of movement and reduce injury risk.

THE NON-HOMOGENEOUS NATURE OF BACK PAIN

Low back pain is a complex, non-homogeneous condition, meaning its causes and manifestations vary widely among individuals. For instance, a tennis player's extension-based back pain differs from a desk worker's flexion-based issues. Eric Cressey emphasizes that the medical system often struggles with such varied conditions. Therefore, personalized assessment, considering an individual's activity history, symptoms, and previous treatments, is paramount. This tailored approach moves beyond a one-size-fits-all medical model to address the unique drivers of each person's pain.

MISINTERPRETING MEDICAL IMAGING

Medical imaging like X-rays and MRIs can reveal 'incidental findings'—abnormalities in asymptomatic individuals. Cressey highlights that many people, including elite athletes, have significant structural issues on scans without experiencing pain. Conversely, some individuals with severe pain may have seemingly normal images. This disconnect means imaging should only be one piece of the diagnostic puzzle, always accompanied by a thorough physical exam and patient history. Relying solely on imaging can lead to unnecessary fear, misdiagnosis, or treatment of findings that aren't the root cause of pain.

THE VALUE OF A MOVEMENT DIAGNOSIS

Beyond a traditional medical diagnosis, Cressey advocates for a 'movement diagnosis'—understanding how a person moves in relation to their symptoms. This involves static postural assessments, orthopedic range of motion tests, manual muscle testing, and general and specific movement screens (e.g., overhead squats, lunges, toe touches). These assessments help identify aberrant movement patterns, compensatory strategies, and limitations (like poor hip or thoracic spine mobility) that contribute to pain. The movement diagnosis guides corrective interventions, preventing reliance on imaging alone where correlations to pain are often weak.

SYSTEMIC CONTRIBUTORS TO MUSCULOSKELETAL PAIN

Pain can stem from systemic issues often overlooked in musculoskeletal assessments. Cressey notes that factors like severe Vitamin D deficiency or side effects from prescription medications (e.g., certain acne medications causing joint pain, statins causing muscle soreness, some antibiotics increasing tendon injury risk) can significantly contribute to pain. A comprehensive initial conversation with the patient, delving into their medical history, medication use, and even lifestyle factors, is crucial. This holistic approach ensures that potential systemic causes are identified and addressed, preventing misdirected interventions.

THE OVERLOOKED FASCIAL SYSTEM

The fascial system, a spiderweb-like matrix of connective tissue, is critical for force transfer, mobility, and overall biomechanical integrity. Cressey explains that it's often overlooked in anatomical studies but is key to understanding athletic movements, particularly in 'fascial-driven athletes' who are elastic and efficient. Misconceptions about fascia often lead to skepticism about manual therapies like dry needling, active release technique (ART), and cupping. While mechanisms are still being fully understood, these interventions likely improve tissue gliding, reduce neural threat, and create transient windows for motor learning, provided they are followed by appropriate exercise.

ADDRESSING THORACIC SPINE IMMOBILITY

Poor thoracic (mid-back) mobility is a common issue, heavily influenced by prolonged desk work or, conversely, excessive extension in some athletes. For desk-bound individuals with kyphotic (hunched) posture, Cressey recommends exercises that introduce movement variability and rotation. Examples include unilateral cable rows with opposite arm reach, yoga push-ups (to downward dog), standing cable presses, and landmine presses. These exercises encourage scapular movement, thoracic rotation, and safe overhead arm positioning. The goal is to counteract ingrained postures and restore optimal movement patterns rather than reinforcing them.

THE IMPORTANCE OF HIP MOBILITY AND GLUTE FUNCTION

Adequate hip mobility and proper glute function are fundamental for low back health. Cressey notes that a lack of hip extension mobility often leads to compensatory lumbar extension, placing undue stress on the lower back. "Glute amnesia" or poor activation contributes to hamstring-dominant patterns, which can cause anterior hip irritation. Exercises should focus on cleaning up hip extension patterns to ensure the glutes effectively contribute to terminal hip extension. Strengthening the entire posterior chain (hamstrings, glutes, adductor magnus, lower back) through variations of deadlifts, kettlebell swings, and hip thrusts is vital for functional strength and injury prevention.

POWER TRAINING FOR LONGEVITY AND FALL PREVENTION

Power, defined as strength with a time component (how quickly force can be applied), is a crucial but often de-trained physical quality, particularly as people age. Cressey emphasizes its importance for preventing falls in older adults, as it aids in quick reactionary movements. Unlike strength or aerobic capacity, power detrains rapidly, often in as little as five to seven days, necessitating consistent training. Examples of low-impact power training include throwing medicine balls, kettlebell swings, or engaging in activities like tennis that require rapid changes in direction and velocity, helping to maintain athleticism well into older age.

THE 'GET LONG, GET STRONG, TRAIN HARD' PHILOSOPHY

Cressey endorses Charlie Weingroff's "Get Long, Get Strong, Train Hard" mantra. 'Get Long' involves transiently or permanently improving range of motion through warm-ups, positional breathing, or soft tissue work. 'Get Strong' follows, using exercises to solidify these new ranges of motion under load (e.g., kettlebell arm bars after thoracic mobility drills). Finally, 'Train Hard' means applying sufficient volume and load (if appropriate) so the body perceives these newly acquired patterns as normal, making the changes stick long-term. This sequential approach ensures that improved mobility is reinforced with strength and integrated into functional movement.

RETHINKING STRETCHING AND ISOMETRICS

Cressey advises against stretching simply because a muscle feels 'tight,' as tightness often signifies protective tension (e.g., hamstrings protecting an anteriorly tilted pelvis). Instead, understand the rationale behind stretching and consider adding stiffness or motor control elsewhere to resolve the underlying issue. He's also changed his view on isometrics (muscle activation without length change), now recognizing their profound benefits for joint-hypermobile athletes to 'own' positions and for tendon health, particularly Achilles and patellar tendinopathies. Isometric holds (e.g., 30 seconds) appear to elicit unique biochemical responses beneficial for tendon integrity.

THE BENEFITS OF HANGING

Initially cautious, Cressey now advocates for hanging (from a pull-up bar) as a valuable tool, especially for individuals with stiffness or limited shoulder flexion. While hypermobile athletes may need modifications to prevent hyperextension, loaded or deloaded hangs (e.g., feet on a box) can act as 'distraction exercises' for the upper extremity. When combined with correct breathing techniques, hanging helps decompress the spine, improve overhead arm movement, reduce tone in muscles like the lats, and restore length to areas that become dense from daily activities, contributing to overall mobility and shoulder health.

ADVOCATING FOR ONESELF IN ORTHOPEDIC CARE

Patients must become advocates for their own healthcare. Cressey advises asking for referrals from trusted individuals with positive experiences with physicians and seeking out specialists for complex conditions (e.g., elbow specialists for throwing injuries). When selecting rehabilitation, inquire about the model (e.g., one-on-one vs. group, manual therapy component), the therapist's experience with specific injuries, and their ability to tailor interventions. The goal is to find practitioners who prioritize 'return to performance' not just 'return to play,' ensuring not only symptom resolution but also restoration of high-level function through a comprehensive, team-based approach.

UPSTREAM VARIABLES FOR LONG-TERM HEALTH

Cressey highlights several "upstream" variables critical for long-term musculoskeletal health. These include avoiding early sports specialization in youth to foster a broad foundation of diverse movements. Consistent sleep, proper nutrition, and regular varied movement throughout adulthood are paramount, as maintaining mobility is easier than regaining it. He also warns against 'loading bad patterns'—continuing high-volume or high-intensity exercise on top of existing dysfunctional movements or pain. Such actions often magnify problems, emphasizing the importance of mindful training and listening to one's body signals to prevent snowballing injuries.

IDENTIFYING QUALIFIED FITNESS PROFESSIONALS

Navigating the fitness industry to find a qualified professional can be challenging due to low barriers to entry. Cressey suggests looking for professionals who emphasize movement competency over just lifting heavy weights, possess a variety of philosophical approaches to training, and prioritize comprehensive client intake (e.g., medical history, waiver collection for emergency contacts). Certifications (like NSCA's CSCS) establish a minimal standard, but practical experience and a commitment to continuous learning are often more indicative of a skilled practitioner. Seek those who treat clients like athletes, aiming for improved quality of life and pain reduction.

Mentioned in This Episode

●Supplements

●Products

●Software & Apps

●Companies

●Organizations

●Books

●Concepts

●People Referenced

Tactical Deep Dive on Back Pain & Movement

Practical takeaways from this episode

Do This

Ask around for physicians with favorable experiences and good bedside manner, especially for specialized conditions.

Ensure any rehabilitation model involves one-on-one, hands-on manual therapy and addresses specific post-operative cases.

Look for practitioners with diverse skill sets, not just those with a hammer, to handle varied issues.

Work with clinicians accustomed to competitive athletes, as their outcome measure is 'return to performance,' indicating a higher standard of care and focus on timelines.

Prioritize a comprehensive medical intake, like checking for prescription medications or underlying health conditions (e.g., Vitamin D deficiency), for a holistic view.

Optimize rotational capacity in your movement, as people often lose this flexibility, but it's vitally important for daily life and athletic activities.

Understand why you are stretching; stretch with a rationale, and consider adding good stiffness/motor control elsewhere in the system.

Make the most of your warm-ups by incorporating self-myofascial release, positional breathing, and larger amplitude movements to expose yourself to new movement patterns.

Integrate power training (e.g., Med ball throws, kettlebell swings, tennis, golf) into your routine as you age to protect against falls and cognitive decline.

Utilize isometric holds for at least 30 seconds to improve tendon health, particularly for Achilles and patellar tendons, and own positions for hypermobile athletes.

Incorporate hanging variations, even deloaded, to improve shoulder flexion, thoracic mobility, and reduce lat tone, integrating correct breathing patterns.

For desk-bound individuals, emphasize unilateral cable rows with opposite arm reach, yoga push-ups (to downward dog), cable presses, and landmine presses to drive thoracic rotation and free scapular movement.

Avoid This

Avoid routine, immediate lumbar imaging for low back pain without indications of serious underlying conditions; it often leads to false positives and unnecessary interventions.

Do not under-report pharmacological interventions or previous musculoskeletal injuries, as they can significantly impact diagnosis and treatment.

Do not just focus on a medical diagnosis; always seek a movement diagnosis to understand how your movement patterns contribute to pain.

Do not solely rely on exercises that reinforce existing poor posture (e.g., excessive cycling or bench pressing for kyphotic individuals); diversify your movement patterns.

Do not ignore the downstream effects of orthopedic interventions; compensate for lost motion in other areas during recovery (e.g., training the non-injured side).

Avoid specializing in sports at a young age; prioritize varied movement experiences into adulthood for a broader foundation and to prevent overuse injuries.

Do not load aberrant or dysfunctional patterns excessively; this can magnify pain and lead to severe injury, whether from heavy weights or high-speed movements.

Do not follow the advice to 'Follow Your Passion' without also developing marketable skills; differentiation is key in competitive fields.

Do not get started with high-level Olympic lifting or gymnastics training in middle age if you have lost significant movement capacity, as this predisposes you to injury.

Avoid training environments that lack basic safety measures like waivers or proper equipment maintenance; this indicates a lack of professional standards.

Do not just stretch something because it feels tight without understanding the underlying cause; stretching a protective tension can make the problem worse.

Common Questions

Effective self-advocacy involves understanding that back pain is non-homogeneous and images don't always correlate with pain. Seek second opinions on MRI images, find specialized practitioners, and question their approach to manual therapy, supervision, and comprehensive care. Discuss previous injuries, medications, and lifestyle factors like vitamin D and magnesium levels, as these can impact musculoskeletal health.

Topics

Injury Prevention Strength Training Longevity Health & Longevity Mental Health & Psychology Human Performance Career Development Youth Sports Low Back Pain Movement Assessment Fascial Health

Mentioned in this video

Products

Pod Cover

A device by Eight Sleep that fits on any mattress and allows temperature adjustment for optimal sleep, featuring Dual Zone temperature control and tracking health metrics.

Aeropress

A highly-rated coffee maker praised for combining French press, pour-over, and espresso brewing methods into a compact, easy-to-clean device. It has a new crystal clear version.

Aerobie

An amazing UFO-like disc that could be thrown farther than a football field, created by Alan Adler.

People

Eric Cressey

President and co-founder of Cressey Sports Performance, director of player health and performance for the New York Yankees, and an expert in exercise science and kinesiology.

Dan Paff

A coach mentioned for distinguishing between mechanically and fashionably driven athletes.

Shirley Sahrmann

Author of 'Diagnosis and Treatment of Movement Impairment Syndromes', known for her pathology-driven model of movement which inspired Eric Cressey's shift towards movement diagnosis.

Brijesh Patel

A former graduate assistant strength and conditioning coach at the University of Connecticut who inspired Eric Cressey to pursue strength and conditioning following his articles.

Peter Attia

Peter Attia's book, which Eric Cressey mentioned as being beneficial for both longevity and optimizing athletic performance, highlighting the need to address general health in athletes.

Cal Newport

Author of 'So Good They Can't Ignore You', whose concept of 'career capital' Eric Cressey discussed regarding marketable skills over passion.

Mike Boyle

A professional whose 'Certified Functional Strength Coach' certification is highly regarded in the industry for setting a standard above the basic professional level.

Kelly Starrett

Co-author of 'Built to Move', who emphasizes daily living activities as a proactive screen and normalized Tim's MRI findings as part of an athletic history.

Juliette Starrett

Co-author of 'Built to Move', which discusses things people should be able to accomplish in terms of daily living activities.

Tina Murray

A mentor of Eric Cressey from UConn who is now with the Pittsburgh Penguins.

Stewart McGill

A researcher known for his work on back pain, particularly the concept of non-homogeneous conditions and understanding lumbar spine range of motion correlating with injury risk.

Dan Heath

Co-author of several excellent behavioral books, including 'Made to Stick', 'Decisive', and 'Upstream', which focuses on thinking about upstream factors for success.

Keith Barr

A researcher whose work on the favorable impacts of isometric holds on tendon health (Achilles and patellar tendons) significantly influenced Eric Cressey's thinking.

Bruce Lee

Mentioned as a historical figure and a huge fan of isometrics, known for his high neural drive and connective tissue focus.

Mike Robertson

A professional whose certification is mentioned as excellent in the strength and conditioning industry.

Alan Adler

A mechanical engineer and Stanford University lecturer who created the Aerobie and later invented the Aeropress.

Chip Heath

Co-author of several excellent behavioral books, including 'Made to Stick' and 'Decisive', which provided insights into human behavior and decision-making.

Andrew Hutson

A mentor of Eric Cressey who is now back at UConn.

Thomas Myers

Author of 'Anatomy Trains', who spoke about the fascial system and emphasized multi-joint movements and patience for fascial fitness.

Chris West

A mentor of Eric Cressey from UConn, under the soccer umbrella.

Books

Journal of Strength and Conditioning Research

A publication where Eric Cressey's research has been published.

Made to Stick

A book by the Heath brothers, mentioned in the context of effective communication and behavioral change.

American Journal of Medicine

Published a study in 2000 on elite Spanish athletes, revealing stress fractures in 8% with only 50% showing symptoms, particularly common in track and field throwers, rowers, gymnasts, and weightlifters.

The 4-Hour Chef

Tim Ferriss's book where he highly recommended the Aeropress as his favorite brewing method after extensive testing.

Built to Move

A book by Kelly and Juliette Starrett that discusses activities of daily living and tasks as proactive movement screens.

Anatomy Trains

A book mentioned as a foundational text by Thomas Myers, discussing fascial chains in the body.

Upstream: How to Solve Problems Before They Happen

Dan Heath's latest book, commended for encouraging thought on 'upstream' variables like sleep and nutrition for athlete success.

Decisive

A book by the Heath brothers, recommended by Eric Cressey to athletes making major life decisions, such as signing with a team or going to college.

Diagnosis and Treatment of Movement Impairment Syndromes

A landmark book by Shirley Sahrmann that influenced Eric Cressey's shift from medical to movement diagnosis, helping him understand how one movement issue can create multiple pathologies.

The 4-Hour Workweek

Tim Ferriss's then-forthcoming book, mentioned in the context of his first presentation.

Supplements

Vitamin D

Mentioned as a systemic cause of musculoskeletal pain if deficient and having big relationships to musculoskeletal health.

Magnesium

Mentioned as a systemic factor that can affect musculoskeletal health if levels are deficient.

Statin

Mentioned as a prescription medication that can cause significant muscle soreness in some people.

Concepts

Certified Strength and Conditioning Specialist

A certification from the NSCA considered a critical threshold in the strength and conditioning industry, verifying basic first aid, CPR, and awareness of training facility design.

Certified Functional Strength Coach

A certification developed by Mike Boyle, recognized as being above the basic professional level in the strength and conditioning industry.

Selective Functional Movement Assessment

Described as a more clinical add-on to the FMS, providing a deeper diagnostic approach to movement.

Companies

Eight Sleep

A company that manufactures the Pod cover, a mattress accessory that regulates sleeping temperature for optimal sleep.

Cressey Sports Performance

Eric Cressey's training facility with locations in Palm Beach Gardens, Florida, and Hudson, Massachusetts, known for working with professional and Olympic athletes, especially baseball players.

New Balance

A company for which Eric Cressey serves as a consultant.

Athletic Greens

A nutritional supplement and company for which Eric Cressey serves as a consultant. Tim Ferriss also endorses AG1 as his all-in-one nutritional insurance.

Proteus Motion

A technology company for which Eric Cressey serves as a consultant. Also mentioned as a cool technology for purely concentric training in fluid ways.

Organizations

Stanford University

The institution where Alan Adler worked as a lecturer.

New York Yankees

Major League Baseball team where Eric Cressey serves as director of player health and performance.

Pittsburgh Penguins

An NHL team where Tina Murray, Eric Cressey's mentor, is now working.

University of New England

Where Eric Cressey double-majored in exercise science and Sports and Fitness Management.

National Strength and Conditioning Association

Mentioned as the 'gold standard' for certifications in the strength and conditioning industry, with the CSCS certification being a critical threshold.

University of Connecticut

Where Eric Cressey received his master's degree in kinesiology with a concentration in exercise science.

Posture Restoration Institute

An approach that focuses on a predictable pattern of asymmetry in movement and posture.

Studies & Research

The Lancet

A medical journal that published an article in 2009 stating routine lumbar imaging for low back pain without serious indications does not improve clinical outcomes.

New England Journal of Medicine

A journal that published a landmark study showing a high percentage of asymptomatic spines have disc bulges, protrusions, and extrusions.

Software & Apps

Active Release Technique

A focal approach to manual therapy involving pinning down tissue and then stretching it, which Eric Cressey found significantly helped his shoulder issues.

Dry Needling

A focal soft tissue intervention targeting trigger points, using tools similar to acupuncture needles but not based on meridians.

Media

Elite Baseball Podcast

Eric Cressey's podcast, complementing his website and training facilities.

Late Night with Jimmy Fallon

A TV show where Tim Ferriss demonstrated making coffee using the Aeropress.

Drugs & Medications

Cipro

An antibiotic mentioned that may make people more susceptible to tendon injuries.