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.

TRX Corrective Exercises for Pitchers

You don’t run to get in shape, you get in shape so that you can run. Simply running every day will not improve your running ability. Cross training, improving muscle imbalances through corrective exercises, and strength training are all required in order to improve performance with running, and minimize the risk of overuse injuries.

You can take the same concept with any activity which requires repetitive motion, especially pitching. Simply throwing every day as hard as you can will only decrease performance and increase the likelihood of injury. There is a certain amount of core strength, rotator cuff stability, hip flexibility, and lower quarter stability that is required to optimize the movement of an overhead athlete. When an athlete has reached a certain level of strength and flexibility, I encourage using a TRX suspension strap to train these elements of pitching. My favorite TRX exercises for pitchers are listed below, but with a disclaimer: as healthcare professionals, we cannot simply prescribe exercises without a thorough examination of the athlete. These exercises should only be performed after an assessment and under the instruction of your healthcare specialist.

1) TRX Side Lunge

The stride phase of the pitch may be the most important phase of pitching. The stride length of a professional pitcher is approximately the length of the pitchers height, and the shoulder has to move towards end range of external rotation. Needless to say, in order to maintain proper mechanics the pitcher requires a certain amount of trunk control. Therefore, the TRX side lunge becomes a great exercise to work on adductor length of the stance leg (ensuring increased stride length) and trunk control during this motion.

2. TRX W Deltoid Fly

This exercise is named for the large deltoid muscle which assists with the abduction of the shoulder, but I like to use it to work the external rotators of the shoulder. This is also important for the stride phase of pitching, and requires a certain amount of instruction without the TRX before it can be done appropriately. After a pitcher learns appropriate joint centration of the glen0-humeral joint (to be discussed in a future blog) he can begin to train the rotator cuff to maintain the stability of the joint during pure external rotation. Again, all of this is being done while maintaining trunk control.

3. TRX T-Deltoid Fly

The cocking phase of the pitch requires scapula adduction and full external rotation of the gleno-humeral joint. At this phase of throwing, the middle trapezius operates at approximately 50% Maximal Voluntary Isometric Contraction (MVIC) and the Infraspinatus works at 74% MVIC. This exercise places works on these muscles to place the scapula and glen-humeral joint in the appropriate position for this phase of throwing.

4. TRX Lunge

 

Of particular note, at this time all exercises have focused on  phases of pitching before the ball is released (showing the emphasis I place on the early phases of pitching). The most important component of the pitch after the ball is released is the follow through. Flexing through the hip and trunk can attenuate the force developed in prior phases from the shoulder. The TRX lunge can work on strengthening the gluteals and hinging from the hip to assist with this phase of throwing.

This form of training requires appropriate flexibility, strength, and supervision, but it can greatly improve your pitching mechanics. If you live in the Redlands area, a great spot for TRX training is at The Energy Lab. Check them out for their TRX classes and all fitness goals.

For rehabilitation, movement screenings, and to work towards your fitness goals, check out OMPT and email me at alan@optimalmovementpt.com

 

http://www.optimalmovementpt.com

Running Assessment

This is why I wanted to be a Physical Therapist…

I just completed my first running evaluation at Optimal Movement Physical Therapy. My client, marathon runner, John Hackney, has been having some knee pain of late during his runs. I think even more frustrating is the recurrence of a hamstring strain during his marathon competitions. Seeking a biomechanical evaluation with his insurance and scouring the internet for some information yielded little results. I was very happy to be able to provide some answers.

Running is hard to analyze. The movements occur so fast that it becomes very hard to see the movement faults. One second you think you see something important, but the next second it has disappeared. The best way to break down a runner is with video analysis, but the problem with this technique is that it requires more time than most therapists have with their patients. I have come to realize through several of Chris Powers’ lectures and discussions, that the only way to provide a meaningful assessment to high level athletes is by giving them the time they need to be thoroughly assessed. In fact, pain and movement can be so confusing, that the majority of clients need more time than most therapists can give in order to clear up the confusion (but more on that subject in a later blog…).

Seeing the majority of clients (especially high level athletes) leave a clinic without a thorough understanding of their problem is part of the reason I started Optimal Movement Physical Therapy. Within John’s first session, we were able to analyze not only his running, but several other functional tasks including squats, step downs, and single leg stance. Further, the video analysis provided by Simi provided specific metrics on all functional movements. The measurements taken of body angles during running and step downs will allow a post treatment comparison after John has completed some corrective exercises. After analyzing all of the functional movements, I still had time to measure John’s strength and flexibility (decreased hamstring length, decreased gluteal activation, and quad dominant movements – no surprise there). Lastly, John and I had time to discuss the problem, strategize how he can reach his goals, and determine the most appropriate corrective exercises for him (again, more on specific corrective exercises of individuals in a later post).

Motion analysis of marathon runner in saggital view.

In my opinion, this is the way physical therapy evaluations should be. Full of information on the individual’s specific movement with measurements and goals to attain. Oftentimes, a client is left to simply trust a therapist’s or healthcare professional’s word. When given specific measurements, a client can better understand the problem and is more motivated to correct the problem. At first glance, John does not have a lot of faulty movements or impairments, but after 26.2 miles every impairment is magnified. In order to identify and measure these impairments, skilled physical therapists need only spend a little more time with their patients.