A Hip Solution to Low Back Pain

Welcome to the new Physical Therapy world. Gone are (or should be) the days of the ultrasound, hot pack, and nice massage. No longer do we treat only the location of pain. Each patient who fell through the cracks after their e-stim machine turned off begged for something more, and the time has certainly come.

Say hello to your new Physical Therapist. Your new therapist doesn’t bother dusting the ultrasound machine as he or she is too busy examining movement. One hour of pain free walking after short term treatments is not enough. Your new Physical Therapist is asking why the pain always comes back after one has sat for too long. A manipulation is only magical if the pain doesn’t return after repeated bending. Physical Therapists don’t simply stop at the area of pain, they move on to determine why that area of pain is under so much stress during seemingly simple movements.

Shooting numbness down your leg while sitting? Piercing pain at your low back with only minutes of walking? Could it be that the answer to your problem is not a laser to damaged areas of your spine? Could it be that the reason the pain occurs while you are sitting is due to tight hip musculature? What if stretching the hip flexors could relieve the pain associated with the osteoarthritis found on the x-ray? Some colleagues of mine have recently explores the relationship between hip stiffness and low back pain here.

In a nutshell, every movement is comprised from multiple parts of the body. Even sitting, the most common position for todays common man is quite complex. Sitting in a low seat requires up to 110 degrees of hip flexion. Ideally, the pelvis will not tilt posteriorly, and the low back will not round into flexion. Unfortunately, most people don’t have 110 degrees of hip flexion. Sitting without hip mobility can result in excessive tensile stress to the low back, and therefore cause that aching low back pain after prolonged sitting.

You can have soft tissue done, a manipulation, or even surgery if you can find the right (or wrong!) surgeon. But, when you go back to sitting without the hip flexibility the pain will return.

It works both ways. Some individuals have tight hip flexors and therefore lack full hip extension while walking. This results in excessive extension at the spine, and/or a compensatory rotation at the pelvis resulting in unneeded torque at the spine.

Once again, any treatment at the spine is missing the cause of the dysfunction.

The Physical Therapy world is changing. You can now see your physical therapist without a Physician prescription in most states. More and more therapists are screening movements and looking for this type of hip dysfunction well before the low back pain even starts. Find yourself a great local therapist and determine the cause of the pain today. Check http://www.optimalmovementpt.com for more information.

What are your favorite hip mobility exercises? Stay tuned for the next blog to learn the best mobility exercises for the hip.

5 Common CrossFit Injuries

“WOD, Box, Kipping, muscle-up”.

When you first enter the crossFit world it seems like they’re speaking a different language. Then, you bravely take a step into a “box”, learn some new terms, and you realize, it is a different world. Take your next step into this world and now you’re doing “wall-ball’s, box-jumps, and dominating your WOD (workout of the day). But, like any high level physical activity, there are some common injuries to look out for, prevent, and treat if you are, or are going to be a crossFit athlete.

Let’s get one thing straight before we start talking common crossFit injuries. CrossFit is awesome. The sense of camaraderie and competition has helped tens of thousands of people move and exercise. CrossFit and the common injuries associated with it are far superior to the common injuries and diseases associated with a sedentary lifestyle. Look at other forms of recreational and competitive exercises including running, cycling, playing football and basketball; all are great forms of exercise, but they all have common injuries as well. Move better, listen to your body, and exercise smartly. Get in touch with a good physical therapist to help you initiate and maintain a healthy lifestyle.

With that disclaimer out of the way and without further adieu, here are the 5 most common injuries associated with crossFit, as well as tips you can do to treat and prevent them.

1) Low Back Pain

If you are going to participate in crossFit, get ready to squat. The squat is simply the best exercise to work the whole posterior chain (glutes, hamstrings), a vital area of the body that is typically ignored. For this reason, the inclusion of the squat in any exercise program is a great idea, as long as you have the flexibility and strength to pull it off. When one lacks hip flexion, or has poor abdominal and glut activation, or weakness of the glutes, the compensation is excessive trunk flexion and overuse of the lumbar spine paraspinals. This muscle group is simply not made to support the trunk during a squat, let alone several repetitions of the squat, and especially not with weight over the shoulders.

Treatment / Prevention

– Have your physical therapist check your hip flexion ROM as well as the strength and activation of your glutes during a squat.

– Ensure proper squat form without weight before adding weight. You may require corrective exercise for flexibility and muscle coordination before performing a multitude of squats with weight or for time.

2) Anterior Shoulder Pain

Shoulder pain amongst this group is due primarily to one of two factors (or a combination of the two). One factor is that many crossFit exercises including the overhead squat, the snatch, and the thruster all require the shoulder to move to its end range of motion into flexion and external rotation. If you don’t have this range of motion, then aggressively throwing your shoulder towards the end range of motion can result in shoulder impingement. The second factor is that many crossFit exercises place the weight anterior to the body which may result in excessive recruitment of the biceps and pecs. This imbalance between anterior musculature and slap stabilizers can, once again result in impingement at the shoulder.

Treatment / Prevention

– Have your passive ROM assessed by your therapist. If you don’t have 180 degrees of passive flexion while lying on the table, don’t expect to lift to 180 degrees during a snatch.

– Assess the activation and strength of your middle trapezius, lower trapezius, and serrates anterior. These guys should be working to counteract the pull of the biceps and pecs.

3) Wrist Pain

Once again, crossFit is bound to incorporate squats, and lots of them. One version of the squat is the front squat where you place the barbell in front of you in the rack position. This position places your wrist into maximal wrist extension while holding a load. This is very similar to any plank work you may do, again a favorite amongst crossFit trainers.

Treatment / Prevention

This one is pretty simple. You need full wrist extension range of motion to get into this position. Without it, you will have discomfort every time you place your wrist in maximal extension.

4) Knee Pain

Squats, squats, and more squats. And some times lunges. Once again, squats are great for the posterior chain and they are a very functional exercise. That myth that squats are bad for your knees is completely false. Let’s change the phrase to “bad squats are bad for your knees”. Squatting with excessive knee flexion compared to hip flexion, and/or excessive femoral adduction, and/or poor gluteal activation can result in a high amount of stress on the knee joint. Read this previous blog for more specifics on Physical Therapy and knee pain here.

Treatment / Prevention

– Have your physical therapist assess your squat

– Have your glute strength assessed and perform corrective exercises to activate your glutes in order to avoid the excessive knee flexion and/or femoral adduction compensations.

5) Elbow Pain

One of the most common causes for elbow pain is excessive gripping, something crossFit athletes do a lot of when they begin adding weight to their exercise program. All of the muscles responsible for gripping originate at the elbow. Repetitive gripping therefore results in overuse injuries at the elbow.

Treatment / Prevention

A new focus for treatment of lateral epicondylitis, or elbow pain with gripping, is strengthening of the scapula stabilizers. Improving the stability at the proximal shoulder has resulted in a decreased amount of stress at the elbow and may therefore eliminate elbow discomfort with gripping tasks. For more on scapula stability for the lateral elbow, check out this article.

How can Physical Therapy help with my Low Back Pain?

This post continues the discussion on how we as physical therapists can best treat our patients’ ailments. Check out the previous post regarding treatment and communication of a patient with knee pain here.

“Well, the reason for your low back pain is that you have degenerative disc disease.”

or,

“You have a slipped disc at L4/L5 which is compressing a nerve.”

or,

“the arthritis in your back is equivalent to a 90 year old.”

Pretty scary huh? How can physical therapy help with diagnoses like these? Can physical therapy remove the arthritis found on imaging?

No it cannot. But perhaps there are more important questions to ask. I would assume that the more meaningful question(s) may be; Can physical therapy eliminate the low back pain I experience when I am walking my kids to school. Can physical therapy allow me to lift items from the floor, and therefore allow me to perform my household duties? Can physical therapy eliminate the discomfort I experience while sitting for prolonged periods at work, and therefore allow me to be more productive? Can physical therapy eliminate the discomfort I have while I play recreational sports so that I can get back to playing basketball?

The answer to these questions is yes. But, look at the disconnect that many patients experience. Originally, they seek out a healthcare professional with a complaint during some type of meaningful activity. Rather than receiving an answer or a long term intervention, the original complaint gets warped into a diagnosis of “degenerative disc disease”, “arthritis”, or “stenosis”. Could it be that what’s causing the discomfort is not the diagnosis, but rather faulty movement?

Why do we rely on imaging to dictate the cause of our discomforts? Look at this research article performed on individuals without low back pain. This study utilized MRI images on individuals without low back pain. Only 36 percent of individuals without low back pain had “normal” findings. 52 percent had a disc bulge, and 27 percent had a disc protrusion. This, once again, begs the question, could it be that what’s causing the discomfort is not the diagnosis, but rather faulty movement?

This is actually great news for individuals suffering from low back pain. Nobody can treat  a diagnosis of stenosis or arthritis. But a movement expert can assess and implement a program to help individuals who have pain with specific activities. Treatment begins with identifying faulty movement, understanding the reasons for the poor movement, and specific corrective exercises to eliminate the poor mechanics.

For example, take a look at this diagram;

No diagnosis is causing this discomfort. Poor movement places a high amount of stress on the joint, the disc, the muscles, everything. Change the movement, change the pain. 

That being said, sometimes the desired activity requires more strength and flexibility than an individual has.

This individual likely does not have the core strength to lift appropriately given this quick movement screen. In order to lift appropriately, she may require a strengthening regimen. Every body is different and requires an individualized assessment and program prescription.  In order to get here, push your diagnosis to the side and begin identification of movements which may cause the discomfort.

Optimal Movement Physical Therapy is dedicated to helping individuals identify and treat their movement faults. Visit our website or e-mail us at alan@optimalmovementpt.com so that we may help answer any questions.

My Knee Pain is due to Arthritis, how can Physical Therapy Help?

“I have arthritis in my knee, can Physical Therapy get rid of the arthritis”?

No, it wont. Anybody that tells you differently is wrong.

In fact, you can replace the diagnosis with nearly any degenerative diagnosis for the knee.

Can Physical Therapy heal the torn meniscus?

No.

Can Physical Therapy heal the remove the cyst found under the patella.

No.

But, there’s a caveat. After confirming the patients correct belief that physical therapy cannot make the anatomical change which is the source of pain, the education typically goes something like this:

“Physical Therapy will not remove the arthritis found in your knee, but it’s possible that we can identify how your movement, flexibility, and/or strength issues may be placing excessive stress through your arthritic joint, therefore causing the pain. While we can’t remove the arthritis, if we relieve the stress we may remove the pain allowing you to perform your desired activity”.

Potential further education may be:

“In fact, the profession has done studies in which individuals without pain have similar radiographic findings as your x-rays. Potentially it is not the arthritis that causes the pain, but the stress placed on that arthritic joint during walking, ascending stairs, squatting, or any other movements is causing the pain”.

Let’s optimize movement to relieve the knee pain.

This is important education for Physical Therapists to give to their patients to assist in defining what the profession can do. Physical Therapists can help optimize movement to reduce the stress placed on the body. The switch from pain is due to the tissue source needs to be changed to the pain is due to the excessive stress placed on the tissue source.

How can changing movement change the amount of stress through the knee? Take a look at this research article which focuses on the amount of torque placed on the hip and knee during a common squat exercise.

Keep in mind that the squat is a very functional movement. What I mean by functional, is that this is a motion which is performed often by nearly all individuals. A simple motion of sitting in a chair, or lifting an item from the floor is a squat. Minimizing the amount of stress through the knee during a squat, therefore decreases the amount of stress through the knee during other functional tasks.

In this picture the amount of force placed through the knee is cut by 30% simply by cueing the individual to squat with his knees behind his toes. Imagine how much force could be eliminated when his strength and flexibility are even further optimized.

Check out www.OptimalMovementPT.com to learn how you can reduce the amount of stress through your painful knee, or any painful areas during your desired functional task.

World Physical Therapy Day!!!

World Physical Therapy Day is September 8, 2014!!!

World Physical Therapy Day is a day to recognize the profession and all the benefits a Physical Therapist provides to the community. Are you currently participating in therapy? Have you had therapy in the past? How has therapy helped you? How could therapy help you?

For most individuals who have participated in therapy they are aware of the importance of the Physical Therapist as well as the role a therapist can provide in improving movement and function. For those of you who are not aware, the benefit therapy can provide is different for every individual. Every person you encounter has their own concerns and fears. My profession gives me the time to really understand and empathize with concerns and fears, which opens a window into making a real change on the individual level.

Whether it’s running that extra mile, picking up a grandson, getting up the stairs at night, or simply making it through the work day, Physical Therapists help individuals meet their specific goals. A Physical Therapist is a specialist on movement and can help optimize performance, return from an injury, and prevent future injuries from occurring. Imagine the health benefits of having a Physical Therapist who knows you. Think about it, most individuals have their own personal Physician and Dentist. Why not having your own Physical Therapist who can screen and educate on proper movements to maintain optimal health.

Optimal Movement Physical Therapy provides these benefits to many resident in the Redlands area. If you need someone on your team, we would be happy to listen to your concerns. Check out our website here. If you would like to learn more about World PT day, check out the World Confederation for Physical Therapy website.

In celebration of World PT Day we’re holding a contest! If your life has been significantly impacted by a Physical Therapist, let us know in the comments for a chance to win a $25 gift certificate to one of our favorite stores that encourages movement – REI! Follow us on Facebook, Instagram and Twitter for additional entries! Please leave individual comments letting us know where you’re following us! Giveaway ends Monday, September 15th at noon PST. Winner will be chosen by random draw and will be posted Monday evening!

Disclaimer: we are not affiliated with REI in any way. We just really like them and what they stand for!

http://www.OptimalMovementPT.com

A winner has been chosen for World PT Day contest. Thomas has been selected via the website random.org. Please email me at alan@optimalmovementpt.com.

Low Back Pain Paradigm Shift

Ten years ago, if you had low back pain and saw a Physical Therapist, you would most likely be prescribed “core strengthening” exercises. In fact, even today, you will most likely be given some exercises for the muscle group which provides stability at the low back. It’s not a bad idea, it works and there is a lot of research to support this paradigm. It’s become so commonplace that the argument is no longer whether you should train the abdominals, but more on how you should strengthen this muscle group. Brace or hollow? Sit-up or plank? There is multitude of articles and blogs on which exercises are best for persons with low back pain, and professionals often prescribe them without a second thought.

But, what happens when getting stronger doesn’t work? What are we missing?

The truth is, nobody has a “strong” core. It’s something we all have to work on. That’s why we can get away with prescribing it to everyone, because it always tests weak. Sure, some people have a stronger core than others, but in relation to the stiffness of the hip or shoulder, the trunk is often less stiff. Further, some people with a strong core still have back pain. So, again, what do we do when simply getting stronger doesn’t work?

That’s when it’s time to look at the movement. Look at the person’s function. Which movements are they required to do? What are their preferred movement patterns? Are they using the strength they already have?

Case in point: This client complained of low back pain and sciatica for the past 6 months. We began looking at abdominal strength as part of our objective exam only to find that she had great strength. When pointing this out to her, she noted that she is quite active. She hikes, does yoga, runs, stand up paddle boards, does pull-ups and planks. How could she have back pain?

Standing posture with measurements showing mild swayback posture.

The examination did not show many treatable impairments. When a client has a fairly clean strength and mobility examination, we get to move on to function. This client is very active, but the activity she does the most is holding her one year old son who weighs nearly twenty pounds. So, it’s time to check out her function.

Increased swayback posture when standing with twenty pound load (aka her son).

As you can see, the standing posture changes dramatically. The shoulders are no longer lined up with the hip, but they have shifted posteriorly. This client has shifted into extension when she holds her child. This excessive extension is just enough stress through her low back to cause some discomfort.

So, if she has enough strength, then, what is the treatment?

There is no exercise that will magically cure this shift. The only exercise or treatment for her is awareness. After a few small corrections, we are able to prescribe her only “exercise”.

Improved standing posture with 20 pound weight.

No rehab exercises needed. In fact, she is already doing more than I ask most patients to do anyways. She just needs to use what she already has and contract her abdominals while holding her son. She has all the moving parts to perform this movement optimally, and her rehab sessions have been cut from several to one.

This client is a great example of a client with low back pain who will not respond to abdominal exercises. The paradigm has shifted. It’s time to look at function. It’s time to look at movement. At Optimal Movement Physical Therapy, we assess, diagnose, and treat movement.

www.optimalmovementpt.com

Rebecca is the owner of be. Her mission is to inspire and educate people to live healthier and happier lives by spreading knowledge about the importance of nourishing their bodies with the best food. Check out her site at http://www.benourishedbehealthy.com.