Monday, September 16, 2019

Injury Prevention in Grappling Sports - Part IVD

Over the course of the last several weeks, we have been discussing specific types of shoulder injuries that can occur in grappling sports.  Last week, we discussed some specific stretches we can do to prevent injury.  These stretches can be added to your routine and should be done prior to practice, drills or live rolling or competition. 

In addition, there are some exercises we can add that will also help to prevent injuries.  Before we go into specific exercises, I want to discuss how you put these into your routine.  One thing we know from the research (Soomro et al Am J Sports Med 2016) is if a "prevention program" goes over 20 minutes in duration, then compliance with that program drops off drastically.  We all know our time is very limited and adding an additional 20-60 minutes of "preventative exercises" onto your routine will many times prevent us from doing the things we know we should do.  But, what if I told you there is a way that you can add exercises to your routine that will 1/2 the time as the traditional route and when done in this fashion not only help prevent injuries but also improve athletic performance. 

In our research, in an effort to make our programs more efficient (not require high volume but still provide same training effect) we developed an approach called fatigue state training.  Fatigue state training simply uses the fatigue you create in training, weight lifting or practice to pre-fatigue the body prior to performing our preventative program.  Theoretically, we could then do less volume and still have the same training effect because you are starting from a state where the muscle is already tired.  Applying this approach, we discovered several interesting things. 

  • Improved Compliance - since the program is shorter and takes less time to implement, the compliance rate with the program is much better.  This has had a dramatic impact on injury rates and team performance.  Why team performance?  In sports, better players play more and therefor are more likely to get injured.  Reduction of injury rates meant better players stay in the game longer and contribute to overall team success.
  • Training Effect - by using fatigue state training, you get the same training effect with 1-2 sets that we would normally get with 4-5 sets.  We also found by training the muscles in a fatigue state, when the athlete became fatigued during play, they actually were moving better and getting injured less.  This falls under the training philosophy of specificity of training.  We trained the muscles in a fatigued state so when the athlete is fatigued this is a state the muscles are trained for so they can respond better.  
  • Performance Impact - by doing fatigue state training, we found that athletes were actually performing better in the later stages of the game or competition.  So not only was team performance going up but athlete's individual performance was improving.

All of this to say, if you are going to do these exercises, you can make it more efficient, more impactful on injury rates and athletic performance if done at the end of practice.  I am also putting in some exercises that will address several links in the chain (core, shoulder, arms) instead of just pure isolation to one muscle.  This is more functional (since this is how the body works) and more time efficient (train multiple parts at one time).

*Note - some of the exercises I do with CLX.  This is a new theraband product that has continuous loops and allows you to do somethings you could not do with traditional theraband.  I have no financial relation with them but do love their products so you will see this used below*

Turkish Get Up - This is one of my favorite exercises for overall body conditioning.  Not only does this work the shoulder/upper body, core and legs, it is also a great exercise to strengthening for your escapes from mount, goon grip, etc.  There are some cues on the diagram below that you should follow to keep proper form.  When doing this, if done in fatigued state, do 1-2 sets of 10-15 reps per side.



Pull ups with a Gi- I like incorporating pull ups with a Gi or rope as this not only strengthens my shoulder girdle, arms, parascapular musculature and lats but is also a great exercise for helping me with my grip strength and explosive power for collar drags and pulling guard.


Scapular retraction with external rotation -   using the CLX, grab the middle of the band and put your hands in two loops next to each other.  With palms facing up, pull shoulder blades back and down (by bringing your chest up) and slowly rotate hands out like pictured below.  Pause at end range and slowly return to start.  Do 1-2 sets of 30 reps each.  To bring in more core, I typically do these on a ball.

Side plank with external rotation - to work the hip, core and the shoulder at the same time (which is actually very important for performance) go into a slide plank.  Holding the band as pictured here with palm up, slowly rotate out, pause and slowly return to starting position.  Do 1-2 sets of 30 reps on each side.


Side plank progression - the video below shows you a great progression for this exercise.  This uses the CLX and draws in the entire lower kinetic chain, core, scapula stabilizers and shoulder girdle.  You can do this one for a set period of time or for 1-2 sets of 30 reps.


Adding these as a normal part of your routine will not only increase your shoulder strength but also help improve performance.  We hope you continue to enjoy this series and find the information valuable.  Next week, we will start the final part of this series on knee injuries.  If you did enjoy, please share with your colleagues, training partners and BJJ enthusiast and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention. #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI,  ViPerform AMI RTPlay, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training in Brazilian Jiu Jitsu for 5 years and complete BJJ junkie. 

Monday, September 9, 2019

Injury Prevention in Grappling Sports - Part IVC

Last week, we concluded our discussion of certain types of shoulder injuries that can occur in grappling sports.  Keeping in mind this is not an exhaustive list, but more along the lines of the ones that we typically see.  As with any injury, if you have pain that is limiting your range of motion, waking you at night and impacting your daily activities (preventing you from combing your hair, getting dressed, working, etc) then you should seek an evaluation by your health care provider.

For those injuries that do not require medical intervention, you can attempt manage these by icing on a frequent basis and by monitoring your frequency, intensity and duration of your pain.  For more information on both these topics, please refer back to our previous blog on ice and managing pain.

As with most injuries, there are exercises that we can do to help prevent these types of injuries.  Obviously the best preventative technique is improving our Jiu Jitsu skills and avoiding getting caught in these positions but we all know, that does not happen all the time.  So whether getting put in these positions with practicing of a technique, in live rolling or competition, properly preparing the shoulders should be an important part of your training.  What does preparing the shoulders actually mean?  Ensuring that your shoulders have the full range of motion needed for the sport and the shoulder strength to participate in the sport are a critical part to avoiding injury. 

Total shoulder range of motion is a concept that has been described in the orthopedic literature for some time and is a common measurement taken in collegiate and professional athletes (baseball pitchers as an example).  Total shoulder range of motion (TSM) is the range of motion in external rotation (ER) and internal rotation (IR) when arm is at 90 degrees of abduction.  In other words, TSM = ER at 90 degrees abduction + IR at 90 degrees abduction.  It is not uncommon for the right and left to have a variance in IR or ER side to side but the total shoulder range of motion should be close to equal.


The research is clear that if you have >10 degree difference in your right TSM versus your left TSM, you are 3xs more likely to suffer a labral tear, rotator cuff tear or ulnar collateral ligament tear or UCL (elbow injury) in  (Shanley et al Am J Sports Med 2011) overhead sports.  This makes sense if you think about it.  If the range is limited and you get to the end range of motion, then other tissues then become stressed (in particular the rotator cuff, labrum and UCL).  This same concept has been applied to swimmers.  In these types of sports, the shoulder has to go through such a large arc of motion and if it is limited, it is much more likely to get injured.  This concept of TSM can and should apply to the Jiu Jitsu athlete as well.  Since our sport not only takes you into these extreme end ranges of motion, it also does this with high stress and loads applied at these end ranges, then it is imperative we make sure to include range of motion or stretches as a part of our shoulder healthy routine.  Therefore the greater total shoulder range of motion, the less stress there is to the tissues.

Considering, here is a series of stretches we can do for limitations in TSM. 

Sleeper Stretch - lying on your right side with your arm at 90 degrees abduction and 90 degrees horizonal adduction and palm facing down, using your left hand push your right hand to the floor until you feel a good stretch.  Hold that for 30 second and repeat 4 times.  Repeat on the left.


Structures stretched - posterior capsule, rotator cuff.

Kimura hamstring stretch - placing your belt around your foot, grab the end of in your hand by reaching around your back with your palm facing up.  As you bend forward as far as you can so feel a stretch in your hamstring. Keeping your hand in the position, as you extend back and ease the stretch off your hamstring, you should feel a stretch in your shoulder.  Hold each position for 30 seconds and repeat 4 times.  Do on both right and left.


Structures stretched - anterior capsule, rotator cuff, long head of biceps

Posterior shoulder stretch - start with laying on the mat with your right arm in the position depicted below.  Slowly bring your left chest toward your right elbow (effectively rolling onto your right arm) until you feel a good stretch in the posterior (back part) shoulder.  Hold for 30 seconds and repeat 4 times.  Repeat on the left side. 


Structures stretched - posterior capsule, rotator cuff

Pec stretch - standing, place your palm on the wall with elbow straight.  Slowly turn your upper body until you feel a stretch in your pec.  To add some stretch to the nerves (called nerve glides) slowly rotate your head to look over your opposite shoulder.  To increase further stretch, rotate your head and slowly raise palm off the wall while keep arm in contact with the wall.  Hold for 30 seconds and repeat 4 times.  Repeat on the left side. 



Structures stretched - anterior capsule, pec majory, biceps, median nerve & C5-C7 nerve bundles.

Adding these as a normal part of your routine will not only increase your range of motion but also help to keep your shoulders healthy.  We hope you continue to enjoy this series and find the information valuable.  Now that we have covered stretches, next week we will get into some specific exercises for preventing injuries.  If you did enjoy, please share with your colleagues, training partners and BJJ enthusiast and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention. #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, September 2, 2019

Injury Prevention in Grappling Sports - Part IVB

Last week, we discussed some specific shoulder
injuries that can occur and some of the common submissions that will lead to these injuries.  Many times, it is not just the submission position that compromises the shoulder but the resistance that we give to the submission.  Fortunately and unfortunately, these submission puts the shoulder in its end range of motion and the supporting tissues (rotator cuff, biceps, etc) in their elongate positions.  Therefore, when you try to resist the submission, the muscle is in an elongated weakened position and more susceptible to injury.  Next week, we will talk about some specific strategies to help increase shoulder range of motion (which helps in resisting submissions) and strengthening of the shoulder muscles so they are less susceptible to injury. 

This week, we want to look at two more injuries, one in the shoulder and one that is often misdiagnosed.  In the shoulder is a joint called your AC joint or acromioclavicular joint.  We talked about this briefly in our first part of this blog but this is a common enough of an injury that it is worth discussing here in some more detail. 

The AC joint is held together by a ligament (depicted in this picture).  An AC joint injury is an injury to this ligament where the ligament is torn and allows the clavical to migrate upwards.  One of the most common mechanism of injury of this ligament is a fall on the shoulder or onto an outstretched hand.  Most commonly this occurs during take down.


In the case of a takedown, this can happen on the person shooting for the takedown or the opponent.  For those shooting for the takedown, if they are shooting for a double leg takedown (as depicted here) and their head is in the proper position (head up on the inside) when they drive backwards or at a diagonal, it is not uncommon to land on the shoulder.  If this impact is more toward the top of the shoulder, the driving force is directly through the acromion and the clavical.  This puts a lot of stress on the ligamentous structures of the AC joint and can cause an AC separation.  For a classifications of AC  separations, please see our previous blog.   The other common mechanism of injury for the AC joint is the opponent that is being taken down.  Sometimes out of instinct, the opponent being taken down will reach out his arm to break the fall and end up landing on the shoulder.

In either situation, the athlete will commonly feel a sharp pain that will be localized to the small area on the shoulder.  If there is separation and depending on the grade, the athlete may see a deformity of the area.  The picture below shows two ends of the spectrum.  From a low grade level I separation to a grade III - IV.  I have included this picture so you can see what this looks like and be able to recognize this when or if you see it in the mirror. 


In the first instance, this can most likely be treated conservatively and in the second case, this individual should see a health care provider.  In either instance, use of an ice massage is very effective at reducing inflammation and pain.  For this you can purchase a cyrocup on Amazon or eBay for ~$10.  I prefer these over the metal round balls being sold in Jiu Jitsu circles and here is why.  What makes this effective is when the ice melts it forms a layer of water between the skin and the ice cube.  This conducts the cold much more efficiently than just ice on the skin or cold metal.  This means deeper penetration and colder temperatures are achieved.  This means better inflammation control.

Another injury (not in the shoulder but worth mentioning here) is a rib subluxation.  Rib subluxations primarily occur at the costovertebral joint.  This will often occur reaching around your opponent (getting an underhook during take down or something similar) and they resist you or you pull with a lot of force.  Commonly it is this outstretched position with thoracic rotation followed by maximal contraction that will cause this joint sublux.  Where you will feel this is in a pin point location in the back or upper back and you will get a sharp (sometimes debilitating) pain with a deep breath, cough or sneeze.  Inflammation reduction (ice) is important to allow the tissues to relax and allow the joint to self reduce (which sometimes it does).  If it does not, you can see a chiropractor or PT to help put the joint back in position.  The same strengthening exercises we recommend with the shoulder will help with this as well.

One common injury in wrestlers and jiu jitsu is athletes is an oblique or intercostal strain.  This happens a lot when you have your opponent in your guard and you reach for cross collar or across your midline to pull them down or when doing a bump sweep.  This injury will often occur where the oblique muscle attaches to the rib cage and will be tender to the touch at the intersection of the ribs and abdominal muscle.  This injury will hurt a lot when you sit up and when you take a deep breath or sneeze.  Due to the location of the pain and the orientation of the symptoms, this is often misdiagnosed as a rib injury.  Two very different injuries and two different treatment approaches.  It is for that purpose that I mention this here.  The key preventative technique for this injury is training the abdominals and the obliques.  High reps and preferably on an unstable surface.  I will have athletes do 8-10 sets of 10-15 reps of abdominals and obliques on a physioball to help prevent..

We hope you continue to enjoy this series and find the information valuable.  Next week, we will get into some specific stretches and exercises for preventing injuries.  If you did enjoy, please share with your colleagues, training partners and BJJ enthusiast and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention. #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, August 26, 2019

Injury Prevention in Grappling Sports - Part IVa

Last week we started discussing another common area of injury in grappling sports, the shoulder.  In starting our discussion, we talked about the anatomy of the shoulder that is commonly involved or impacted in grappling.  This is important to know because the time that it takes you to recover can depend on the injury that occurs and what structures are involved.  Keep in mind, the information in this blog should never replace the advice of your medical provider.  Nothing can replace a physical examination with your health care provider.

In this week's discussion, we will start to look at how those structures are involved and what submissions or positions usually injure these areas.  Keeping in mind there are a lot of submissions that can injure the shoulder, this will not be an all inclusive list.  What we will do is go over the most common ones we see in the clinic and the tissues that are involved.

Arm Bar - obviously arm bars can be done from a lot of positions and the injury that can be sustained will be position dependent and depended on the opponents position.  For example, in the example depicted here, the opponent is standing when the arm bar is applied.  This will put a lot of pressure on the elbow with driving his hips forward.  However, if he drives his hips forward and kicks the legs back at the same time, this creates pressure on both the elbow and the anterior (front of) shoulder (specifically the labrum of the shoulder).

Couple things to keep in mind, if the opponent depicted here, steps back with the left foot, this will increase the pressure to the shoulder and can involve more pectoralis.  When I first started training >5 years ago, this was one of my first injuries.  An injury to my pectoralis major from resisting an arm bar and stepping back.

In addition to the stress applied by the arm bar itself, resistance to this position (especially as depicted above) is primarily provided by the biceps.  If the anterior shoulder is under pressure (as in the picture above) and a maximal resistance is given to the resist the arm bar, this can result in a a long head of the biceps pulling on an already stretched and stressed labrum.  This can cause the labrum to tear or the biceps tendon to tear.

In this scenario you may have one of 4 things:
  • Pop in the shoulder and balling up of the muscle - typically this is associated with a biceps rupture.  This is a hard one to miss as there is typically a lot of pain, more diffuse pain, bruising in the arm (usually in the next 48-72 hours) and balling up of the bicep muscle (Popeye bicep).  In this case you should see your physician.        
  • Pop in the shoulder with pain - this can be associated with a lesser of a degree of bicep tear or labral tear.  This will result in more localized pain, to the front of the shoulder.  If bruising occurs, more likely bicep.  If shoulder feels unstable (feels like comes in and out), this can be a sign of larger labral tear.  If this is the case, you should see your MD.  If no bruising in 24-48 hours, pain resides and shoulder feels stable, this can most likely be self treated with ice and shoulder exercises.
  • Pop in shoulder without pain - there are a lot reasons you can get a pop in the shoulder.  However, if there is no pain, you have full range of motion and no change in strength, you should be good doing activities that do not bother you.  I would suggest take it easy and ice proactively.
  • Shoulder pops out - this is shoulder dislocation.  If it self reduces (goes back in) you should have it checked out by your physician.  If it does not self reduce (stays out of place) this is considered a medical emergency and should be seen right away.  There is the possibility of compromised blood flow and neural input to the lower arm and should be relocated (put back in place) ASAP.   

*If you have constant and significant tingling and numbness down your arm, loss of sensation in your arm or loss of circulation in your arm, seeking a medical evaluation is strongly encouraged.* 

One common escape from an arm bar is turning the thumb down, bending the elbow and swimming around. This escape can also put the shoulder in a compromised position and can lead to shoulder injury.  With the arm extended and rotating in this position puts a significant amount of stress on the labrum and rotator cuff.  As a seasoned jiu jitsu athlete (5+ years training and 50+ years old) this is not an escape that I can do.  If in your training or drills you attempt this position and it bothers your shoulder, this should not be an escape you rely on to get out of an arm bar.  If it bothers you under lower load (drills and training) this should not be the one you resort to under higher loads and competition. 


Kimora, Americana, Key Lock, etc. - there are a lot of shoulder submissions we use in the sport and they are achieved in a lot of different positions.  Obviously these are shoulder submission and each will place a lot of stress on the tissues of the shoulder.  The tissues that are involved will not only depend on the submission itself but the position in which the submission.  As a sports medicine physical therapist, one of the most interesting things I first learned in Jiu Jitsu is that a lot of the submissions in the shoulder mimic special tests we use to determine what is wrong with the shoulder. 
For example, this test (internal rotation lag sign) looks like a badly performed kimora with a wrist lock.  The reason for pointing this out is that these submission positions are, sometimes, the same positions we use to stress the tissues of the shoulder to determine what is wrong.  This is why they work, they are designed to stress these tissues.  This is important to keep in mind because with constant stress we can outpace our bodies ability to repair these tissues.  This leads to injury.  As a practitioner, we have to be proactive in our shoulder health

With shoulder submission positions, the most common tissues involved are the rotator cuff, labrum and long head of biceps.  Injuries commonly occur due to the submission itself as well as when we try to resist the motion.

  • Rotator cuff injuries.  >80% of rotator cuff injuries occur in the supraspinatus.  This will result in pin point pain on the outside of the shoulder (lateral aspect in the subacromial space) and may refer to your deltoid insertion (down the outside of your arm).  This will be painful to resistance to the external rotation (rotating the arm out) or raising your arm out to the side.  A physician visit is advised if you hear a pop in the shoulder with any of the following: significant pain in the shoulder (5/10 pain or greater), loss of range of motion of the shoulder (unable to move it overhead), significant pain (5/10 or greater) with moving your arm, tingling and numbness down the arm.
  • Long head of biceps tendon.  Due to the attachment and crossing of the shoulder joint and the resistance we often give to avoid the submission, this is often involved.  A physician visit is advised if you have any of the following: pop in shoulder with bruising down the arm or balling up of the biceps, inability to flex the arm, significant pain (5/10 pain or greater) in the arm or with trying to raise the arm or significant pain (5/10 pain or greater) with turning door handles, screw driver or getting gallon of milk out of the fridge (all very active biceps activities). 
  •  Labral injuries.  This is a common injury in Jiu Jitsu.  Most think if their labrum is torn that this will require surgery.  I can tell you that I have treated a lot of athletes (high level and not so high level) and this is really dependent on the location and severity of the tear.  Personally, I tore mine in my 30s.  As a weightlifter and someone that does Muay Thai and Jiu Jitsu and is over 50, I have not had my repaired.  If you have pain that limits your range of motion, prevents you from sleeping at night or your shoulder feels unstable (sensation comes in and out), then you should see a physician.  
As with cervical injuries (please refer to this previous blog), you can monitor your progress by how your pain is.  You should also start icing right away.  The more you ice and the more likely you are to return to the mat and full training quicker and with less problems.  


We hope you continue to enjoy this series and find the information valuable.  Next week, we will talk a few more injuries then move into some specific stretches and exercises for preventing injuries.  If you did enjoy, please share with your colleagues, training partners and BJJ enthusiast and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention. #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, August 19, 2019

Injury Prevention in Grappling Sports - Part IV

In addition to neck injuries, another common injury we see in grappling sports are injuries to the shoulder.  Before we get into the specific types of injures, we will first take a look at the shoulder anatomy as it relates to grappling sports. 

The shoulder is an inherently unstable joint due to the architecture of the joint itself.  Unlike the hip joint, a ball and socket joint, which has its stability provided by its bony structures, the shoulder relies primarily on the muscles and ligaments that surround it to provide its stability.   As a result, it is more susceptible to injury, especially when someone is cranking it to its end range of motion.  Because there is not bone there to stop the motion, the muscles and ligaments are the only restraint and thus are easily injured. 

There are a lot of shoulder injuries that we see in grappling sports but for the purposes of our discussion, we will stick with the most common structures that are involved in the injuries we see most frequently.

The shoulder is primarily composed of the following bones: humerus (upper long arm bone), the scapular (shoulder blade), the clavicle (collar bone), and the rib cage.  Although fractures do happen, it is more common to see injuries to the ligamentous and muscular tissues.  As such, it is worth identifying these structures, what they are and what they do.


  • Rotator Cuff - the rotator cuff is a group of 4 muscles of the shoulder which provide stability to the shoulder.  The supraspinatus, infraspinatus, subscapularis and teres minor (pictured above).  These muscles originate on the scapula and attach to the humerus.  They  hold the humerus firmly in the glenoid fossa (shoulder joint) so that you can move your arm around without having the humerus move in and out of the joint.   Injury to these muscles can cause pain and excessive movement of the humerus within the shoulder joint.  This can cause pain, decreased motion and lose of function.  The muscle most commonly injured (>85% of the time) is the supraspinatus.
  • Labrum - the labrum is the circular tissue depicted in the picture above and the humeral head is seated right inside that cup.  The labrum provides a cushion between the humerus and the glenoid fossa and also provides stability to the shoulder.  The way the humeral head is seated in the labrum in addition to the glenoid and capsule, the labrum provides stability to the shoulder.  Injury to this structure can sometimes lead to instability in the shoulder.   
  • Biceps tendon - the long head of the biceps runs in the grove in the humerus (pictured above) and attaches to the superior (upper) portion of the labrum.  Injury to this tendon and/or rupture of this tendon can often lead to an injury of the labrum.  
  • AC joint - the acromioclavicular (AC) joint is the joint between the clavical and the acromion (pictured above).  This joint is held together via ligaments.  This joint can become a source of pain if swollen or if separated.  All AC seperations are not created equal.  AC seperations are classified on a grading scale.

  • costovertebral joint - the costovertebral joint is where the individual ribs attach to the spine.  One of the common misdiagnosis in grappling athletes is a rib popping out.  Typically if a rib pops out of place, this is at the costovertebral joint (located in the back - pictured to the right).  This injury you will have a lot of pain with deep breath, coughing, sneezing and localized to the joint involved in the back.  Often grapplers are told they have a rib out of place on the anterior (abdominal) region.  This is more often then not a intercostal strain (muscle between the ribs) or internal oblique strain (pictured below).
In relation to the rib injury versus oblique injury, it may seem like I am getting caught up on schematics here but it is important to know the difference.  Why?  because these two injuries are treated very differently and the timeline for recovery is different.  It is also going to change my recommendations for you as you return to the mats and start rolling again.  It also emphasizes why it is important to align yourself with a health care provider who understands this sport.  This helps in reducing misdiagnosis and expedites your safe return to the mat.

We hope you continue to enjoy this series and find the information valuable.  Next week, we will get into some specific submissions that lead to shoulder injuries and treatments.  If you did enjoy, please share with your colleagues, training partners and BJJ enthusiast and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention. #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, August 12, 2019

Injury Prevention in Grappling Sports - Part IIIc

Last week, we continued our discussion on neck injuries in grappling sports by diving into some range of motion exercises and stretches we can do as a part of our preventative routine.  Typically, as a part of our training, we will do some form of range of motion and neck strengthening as a part of our warm up for class.  Traditionally this will include laying on our back and going through 10-20 reps of chin to chest, looking over your shoulder and ear to shoulder.  This is a great to help with both range of motion and strength as a warm up however does not build the strength we need to prevent these types of injuries.  This week, we will dive into some exercises you can do in the gym that will help prepare you for when you are on the mat.

The following neck exercises are laid out in a progression.  These are progressed from ones we use in rehabilitation to ones we use in wrestling.  If you have not been doing these, start with the isometrics and as you gain strength and as these get easier, move to the next level of exercise.   
  • Level I - cervical isometrics - keeping your head stationary, you are going to push your head in various directions (like depicted here) without allowing your head to move.  You should do forward/backwards, rotation and side bending, 15-20 reps each direction, 2-3 sets.

  • Level II - cervical stabilization with CLX - this video shows how to do this same exercise against resistance.  The video only shows one direction but you can do the same thing in multiple directions.  


  • Level III - wresting neck exercises with hands - this series should be done only once a base level of strength in your neck is obtained.  Start with using your hands as support then progress to no hands.
  • Level IV - neck planks - this is the most advanced level and should only be done once all other levels achieved.  Should start at 10 sec and progress to 30 sec holds.

The final exercise is for your shoulder girdle and rotator cuff.  Several of the muscles (trapezius, rhomboids, levator scapula, etc) which attach to the cervical spine also attach to the scapula, proper neck strengthening should also include shoulder stabilization.  This exercise will help to create that stability.  
  • Retraction with external rotation - start with standing upright with band in your hands, palms facing up and elbows at 90 degrees.  Retract (pinch together) your shoulder blades and hold that position.  While holding that position, externally rotate (rotate out) your arm and pause for a 3 sec count.  Slowly return to the starting position while holding your shoulders back.  Repeat that for 3 sets of 10-20 reps.   
Including these exercises along with your range of motion exercises will help to maintain good range of motion and strength to your neck.  Doing this will aid in reducing your risk for a neck injury while on the mats.  Next week, we will start to dive into shoulder injuries. 

We hope you continue to enjoy this series and find the information valuable.  If you did, please share with your colleague and follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention. #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, August 5, 2019

Injury Prevention in Grappling Sports - Part IIIb

Over the last couple of weeks, we have discussed neck injuries in grappling sports.  Specifically, we have talked about some different mechanisms for neck injuries, how all neck injuries are not the same.  We discussed what some of the signs and symptoms associated with neck injuries and how this can distinguish severity.  It is important to state that the information in this blog should never replace advice or guidance provided by your health care professional.  This is solely intended to educate us all on a common injury in our sport and help us manage and prevent those injuries.  That said, let's state the obvious.  The best prevention is protecting your neck.  Typically we are caught in a choke as a result of a mistake we made and one which our competitor has capitalized on.  That said, we are going to talk about things we can add to our training to prevent.

As with any injury, the sooner you start treating the injury the better.  When I am evaluating athletes at the gym, if they present with tingling and numbness down their arm, weakness in the arm, severe limitation in range of motion or report pain that is greater than 6 out of 10, then I will refer them onto to a sports medicine physician.  Locally, I have several primary care sports medicine physicians that I work with who understand the sport and how we can progress athletes back to sport while managing their injury.

One of the first things I will ask an athlete is for them to rate their pain on a 0 out of 10 pain scale.


Pain is very subjective but for most Jiu Jitsu athletes, pain is a normal part of the game.  That being said, I find these athletes tend to have a higher pain tolerance and thus rate their pain more accurately. Pain is also something that I use to determine how an athlete is progressing.  I will ask an athlete to rank their pain when their neck feels it's best and when it bothers them the most.  If your neck is getting better, what you should find is that both of those numbers improve or go down.  If not, you know you have to modify what you are doing.

The number one thing people can do to treat the initial injury is ice.  In 20+ years of practice, I have yet to see an athlete that does not respond to ice.  What I tell all my athletes is that I usually recommend icing 3-4 times per day for 15 min each bout.  It should be cold enough to make you numb in 5 min, if not, it is not cold enough (be cautious not to burn yourself).  I realize that recommendation is a pain and a lot of time but put it this way, how important is your Jiu Jitsu to you?  Are you willing to make this small commitment to get you back on the mats faster?  End of the day, the more you do it the faster you will get back to the mat.  Period!  If you don't have an ice bag or enough ice bags, you can make your own by doing the following:

  1. Fill the plastic freezer bag with 1 cup of rubbing alcohol and 2 cups of water.
  2. Try to get as much air out of the freezer bag before sealing it shut.
  3. Place the bag and its contents inside a second freezer bag to contain any leakage.
  4. Leave the bag in the freezer for at least an hour.

Aside from icing the injury, you can also add these exercises to your routine to help reduce your risk of sustaining a neck injury.

  • Cervical range of motion - you want to make sure that you maintain full range of motion of your neck in all planes of motion.  If you have full range, if your neck is cranked into end range, this is less likely to cause you a problem.  Below are some range of motion exercises you can put into your normal warm up.  These should only take you a couple of minutes and best if done before practice.  Each stretch should be in pain free range of motion and held for 20-30 seconds.

  • Pec major and minor stretch - with the pecs attachment to the shoulder and the shoulders influence on the neck, it is important to stretch out this area.  If the pecs are real tight, this can cause an impingement on the brachial plexus which can give tingling and numbness.  This video provides a couple different stretches for the pecs.  I especially like the ones done on the floor as I think these have a lot of application to the sport.  
  • Nerve glides - many times when we are caught in an arm bar or choke where our arm is extended and the neck is trapped, this can cause irritation of the nerve that runs from the neck to the arm.  If the nerve is not use to going through this full range of motion, then it can respond by becoming irritated and giving tingling and numbness to the hand.  Doing nerve glides as a part of our warm up can help to reduce chances for this.  Below is a great nerve glide exercise.  Start with the hand on the wall, extend the elbow then slowly sidebend the neck.  Stay in pain free range of motion and hold for 20-30 seconds.


Next week, we will start to dive into some specific strengthening exercises we can do in the gym and prior to practice that will help increase neck strength and reduce the chance for neck injuries.  We hope you continue to enjoy this series and find the information valuable.  If you did, please share with your colleague and follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years.