Author: Dr. Emily Splichal

Topics: Rehabilitation, foot and ankle health

All information is attributed to the author. Except in the case where we may have misunderstood a concept and summarized incorrectly. These notes are only for reference and we always suggest reading from the original source.

1. Barefoot, Beyond Running

To truly become BAREFOOT STRONG, I believe that one must:

• Accept that the neuromuscular system is a deeply integrated network of joints, fascia, muscles and nerves which work together like a symphony providing the beauty we call human movement
• Respect the foot as a kinematic structure serving as the foundation to all closed chain movements
• Appreciate the sensitivity of the plantar proprioceptors and their role in maintaining balance, perceiving impact forces and stabilizing the lumbopelvic hip complex for human locomotion
• Refuse to allow the continuous damping of neuromuscular input due to footwear and unnecessary orthotics but rather welcome the proprioceptive input from the ground on which we stand.

2. The Bare Foot

26 bones, 33 joints,19 muscles, and 107 ligaments in the human foot.

80% of our plantar proprioceptors are sensitive to vibration.

Smaller nerves in the feet play a role in quiet stance and upright stability. If you wear socks and shoes, you block these highly sensitive small nerves on the bottom of the foot. Any blocking causes a delay in response time and creates a greater reliance on the larger and slower nerves in the ankle and lower leg. This is especially apparent as it relates to our ability to load impact forces during walking.

The foot can adapt to uneven terrain and also generate up to eight times our body weight in elastic forces. The joint responsible for these elastic forces is the subtalar joint (STJ). The stability of this joint dictates how we transfer forces and load potential energy between heel strike and push off.

Experience STJ Mobility

• Start by standing with your feet shoulder width apart. Roll onto the outside of the foot so that you’re increasing your medial arch. This is STJ inversion. STJ inversion is associated with rigid, stable, and locked feet. This is the position we want to be in when releasing energy or accelerating. Think sprinting and jumping.
• Now roll onto the inside of the foot, so that you’re flattening your arch. This is STJ eversion. Associated with a flexible, unstable, and unlocked foot. This is the position we want to be in when we unload energy or decelerate. Think squatting.

Experience Joint Coupling

Moving between inversion and eversion, there are knee, hip, and pelvis rotational movements too. These rotations that travel from the foot, up into the leg are referred to as joint coupling.

STJ eversion is coupled with internal rotation of the knee and hip and equals loading energy.

STJ inversion is coupled with external rotation of the knee and hip and equals unloading energy.

When we are not moving, our foot should be in a neutral position. Any deviation from neutral demonstrates different foot types.

The Neutral Foot

If your Achilles insertion is straight or you do not notice any concavity on the inside or outside of the heel, your STJ position would be considered neutral.

To maintain optimal foot function the neutral foot would want to incorporate daily foot recovery and foot strengthening exercises.

The Inverted Foot

If the Achilles insertion is curved towards the inside of the foot or there is concavity on the inside of the heel, then your position is inverted.

Functionally more rigid and more at risk of impact-related injury including stress fractures or Achilles tendonitis.

Daily foot mobility is key for optimal function.

The Everted Foot

If the Achilles insertion is curved towards the outside of the foot or there is concavity on the outside of the heel.

Unlocked foot that is generally unstable, and has a hard time acting as a rigid lever or releasing potential energy. The ability to unlock and lock is necessary for peak performance.

Greater risk of diffuse foot pain, knee pain, and low back pain. Daily foot strengthening is key for optimal foot function.

Foot to Core Sequencing

Proximal stability for distal mobility. You need a stable and strong core to be able to transfer force distally.

Feet and the core are integrated via co-activation patterns and fascial integration.

Co-Activation Patterns

The firing of one muscle leads to a simultaneous firing of another muscle. From a functional perspective, co-activation patterns lead to faster stability allowing more efficient movements and improved performance.

Activation of the pelvic floor leads to co-activation of the transverse abdominus, which leads to co-activation of the multifidi, internal obliques and so on.

The co-activation between the feet and core is called the foot to core activation cascade.

Deep Hip Stability

Within milliseconds of foot contact our hip must prepare for the single leg stability needed during midstance. Any delay in hip stability will result in improper knee and foot alignment which presents as IT band syndrome, patellofemoral pain syndrome or ankle sprains.

There are a group of muscles called the deep lateral rotators or deep six rotators that surround the hip joint. Acting like the rotator cuff of the shoulder, these deep muscles suction the femoral head into the hip joint providing the first layer of deep hip stability. This activation leads to co-activation of the pelvic floor, the diaphragm, psoas major, and so forth, until our glutes are activated and we have optimal hip and core stability.

The foot actually drives this deep hip co-activation cascade.

Foot to Core Activation Cascade

Step 1. Foot Activation (Short Foot): Increases deep hip and pelvic floor activity. Specifically targets the abductor hallucis. Abducts the hallux/big toe. Also associated with neuromuscular co-activation of the deep lateral rotators and pelvic floor.

• Activating Short Foot: Stand barefoot and focus attention on one foot at a time. Find your foot tripod that is under your 1st metatarsal head, 5th metatarsal head, and heel. Lift your toes, spread them out, and place them back down onto the ground. To activate short foot, push the tip of your big toe down into the ground. You should feel the muscles of the arch engage. Hold for 10s before releasing.
• Achieving Short Foot with Flat Feet: First, de-rotate the lower leg before activating short foot. Externally rotating the lower leg will bring the heel bone into a more neutral position.
• Achieving Short Foot with a Bunion: In a bunion deformity, the abductor hallucis has been pulled from the side of the great toe to under the foot, shifting the pull of this muscle. Use kinesiology tape or athletic tape to pull the toe into a proper position.

Step 2. Deep Hip Activation: Starting on one foot with a slight bend in the knee. Because short foot creates a locking mechanism to the foot and leg, you always want to start with a slight bend in the knee. This avoids torque to the meniscus. Hold short foot for 10s, but this time focus on the deep hip and pelvic floor. To increase the intensity, actively engage your pelvic floor and transverse abdominus.

Step 3. Glute Engagement: Back in the single leg stance with a slight bend, test out single leg squats (don’t need to be deep) to experience slight knee flexion and extension. Hold your next rep on the bottom phase of the squat. This is where you should activate short foot to establish deep hip and core lock in and deep hip stability. Keep holding as you press out. Deep hip stabilizers are required for optimal strength from our glutes (mobilizers).

Fascia and Foot Function

This connective tissue envelops our muscles, tendons, and bones, controlling and integrating every move we make. Our fascia is organized in fascial lines. We have a posterior fascial line that runs from the bottom of the foot, up the calves, through the hamstrings, all the way up to the top of the skull. We also have a lateral fascial line that runs from the bottom of the foot, along the side of our lower leg, up the ITB, all the way up through the skull. These lines create an integrated network through which tension is generated, stability is achieved and forces are transferred.

Starting from the bottom of the foot, the deep front line runs up the lower leg, up the inner thigh, and to the pelvic floor. When we engage short foot we are technically activating this deep fascia line and re-enforcing foot to core stability.

3. Understanding Impact Forces

Walking is a series of falls onto a single leg stance in which foot contact is followed by a rapid peak in ground reaction forces. Because our body seeks to conserve as much energy as possible it is actually designed to use these impact forces as energy to take the next step.

These impact forces are perceived as vibrations, which our muscles are programmed to respond to. 80% of our plantar receptors are sensitive to vibration, which allows us to determine if a surface is hard, soft, slippery, etc. We also use vibrations to maintain balance as well as using them as potential energy when we walk.

As the vibrations enter the muscle compartment the muscles respond by contracting isometrically, which dampen the vibrations from vibrating the bones. Like touching a vibrating tuning fork. If this does not occur, stress fractures become more likely. Weak muscles in the foot area common cause of shin splints and stress fractures.

Shoes and fatigue can delay the dampening response by blocking the receptors on the bottom of the feet. Any small delay will have a negative effect. Shoes with cushions make our feet weaker and lazy. Fatigue will delay reaction time. Warming up barefoot can delay muscle fatigue and decrease injury risk.

After dampening impact forces, your body converts these vibrations into potential energy, which is later used as elastic energy to drive the next step. Fascia is able to slide over the isometrically contracted muscle and move with the joints, stretching it like a rubber band. The elastic energy comes from this release as soon as we lift our heel, recoiling the leg forward. With each step, the ability to load and unload our fascia increases until our connective tissue is able to generate twice as much elastic energy relative to the amount of impact forces that were encountered (catapult effect).

Barefoot training creates anticipatory muscle contractions leading to faster loading responses.

Foot Type & Impact Injury Risk

There are two main ways that you can reduce impact forces during walking:

1. Understanding your foot type
2. Changing the way you strike the ground

By becoming conscious of how hard your foot strikes the ground or the degree of dorsiflexion upon heel strike, you can vastly alter the magnitude of impact forces entering the body. Feel how the foot strikes from the outside of the heel, rolls to the center of the foot and then off of the digits. Interestingly the less dorsiflexion you have in the ankle upon heel strike, the lower the impact forces you will encounter.

A tip for plantar fasciitis and Achilles tendonitis patients is to dorsiflex the great toe upon heel strike. The dorsiflexion of the great toe increases the stiffness of foot, allowing better transfer of vibrations. This is one of the reasons why impact injury rate is so high in flip-flops or thongs.

Assess gait: www.youtube.com/ebfafitness

4. From Barefoot to Shod (Unnatural Surfaces)

All surfaces provide a certain frequency of vibrations when contacted by the foot. With the optimal frequency around 15-20 Hz our neuromuscular system is designed to create a reflexive response to this input.

The repetitive movements of a step class or Zumba require a forgiving surface that will match the vibrations caused by thousands of foot to floor contacts in a 60-minute class. Similarly, the high velocity tumbling pass of a gymnast requires a surface that will match impact forces exceeding 10x body weight in less than 150 milliseconds.

Anticipation of Impact Forces

Research by Nigg et al. has shown that as we walk, by the 3rd or 4th step our nervous system has already pre-programmed a response to match the degree of impact forces.

This concept of anticipation is referred to pre-activation neuromuscular responses and is a key component to movement efficiency and ultimately movement longevity.

Eventually what happens is the muscles begin to initiate a response to movement before the joint has moved. This anticipation contraction is in our deep stabilizers that were covered in Chapter 2. With walking this pre-activation response is simply our foot and ankle muscles stiffening and contracting isometrically before foot strike. Nigg’s research has found that these pre-activation responses are the only way in which the foot can load impact forces fast enough – especially when they are entering the body between 50 and 150 milliseconds.

A mismatch between anticipated vibration frequency and loading response leads to injury.

Unnatural Surfaces Impair Efficient Movement

Most of the surfaces we encounter on a daily basis, including concrete, tile or marble, do not transmit vibrations well. Impact on these surfaces is still present but instead of vibrations being transmitted through the surface and through the body – all vibrations are transmitted proximally through the body. This increase in forces through the body alters the vibration frequency and therefore impairs the accuracy of the loading response.

These excess vibrations are carried over from the soft tissue into our bones and tendons – presenting as stress fractures or Achilles tendonitis.

Introduction to Footwear

Footwear’s origin dates back to 40000 BC. By the 12th and 13th Century footwear was seen as a status statement that was the beginning of footwear shifting away from function and towards fashion. In the 1950’s with the advance in industrial materials such as rubber and synthetic cloth, the first athletic footwear began to hit the market. Paralleled with the increased awareness towards health and fitness we began to see the first aerobics shoe by Reebok and the first running shoe by Nike. By the 1970’s Nike was at the forefront of athletic and running footwear. Just like today, in the 1970’s runners were experiencing a high rate of overuse impact-related injuries. As a result of this high injury rate Nike designed what we now associate with traditional athletic shoes – extra cushion and a heel toe drop.

With the average heel toe drop being 12 – 14mm or ½ inch, the concept behind this feature was to take tension off of the Achilles tendon. Although a heel toe drop takes tension off of the Achilles tendon it ultimately impairs to foot’s ability to load impact forces. When our foot is placed in a heel toe drop the ankle plantarflexes and the STJ inverts. In a neutral or inverted foot this STJ inversion locks the foot impairing its ability to evert and load impact forces. In an everted foot this heel toe drop could actually be seen as beneficial as it puts the foot in a more stable position.

Surviving in a Shod Society

Step 1 – Keep the feet strong: Strong feet are the first line of defense against impact-related injuries. Our ability to stiffen the foot upon heel strike will ensure vibrations are controlled and do not transition into the bone.

Step 2. – Keep the feet flexible: The ability to unlock the foot is a necessary step in the loading of impact forces. Foot flexibility occurs in the form of fascial tissue therefore daily massage or trigger point release to the bottom of the foot is key. Remember that flexibility should not be confused with instability. A flat foot that is inherently unstable must still focus on foot recovery and fascial flexibility for the proper transfer of forces.

Step 3 – Foot to core integration: The faster we can stabilize the core, the more efficient we will be at transferring forces. This reflexive core stability must be achieved from the ground up.

5. Barefoot Baby Boomers (Neurology of Aging)

Movement Accuracy

To improve the accuracy and efficiency of each movement, our neuromuscular system is controlled by either a feed forward and feedback system or loop.

An example of a feed forward response would be activating the ankle stabilizers before foot contact, while a form of training that falls under feed forward would be barefoot training.

Conversely, feedback responses (aka reactive responses) allow our neuromuscular system to adjust to errors, and auto-correct throughout a given movement. An example of a feedback response would be activation of ankle stabilizers when walking on an uneven terrain, while a form of training that falls under feedback would be a wobble board or Bosu.

With falls being one of the biggest concerns as we age, instability and decreased control can often be attributed to an aging peripheral nervous system.

Studies have shown that as we age, our ability to detect vibration input is impaired. From decreased plantar receptor density to increased input threshold, by the time we are age 70 our plantar foot requires twice the stimulation to create the same response!

Tips for Movement Longevity

Tip #1 – Keep blood sugar under control:

• Elevated glucose in our blood stream is highly toxic to our peripheral nerves. Any excess blood sugar is quickly converted into a free radical called advanced glycation end products or AGEs. These AGEs cause a demyelination of the peripheral nerves causing a disruption in signal transport. In addition the formation of AGEs stimulates an increase in oxidative stress and an up-regulation in pro-inflammatory markers.
• Benfotiamine is an active form of B1 and acts by inhibiting the deoxidation of sugar or glycation.

Tip #2 – Consider Nerve Protective Vitamins:

• L-methyl folate is the activated form of folic acid that has been shown to increase nerve growth factor. When taken over a period of 6 months studies have shown an increase in epidermal nerve fiber density (or in other words more plantar cutaneous nerves. Recommended dosage: 1000 ug X 3 times day.
• Acetyl-L-Carnitine has been shown to decrease painful nerve symptoms, as well as increase vibratory sensation. Remember that we maintain balance and absorb impact forces based on our ability to detect vibration so this is extremely beneficial as we age! Recommended dosage: 500mg x 2 times day.
• Touted as one of the most powerful anti-oxidants, alpha lipoic acid has been shown to improve microcirculation to peripheral nerves while decreasing oxidative stress. A key point about alpha lipoic acid is that it must be taken in the Rlipoic acid form as the “R” form is the one that is biologically active (vs. “S” form). Recommended dosage: 600mg x 1 time day.

Tip #3 – Cardiovascular Exercise:

• Cardiovascular exercise has many benefits, one of which is related to peripheral circulation. The vascular system, just like the nervous system, is very intelligent meaning that if there is a loss in circulation to one area of a muscle the vascular system will create what’s called collateral circulation (or in other words form new blood vessels).
• So just like the collateral circulation formed in muscles, our vascular system can create new micro-vascular pathways to our nerves. The more blood and oxygen to our nerves the healthier they are!

Tip #4 – Myofascial Release:

• From muscle adhesions to a loss in fascial flexibility, inflexibility can often impede nerve conduction. Just like when you sleep on your arm and wake up with it tingling, to a smaller degree this is what’s happening to our peripheral nerves when they get caught in fascial tissue.

Tip # 5 – Go Barefoot!

• If our small nerves are on the bottom of the foot we want to keep them sensitive and awake through frequent barefoot stimulation.
• Whether your barefoot routine includes vibration training, standing on different textures or simply walking around your home barefoot – daily barefoot stimulation is enough to keep these small nerves on point!

6. The Collagen Crosslink Connection

Collagen in Skin, Fascia and Tendons

Collagen, the main element found in connective tissue, provides the structural foundation to skin, fascia and tendons. The soundness of these collagen units is determined by the stability of hydrogen bridges and covalent bonds referred to as crosslinks.

Although crosslinks provide strength and stability, excessive or what are called non-specific crosslinks create stiffness and a lack of elastic recoil in the connective tissue. It is these non-specific crosslinks that we call fascial adhesions. These non-specific crosslinks are formed through a process known as glycation, which occurs in the presence of excessive glucose. The interaction of AGEs with tissue (fascia or nerves) is called glycation.

Glycation & AGEs

The stiffer the connective tissue (collagen) the increased risk of micro tearing during dynamic movement. Although micro tearing is beneficial to building muscle mass and strength, micro-tears in our connective tissue is not so advantageous. Studies have shown that micro-tears in connective tissue are repaired with Collagen Type III vs. the normal Collagen Type I. Collagen Type III is characterized as less elastic and stiffer when compared to Collagen Type I. This creates a repetitive micro-trauma cycle and eventual tissue degradation we know as tendonosis.

Preventing Collagen Aging

Tip #1 Tight glycemic control:

• A 2005 study demonstrated decreased formation of AGEs in diabetic patients with a daily dose of 300mg Benfotiamine. As an active form a Vitamin B1, Benfotiamine acts by inhibiting the deoxidation of sugar or glycation. If you currently take a B Complex, I suggest consider switching to the activated form of all these B vitamins.

Tip #2 – Collagen Protective Vitamins:

• A 2002 study by Abdel et al. demonstrated an 80% decrease in glycation and AGE formation in patients supplemented with high dose Vitamin C. Recommended Vit C dosage is 1000mg/day.
• L-lysine is an essential amino acid that means the body cannot produce it. L-lysine plays an important role in the protection and integration of collagen. By blocking the enzyme that forms AGEs, L-lysine helps to prevent the formation of non-enzymatic crosslinks. Although most people get an adequate amount of L-lysine from their diet, athletes, vegetarians / vegans, post-surgical or those with connective tissue injury can benefit from supplementation. Recommended L-lysine dosage is 500mg / day.

Tip #3 – An aspirin a day keeps crosslinks away:

• Aspirin inhibits the formation of AGEs by acetylating lysine residues (L-lysine + sugar = AGEs). Please note that you should not start taking aspirin daily unless you speak to your medical doctor. Those who are on blood thinners such as Plavix should not start an aspirin regimen. Recommended aspirin dosage is 81mg / day.

Acute vs. Chronic Injury

When we do not have tensile stiffness and elasticity in our connective tissue this would be analogous to a dried out rubber band. When you load the dried out rubber band you eventually reach a “fatigue point” and the rubber band breaks. This is analogous to our connective tissue micro-tearing or even rupturing at a certain fatigue point.

Micro-Trauma Cycle

In connective tissue (tendons / fascia) when there is not enough elasticity in the tissue, micro-tears occur. These connective tissue micro-tears are repaired with a different type of collagen than what the connective tissue is primarily composed of (Type III vs. Type I).

Type III collagen is stiffer and less elastic then Type I collagen, and is laid down in a haphazard manner. In addition, all micro-tears whether it is in muscle or connective tissue are associated with inflammation.

Persistent inflammation around connective tissue whether it be bone or tendon creates thinning of tissue. This micro-tear, inflammatory cycle which begins as an acute stress to the tissue now becomes a perpetual cycle and we start to hit a road block in the tissue repair process. The longer the patient’s connective tissue sits in this micro-tear / inflammatory cycle the more the tissue begins to change composition and the harder it is to establish any long lasting pain relief.

Two-Step Recovery Process

1st – Restore Connective Tissue Health

2nd – Correct Muscle Imbalances

If steroid injections are not your cup of tea there are other options that are also available including:

• oral anti-inflammatories (my go-to is Mobic)
• topical anti-inflammatories
• ice (I never only do ice)
• Class IV laser
• Supplements such as bromelain, quercetin
• Eating pineapples or tart cherry juice

If you are not in the acute state and have had pain for greater than 6 months then the above options may not be as effective.

In the patient that is not responding to anti-inflammatory treatment then we need to consider other options to get the connective tissue back to it’s youthful, pre-injury state. This is where we start to consider:

• PRP (platelet rich plasma)
• Bone marrow aspirate
• Amniotic membrane or
• Procedures such as Tenex and Topaz

The way that the above procedures work is by creating fresh tissue injury and restarting the inflammatory / injury cascade. The above procedures must be followed by limited activity/immobilization and no NSAIDs can be taken during the repair process. Once the connective tissue is returned to a more healthy state then it is time to start focusing on the muscle imbalances and compensations being placed on the connective tissue. This is where the integration of barefoot training begins and the retraining of how to load and unload impact forces from the ground up.

7. Becoming Barefoot Strong

Not all flat feet require the control or support from a custom orthotic. In the patient that’s standing on a very rigid foot evident by calluses on the 1st & 5th metatarsal head, an accommodative orthotic with dispersion area can work wonders. Having said that, if you have a high arched foot and do not have pain or never have experienced pain then just like that flat foot I would begin to ask yourself if orthotics really are appropriate for you.

www.barefootstrong.com

Phase 1. Foot-Specific Programming

1. Foot Flexibility:

• Plantar foot release: Start by releasing the bottom of the foot with a golf ball, tennis ball or stick. The key to the plantar foot release is to not roll on the ball. Stand in various areas on the bottom, shifting to a new area every minute.
• Release the bottom of the foot for 5 minutes every morning, evening and before working out.
• For at least 5 minutes release the back of the calf (soleus), the front of the shin (tibialis anterior) and the side of the lower leg (peroneals).

Step 2. Foot Strength:

• Engage short foot 10 seconds x 5 repetitions per foot every morning or before working out.
• Another great exercise for barefoot strength is called toe-spread out. A study actually compared this exercise to short foot and found high abductor hallucis activation in toe spread out! Perform 10 repetitions per foot x 3 sets.
• Balance on one leg 30 seconds per side x 3 sets every morning.

Phase 2. Foot to Core Sequencing

Step 1. Hip Flexibility:

• Release the anterior hip and glutes 5 min per side at least 3 times a week and before working out.

Step 2. Hip and Core Activation:

• Pelvic Floor Activation: Start by lying on your back with your knees bent and your feet flat on the ground. Find a neutral spine and pelvis position. From here you want to imagine that your pelvic floor is like the face of a clock with 12 o’clock at your pubic symphysis, 6 o’clock at your tailbone, 3 o’clock at your right hip and 9 o’clock at your left hip. Using your pelvic floor muscles imagine drawing 12 o’clock to 6 o’clock and 3 o’clock to 9 o’clock. After drawing in the 4 corners of the clock you want to then imagine purse stringing or lifting the pelvic floor up. The sensation when doing this properly is similar to how it feels when you stop the flow of urine. Hold each repetition for 10 seconds x 5 sets. Do 3 times a week and before working out.
• Hip External Rotator Activation: You want to begin by lying on your side with your hips stacked. Bring your bottom leg forward, flex the knee to a 90 degree angle. Shift your top leg back and also bend the knee to 90 degrees. You may want to prop it up on a yoga block or mat to keep the hip stacked. Focusing on just the front, bottom leg you want to externally rotate the hip by lifting the foot up. Keep the knee on the ground while externally rotating the hip. Lift and hold for 10 secs before releasing x 5 reps per side. Do 3 x a week and before working out.

Step 3. Barefoot Balance Training:

• Perform 5 – 10 minutes of barefoot balance training 3x a week or before working out.

Phase 3. Total Body Integration

Step 1. Shoulder Flexibility:

• Myofascially Release the Pecs: Release for 30 secs and repeat on the other side. Do at least 3x a week or before working out. Use a lacrosse ball.

Step 2. Shoulder Activation:

• After shoulder mobilization we want to activate the shoulder stabilizers. For this we want to be in a pushup plank position. Keeping the elbows rotated forward and the shoulder blades down the back, hold for 10 seconds. Next move the hands into a diamond pushup position. Assume the same elbow rotation and shoulder stabilization before lifting into the pushup plank. Again hold 10 seconds and release. The final shoulder exercise would be shifting the hands wider than shoulder width. Assume the same position and hold 10 seconds. Shoulder activation should be done 3x a week or before working out.

Step 3. Barefoot Body Tension:

• Body tension follows fascial lines and the concept of tensegrity. The more tension created by the body the faster you can stabilize joints, generate force and improve performance. Start by standing on one leg with the knee slightly bent and proper upper body alignment. With the weights out to the side at 90 degrees you are going to push the weights into a military press at the same time as engaging short foot and the core. Relax the foot as you return the weights to the start position and repeat 8 times per leg. Additional total body exercises can be performed this way including reardelt rows, kettle bell swings, lateral shoulder raise. The trick is the integration between foot, core and scapular stabilization.