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Now that we have made it through another Holiday Season it is time to look forward toward 2020 and think about what are our health and fitness goals. For some this could be simply starting down the journey of realizing better health and fitness while for others they may have more performance related goals. Whatever your health and fitness goals are for 2020 a common theme that can derail our goals is injury. All too often when someone gets injured they feel as though this requires complete rest and they stop their fitness routines altogether. This does not have to be the case.
In fact, there are numerous benefits to continuing to work on a general fitness routine as we are injured. Such as the fact that the increase in heart rate will promote good circulation which will help to promote tissue healing and help to control inflammation. Also from a pain perspective, all the research around pain science tells us that movement can be just as effective if not more effective at reducing symptoms as compared to taking medication or using other modalities such as heat or ice. So by continuing some form of training you are likely to improve your healing time. As for the person who is using their training for performance reasons whether that is for sport or in the gym, there is almost always a way to scale or modify movements to allow us to avoid aggravating the injured tissue. This will allow for you to continue to work toward your goals of increased performance, while allowing for appropriate healing. It happens all too often that an athlete will get injured and will be told that they must completely rest for 4-6 weeks meaning no weights and no sport activity. While 4-6 weeks may not be the end of the world but depending on when that 4-6 weeks occurs during your training cycle or competition schedule that can cause major effects on performance. Instead of resting we can use this time to work on other weaknesses that you may have or at the very least be training the opposite side which will help to minimize loss in strength and/or performance in the injured side. A personal example is that I have recently been dealing with a pain in my right hip that can be aggravated by squatting based movements. However, I have scaled and modified workouts to continue to allow me to train the muscles used in the squat so that I do not lose improvements in strength and mobility. As an example, my pain is made worse when back squatting as it puts my hip in an angle of flexion that causes more approximation/compression of the joint. So I utilized more lunge patterns and deadlifts initially. Then I progressed back into squat variations performing things like spanish squats and moving into more goblet squats and/or front squats, all of which allow for a more upright position of the torso which is decreasing load to the hip. So in this way I have been able to use a combination of movements to be able to continue training the different muscles of the legs that are usually trained by utilizing the squat, all while no impeding the healing of my hip pain/injury. So as you can see our training or our focus on our health does not have to stop due to an injury or pain. There are plenty of safe ways to continue training that will allow you to continue to improve performance and will likely having benefits of promoting healing as well. Hopefully this can help prevent someone from allowing an injury of getting in the way of their health and fitness goals in 2020. Keep training and do not let injury prevent you from becoming a Prime Mover!
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When we have persistent pain, want to get stronger, want to make a change to our lifestyle, improve our body image, etc. We generally start by looking for the quick solution. As a culture we have become use to scouring the internet looking for a quick fix. We think that there must be some type of pill we can take or machine we can buy. We are so used to instant gratification that we believe everything should be this way. Well I got news for you when trying to make true long-term changes to pain or your overall health there is no quick fix that can replace putting in the hard work and consistency with things like diet, exercise, and sleep.
I have many patients that ask me about different products that they see in infomercials about rubbing on this cream for back pain, using a certain pillow to fix their neck, or getting this machine that they can put there feet on while they are sitting that will help them with their neck pain. My response to these patients is always the same. We can not expect a passive solution to fix your active problem. We need to seek active solutions for our active issues. If I have persistent low-back pain that is preventing me from being able to perform my normal exercise regimen of weight-training and running I should not expect that using some pain relieving gel will magically make it better. Now I am not trying to say that some of these passive solutions do not have any merit or use at all but we need to see them for what they are and use them as such. Things that I mentioned earlier such as pain relieving topical creams, pills, an expensive vibrating massage chair, insert about a thousand other late night infomercial products here. These are all things that can provide some symptom relief but they are not going to be the solution to your problem. I would even take this one step further and add things like getting a massage, injections, dry needling, and even some surgical procedures to this list. If you are working with someone and they are using these techniques as the sole solution to your issue then it is time for you to find someone else to help you. As I stated earlier I am not saying that some of these things shouldn't be used I believe that there is great value in being able to alter a person’s symptoms, but that should be just the beginning. To go back to the idea of having back pain that prevents a person from performing a weight training regimen, we could perform some type of massage or give them a cortisone injection to help with their pain and they would be feeling pretty good. Now what do you think that person is going to do? They are going to go back to the gym throw on the same weight that they had been trying to do and are going to perform their squats in the same way that they always have, and likely going to experience the same pain that they always have. Now it may not be right away, but that pain will be back. However, if we can take this same person and we actually look at their movement patterns and assess whether or not they have the mobility and motor control to perform the squat correctly, now we can make a true change and allow the person to have the kind of long-term outcome that they are looking for. Taking this more active approach of improving movement patterns does not come easy, but without it most people will not see the kind of change that they want. So it is time to understand that the vast majority of the time we are not going to be able to find some quick fix or passive solution to our problems or toward reaching our health/fitness goals. We need to learn to move correctly, build true strength, and be consistent with good lifestyle choices. So, the solution is simple, it is whether or not we are in the correct mindset and are willing to build the habits that is most often the true barriers to our success. Now quit scouring the internet for the easy way out, because most likely there is not one anyway, and get moving toward reaching your Prime! We are not always going to be able to train completely pain-free, and having pain in our low-back while trying to perform different variations of the squat is one of the more common complaints that you will hear from people that engage in strength training. Most often our intuition would tell us that if I am having pain in my back than my problem must be in my back. So people will resort to performing some sort of stretching and core strengthening routine to make their back more mobile and strong. This can be part of the answer, but for many this will not lead to the effect on their symptoms that they were hoping for. For these people often times the cause of their pain is something wrong with the squat movement pattern itself, and the key to fixing this issue is often all the way down at the ankle. When a person does not have the necessary ankle mobility to get into a full squat position it can lead to compensation in which we may utilize increased amounts of lumbar and hip flexion to get all the way to the bottom of the squat. This can lead to increased shear forces in the lumbar spine, especially as the load/weight increases. In these cases it can help to be able to perform the squat with a more upright torso. However, to get into a more upright torso position a person will need to have the prerequisite ankle mobility to do so. When talking ankle mobility most people just think about ankle dorsiflexion as it relates to proper squat mechanics, however it can be just as important to have proper tibial internal rotation and lateral tibial glide. In this week’s blog we will discuss the concepts of ankle dorsiflexion, tibial internal rotation, and lateral tibial glide. We will talk about how each impacts the squat pattern and give an example of a simple mobilization to address decreased mobility in these ankle movements. Ankle Dorsiflexion Ankle dorsiflexion refers to the ability to bend the foot backwards bringing your toes closer to your shin, this would be in a non-weight bearing position just moving your foot. However, when we are in a weight-bearing position the foot will be fixed and so it is more about how well can the tibia slide anteriorly over the dome of the talus, essentially meaning can the knee go in front of the toes while being able to keep the foot flat on the ground. When performing a full squat with decreased ankle dorsiflexion a person will increase the forward angle of their torso to allow for full squat which can then lead to increased load and shear forces of the lumbar spine. Ankle dorsiflexion can be assessed by the ankle lunge test, which is performed with a person standing or in a half-kneeling position and they move their knee forward in an attempt to touch it to the wall and is scored by the distance that the big toe is from the wall. A normal amount of dorsiflexion is considered 4 inches from the wall.  To improve ankle dorsiflexion you can simply perform the ankle lunge test by trying to touch your knee to the wall and keeping the foot flat. To increase the mobilization I prefer using banded distraction to apply a posterior force to the dome of the talus. As seen in the picture below, utilize a band around the front of your ankle joint with the band placed below the two large bones on both sides of the ankle called the medial and lateral malleoli. Then just like the ankle lunge test or stretch attempt to lunge forward pushing the knee over the toes of the foot keeping the foot flat on the ground. Perform the mobilization for 1-2 minutes.  Tibial Internal Rotation Internal rotation of the tibia helps to keep the knee in line with the foot during a full squat. Having good tibial internal rotation and help to allow for a more forward foot position in the squat will help to minimize medial knee collapse during the squat leading to a more stable position of the squat. The more efficient the pattern the better we are able to use the hip and knee musculature to manage the load being lifted reducing the stress to the lumbar spine and associated musculature. It is tested in the seated position with a person placing weight through their heel and then attempt to point the toes toward the inside as far as possible, a normal test is when the knee is in line with the third toe.  To perform mobilizations for tibial internal rotation you can use the same banded technique as for ankle dorsiflexion, but point the toes as far inward as possible with keeping the knee straight and then perform your lunge again for 1-2 minutes. An alternative if you do not have access to a band is pictured below. Place foot on a stool, box, step etc. then place hands around you lower leg and apply a rotary force toward the inside sustain that force as you lunge forward and back. Again to keep it simple perform for 1-2 minutes.  Lateral Tibial Glide Lateral tibial glide describes the ability of the tibia to glide over the dome of the talus to the outside of the ankle. This allows for an improved ability to maintain the knees in a wider position in the squat which allows for a more upright torso angle as a person is able to bring their hips more straight down between their feet instead of having to lean forward at the trunk and torso to get into the full squat position. This will reduce lumbar flexion shear forces produced during the movement, and also, as described with tibial internal rotation, it will lead to better efficiency in using the hip and knee musculature to perform the movement which also reduces load to the lumbar spine and associated musculature. Pictured below is a common assessment for looking at lateral glide of the tibia. You can see here that the foot is being maintained in a flat position on the ground and the knee is being allowed to drop to outside as far as it can before the inside of the foot comes off the ground. The normal range is considered to be a 30 degree angle from the foot the knee.  To perform a mobilization to improve lateral tibial glide get into the lunge position and use the opposite hand to brace the foot into position and then use hand on same side to give help give downward and outward pressure to the leg as you perform a lunge motion. This can be seen in the picture below. Can also perform with foot on top of a box. Again we suggest 1-2 minutes.  These are all great mobilizations that will help to improve ankle mobility. However, if you only perform them in isolation you will not get the effects that you are really looking for. As with all mobilizations the new movement gained from the mobilization works best if it is able to be put immediately into practice. These should be programmed in on days in which your workout will be involving some sort of squat pattern work. When really tight it can work well to perform these mobilization between sets. We always need to understand that when dealing with the human body the work is never done, so if you find that mobilizing your ankles improves your squat pattern and any pain associated with it, this is something that should be incorporated into your normal movement practice. It takes consistency to make something become a habit and to become a Prime Mover!
It is commonplace in our current healthcare system for people to hear, “If insert common activity or movement here is bothering you than just stop doing that” or “You know that you should not be doing that.” The problem with this is that sometimes the things we are being told to avoid are things that are essential to our everyday life or are an integral part of the activity that we want to perform. Here are two recent examples that I have seen in my own practice of such a thing happening. The first was an elderly patient that hurt his back while gardening because he was attempting to lift a bag of soil out of his truck. He was told by his physician that he knows better than to be lifting things. This is a man that still lives at home, how is it possible for him to continue with his normal way of life and avoid all lifting. The second example of suggesting activity avoidance as a treatment option was a 16 yo female athlete being treated for persistent knee pain linked to patellofemoral issues, and whom had underwent arthroscopic meniscal debridement approx 3 months prior, sidenote the surgery had no effect on her knee pain. This patient was told by her surgeon that she should go to physical therapy but not perform any squatting exercises since that hurts, but that she could return to basketball. In this situation we are expecting someone that cannot tolerate squatting to be able to work their way back into a sport that requires cutting and jumping, which are activities that lead to much greater compression and shearing forces at the knee. Which from a training perspective, how are we going to be able to return someone to basketball without being able to train the squat pattern, a very fundamental piece of jumping and landing.
In both of the above situations the suggestions of avoiding the given activities were impractical for the situations. If we have discovered weaknesses in a person's fundamental movement patterns, such as the hinge in the elderly man, or the squat in the female athlete, should these not be things we are looking to improve instead of avoid. I would agree with the physicians that both of these patients were in a position in which their physical capacity did not match up with the physical demands being placed on their bodies during the activities each person wanted to do. However, I do not agree that the answer is to avoid these activities, as common sense would tell us that if we avoid an activity how will our body ever develop to capacity to perform it. Instead of avoiding these activities we need to train them, and that is exactly what we did in both scenarios. In both cases we began with looking at the person’s movement patterns to look for either mobility deficits that would not allow them to perform the movements fully, or motor control issues that cause them to have poor techniques despite having the necessary joint range of motion and soft-tissue flexibility. Once you are able to determine the limiting factor, which could be both, the solution to the problem becomes simple. Prescribe the necessary mobility and motor control exercises to improve movement quality. Then scale the movements in a way that allows the patient to perform the movement successfully and progressively load the pattern. Often times we like to make musculoskeletal issues more complex than they have to be. There is nothing tricky about the two cases described here and so the solution does not need to be tricky either. A weakness in both patients was identified and a progressive loading strategy for the patterns in which they were weak were created to improve their physical capacity to perform the desired tasks. The only tricky part is getting the person to understand how consistent and diligent we must be if we want to make true changes to our movement patterns and improve our physical capacity. To recap, please stop telling people that they can not do things or that they must avoid certain activities because they are causing a pain stimulus. Instead let's teach people how to move correctly and show them how to progressively strengthen themselves, as this is were a true resiliency against injury occurs. Since most people are not going to make a living as a professional sports star or a fitness athlete, what are we training for? Most people use their training in the gym to keep them healthy and improve their performance in what they do outside the gym. One aspect of training that I believe can be missed in the gym is the idea of working on unilateral and variable loading to more closely resemble the demands of everyday life and sport outside the gym. In our daily lives or in sport we are not always going to be picking up or carrying something that is perfectly balanced and stable, but in the gym this is often times what our exercise regimen will primarily consist of. If we are using our time in the gym to support what we want to do outside the gym then we need the two worlds to resemble one another. Today we will discuss what unilateral and variable loading strategies/exercises are and give examples of a few of our favorites of each that you can start programming into your workouts. Unilateral Loading/Exercise Let’s start by defining the term unilateral, this is loading of one side or one limb. Think of a new mother carrying her baby in a car seat or a waiter/waitress carrying a heavy tray of food over their head through the restaurant. Both of these are simple everyday examples of someone placing a load on one side of their body, and if they have not developed a proper strategy to brace against this type of uneven loading then what do you think they are going to do? They are going to contort their body into some position in which they feel they have created a stable system in their body. This places an uneven stress on many of the joints and ligaments of the joints being contorted to achieve this compensatory position. However, if we program in and train some of these types of movements we can develop the proper motor control and muscular strength to perform these types of tasks in our everyday lives without putting our joints at increased risk of pain or injury. Here are a couple of examples of some unilateral loading exercises. Suitcase Carries  Suitcase carries also known as single arm farmer’s walk is an exercise in which you hold a load such as a kettlebell in the picture above, on one side of the body and walk for a prescribed distance. When performed correctly this is an exercise that can improve strength and control of the core musculature on the opposite side of the weight. The person should focus on maintaining a braced neutral spine (aka tighten the “core”) and upright position of their torso, if you are unable to maintain this position you need to lower the weight. This will help reduce stress to the joints of the lumbar spine when performing a single armed carry such as the mother with the car seat. Unilateral Deadlift  In the unilateral deadlift place a kettlebell, barbell, sandbag, etc. on one side and perform a deadlift maintaining all the principles of the standard deadlift. As with the suitcase carry above, this will help us build the strength and control to perform functional lifting tasks of everyday objects that are not typically going to have perfect balance. Like helping someone move a couch. There is no secret to dosing this exercise the same exercise prescription used for the typical deadlift can be applied the the unilateral deadlift. Variable Loading/Exercise When using the term variable loading we are referring to a load or resistance that will be able to move leading to a challenge in creating and maintaining stability throughout the exercise. Variable load training also provides immediate feedback on a person’s ability to maintain good positions throughout a movement. The less control you have, the more the load is going to move and shift demonstrating lack of muscular control during that particular movement pattern. Consider activities such as carrying a large container of water and as the water moves inside of the container it can cause you to lose control of the container or of your own balance. Again another real world example of activities that are not often practiced in the gym, but do happen in our daily lives.. Here are some exercises to work on variable load exercises. Suitcase carry or Farmers walk with variable load  Keeping it simple we can perform the farmer’s walk or suitcase carry from the earlier exercise with the weights suspended from strong resistance bands. This will allow the weights to swing and bounce on the bands causing the muscles to have to work harder to control the movement. As stated above this provides good feedback on how well you are able to control the trunk lean or sway while walking. Squats with hanging weights  Here the weights are again suspended from the barbell using the thick resistance bands to create a variable load. This will challenge the limits of stability throughout the movement. This exercise allows for challenging exercise under a lower load, and there is no hiding any flaws in your squat technique here.
We hope that this has given you some ideas about how unilateral and variable loading strategies can be incorporated into your exercise regimen to further your resilience to everyday life outside the gym. We must practice for all situations to be ready for all situations. Throw some unilateral and variable training into you programming and become a Prime Mover! When exercising or in everyday life one of the more difficult things to do is to perform sustained work in an overhead position. Many people complain about feeling too tight in the shoulders to be able to get into a full overhead position. While the mobility of the shoulder joint can definitely affect a person’s ability to obtain an overhead position, there are two other factors that can be equally or even more important and they are often overlooked. These are thoracic spine mobility and flexibility of the latissimus dorsi muscle. Without having the ability to obtain full thoracic ext and adequate flexibility of the latissimus dorsi muscle a person cannot obtain and or sustain a proper overhead position regardless of how good their mobility is in their shoulder joint. Let’s dive a little deeper into these two factors and then discuss some simple mobility exercises to help address these issues. Thoracic Spine The thoracic spine is the longest section of our spinal column running from the base of our neck down to the level of our abdomen. It is also inherently more immobile than the cervical and lumbar regions of our spine secondary to the fact that it is attached to our ribs. As you can see in the picture below the thoracic spine has a rounded curve to it called kyphosis.  Because of the kyphotic curvature it can limit how high up a person can raise their arm regardless of their shoulder mobility. Shown in the image below is a depiction of a spine with an increased kyphotic curve of the thoracic spine and how that limits shoulder movement and the ability to get the arm overhead.  This is something that can be worked on through utilizing techniques known as joint mobilizations to the area affected. Joint mobilizations can be applied manually by a licensed physical therapist or chiropractor, or there are self mobilizations techniques that can be very beneficial. There are a number of self-mobilization techniques, shown below is a basic option to get people started. It is the thoracic extension over foam roller technique. Lay on the floor with foam roller running across your mid back, with hands behind head extend yourself over the foam roller and then back up in a slow controlled motion. Perform for approximately 60-90 seconds moving the foam roller over different segments of the thoracic spine.  Latissimus Dorsi The latissimus dorsi is the largest muscle in the upper body and it’s primary responsibility is to perform shoulder adduction, shoulder extension, and shoulder internal rotation. These actions have an almost direct antagonist relationship to the proper overhead position, meaning that tightness within this muscle would cause limitations or compensations to overhead positioning. Below is a picture of the latissimus dorsi.  In the presence of increased tone/tightness of the latissimus dorsi there are mobility exercises that can be done to improve the mobility and stretch tolerance of this large muscle. One simple but effective technique to work on latissimus dorsi mobility is shown below. Begin standing or kneeling, and place arms on a bench, table, chair, etc. in front of you with the thumbs pointing up. Make sure to be bending from the waist and maintaining a neutral spine position, also attempt to sit your body weight back to increase the stretch felt. Can be prescribed in a number of ways, our preference is to perform multiple repetitions moving in and out of the position for 60-90 seconds as opposed to maintaining a prolonged static position.  This has hopefully provided some simple ideas around not just relying on shoulder mobility exercises to improve overhead position, but understanding the relationships of the spine and latissimus dorsi on overhead mobility. There are certainly a countless number of other variations to work on these aspects of overhead mobility. However, regardless of which mobility exercises a person finds that they respond to, it takes consistency over a long-period of time to make the kind of lasting effects that we all want to see. So find mobility exercises that can cause a short-term effect on your overhead position and put in the work and you will be able to obtain and maintain a proper overhead position to continue to improve for your overall health and fitness.
When most people hear the word deadlift they get a nervous look on their face and often times tell you that they have been told by their doctor, physical therapist, chiropractor, etc that they should not perform deadlifts due to their back problems. Well I am here to tell you that avoiding this movement pattern is not the answer, and honestly almost impossible to avoid. So, instead of avoiding maybe we should start prescribing this movement. Every time you bend down and pick up an object from the floor you are performing a deadlift movement, and most of us are doing it wrong. A majority of the population will just bend forward rounding their back and shoulders to pick something up off the ground placing unnecessary stress throughout their spine putting themselves at an increased risk of injury. Here are some statistics about low back pain:
Those are some daunting numbers to digest. When I look at those numbers it tells me that the typical treatments currently being offered in our healthcare system are not as effective as they could be. So what is missing? I believe part of the answer is truly teaching people the proper mechanics of lifting. As I said earlier the deadlift is one of the most common movement patterns utilized by humans while just performing everyday tasks. Most people will tell you that they know they are supposed to lift with their legs and keep their back straight, but that is the extent of the common person’s movement training. Let me tell you from my experience as a doctor of physical therapy, that instruction leads to a wide variety of movement strategies that people are adopting with a vast majority of these movements being inappropriate and likely to lead to injury. It is my belief that there is a significant disconnect in what it truly means to maintain a proper position of the spine and lift with the legs. So today, I want to give some basic instructions on how to safely and efficiently lift something from the floor, utilizing the principles of a deadlift. Here are simple cues that I give my clients when teaching them to perform a deadlift:
Here is a photo of what the finish position should look like:  This movement strategy allows you to maintain a proper neutral position of the spine reducing the injury-producing shear forces to the spine, as well as reducing the amount of stress placed on the knees when compared to squatting all the way down. With this information, let us start to fight the epidemic that is low-back pain, and get people back to being able to lift heavy objects from the floor.
References 1. Jensen M, Brant-Zawadzki M, Obuchowski N, et al. Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain. N Engl J Med 1994; 331: 69-116. 2. Ibid. 3. In Project Briefs: Back Pain Patient Outcomes Assessment Team (BOAT). In MEDTEP Update, Vol. 1 Issue 1, Agency for Health Care Policy and Research, Rockville, MD. |
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