Posted on Monday, October 13, 2014

12 Sure Fire Ways to Injure Your Back

You caught me red-handed! A physical therapist with a lapse in judgment which lead to an injury that I could have avoided had I followed my own advice. During an early morning workout, I recently tweaked my low back. I’m guilty of being exhausted, using poor technique, and not taking a rest day. Sound familiar?

In the following days (as I was forced to rest although I would rather have been at the gym), I drafted a rather cheeky list of risk factors and how to maintain a healthy back.

12 Sure Fire Ways to Injure Your Back:

Start Smoking – Smoking is a major risk factor for low back pain (LBP). The chemicals in cigarette smoke affect both the lunges’ ability to exchange oxygen and the body’s normal healing response. These chemicals alter the blood supply to the discs and other spinal structures which affects nutrient exchange and increases the risk of pain. Healing time for all medical conditions worsen with smoking.
Be Male – Males have a higher risk of LBP. Females tend to experience more cervical or neck pain. (Obviously, you have very little control over this factor other than the knowledge that you’re at an increased risk if you are a male.)
Choose Parents Who have Experienced LBP – A family history of low back pain increases your risk. In some cases, this may be due to actual structural deformities which may be genetically linked. More commonly, it’s a learned behavior, such as chronic sitting and slouching (poor posture), that can lead to a higher risk of LBP.
Prior Episodes of LBP – Once you have experienced LBP, you are more likely to have re-current episodes. This is partially due to weakness in the deep multifidus muscles that help support the spine and prevent shearing forces. This weakness can be addressed with proper physical therapy intervention.
Have a Baby – Pregnancy increases your risk for LBP due to structural changes as the baby develops and hormones change. The expectant mother releases relaxin, a hormone which loosens the whole body, to prepare for the baby’s delivery. Again, a risk worth taking! Most women can manage the pain by modifying posture and movements while learning techniques for self-management.
Don’t Exercise – A sedentary lifestyle will increase your risk for LBP. The spine is designed to work and move. In order for the spine to remain healthy, it requires exercise and movement.
Sit for more than 2 Hours a Day – Sitting for a long period of time not only affects your general health status in a negative way, but it also increases your risk for LBP. To increase your risk further, be a heavy equipment operator who sits on a vibrating surface! Please refer to The #1 Way to Extend Your Life Span for the reasons why sitting has such a negative effect on your body.
Practice Poor Posture – In western culture, we spend most of our day sitting slouched or standing hunched over. This is an excellent way to increase your risk for LBP. It’s one of the major risk factors for disc herniation and development of spinal stenosis. Please refer to How to Improve Posture & Eliminate Pain for exercises that can help you to develop better posture and strength to eliminate back pain.
Don’t Warm Up Before Exercise – This is a common mistake which can lead to injury. Jump out of your bed in the morning without warming up, and then start your exercise routine. (Please don’t!) Instead, prepare your body for challenging activities in order to avoid injury. A warm up should consist of a cardiovascular component and a dynamic stretching routine of the actual exercises you will be performing to insure you’re ready for the movement. This is also pertinent for weightlifting and running.
Keep Moving even when Exhausted – This is a common problem among CrossFitters (including myself). Just keep pushing yourself even when you can’t see straight. Typically, this results in poor technique which further increases your risk. Combine poor technique with muscles which can no longer perform the proper movement pattern, and you are likely to become injured. High Intensity Training (HIT) is a wonderful form of exercise and has many health benefits as long as you’re able to properly perform the exercise.
Use Poor Technique – Poor technique, along with feeling exhausted, often occurs when performing exercises that are too advanced. Performing unfamiliar lifting techniques or lifting too much weight will likely result in poor technique. Please see your coach, athletic trainer, or physical therapist for the proper technique for your activity of choice.
Keep the Training Volume High – Who needs a rest day? All of us can benefit from taking a break. Training every day without regard to rest is an excellent way to cause over training syndrome and injury.

Low back pain is a serious and debilitating condition. It will either most certainly affect you or someone close to you. Be mindful of your risk factors and be pro-active in maintaining a healthy back! Don’t let LBP affect your ability to stay active and keep enjoying your favorite activities!

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Posted on Wednesday, October 8, 2014

Q & A: Can CrossFit Cause Elbow Pain?

Q. A lot of CrossFitters, including myself, seem to have tendinitis of the elbow or other achy elbow issues. Do you know why that is? What exercises are we doing to cause it? What therapy would you recommend to help the pain? I appreciate you and love this blog that you are doing! I always look forward to reading it! -Stephanie

A. Thanks, Stephanie, for the great question! I have worked with quite a few CrossFitters who have experienced elbow pain. I have treated people new to the sport and those who participate at a high level. Elbow pain can be debilitating by limiting your ability to exercise and perform daily tasks. I will address potential causes and how to alleviate elbow pain associated with exercise. (Note: You don’t have to be a CrossFitter to benefit from this information.)

Possible reasons for developing elbow pain include:

Poor grip strength.
Muscle imbalances between wrist flexion and extension strength.
Improper lifting technique (which is the primary problem for the newer participant).
The progression of training is too quick (which again tends to be an issue for the newer participant).
Mobility related issues in the wrist, shoulder, or thoracic spine. (Poor mobility can affect both those who are new to the sport as well as CrossFit veterans.)
Excessive mobility or hypermobility may also be an issue. It tends to be more common in females than in males and is usually associated with the shoulders or elbows.

Poor technique is a frequent complaint in regard to safely performing CrossFit. Many people believe that there isn’t enough emphasis placed on proper lifting technique or specific CrossFit exercise techniques (particularly with the new participant). Some complain that the emphasis is on speed, not form, during WODs (Workout of the Day). This may be true in some Boxes (gyms/clubs), and it’s a valid concern.

Please be honest with yourself when you start a new activity. This is especially important if you’re starting very high intensity activities with very specific movements which require a high degree of skill to perform such as CrossFit. Beginners to CrossFit should spend the necessary time to learn the proper technique. With any new activity, there is always a learning curve. It’s the responsibility of the coach and the client to insure proper form.

The power clean is an example of a common movement in CrossFit and Olympic Weightlifting. This exercise can cause elbow pain when performed incorrectly. One reason for elbow pain to develop during this movement is that the bar is reversed curled. It causes excessive strain on the wrist extensor muscles instead of the participant exploding the bar upward, and then dipping underneath. There shouldn’t be a reverse curl movement to this lift. I witness it fairly often as a common mistake. If you’re experiencing aches and pain in your elbow or elsewhere, please see your coach or athletic trainer to insure that your lifting technique is correct.

Poor wrist, shoulder, or thoracic mobility is also commonly related to elbow pain associated with exercise. If the wrist cannot extend properly, it not only causes wrist pain, but excessive stretching of the forearm muscles and strain on the elbows (possibly leading to pain).

Poor shoulder or thoracic spine mobility can also cause excessive strain on the elbow. Consider exercises like the overhead lift or pull ups. If the shoulder cannot fully flex or the thoracic cannot fully extend (allowing proper shoulder flexion), then the elbows will absorb more of the load. The lack of shoulder or thoracic mobility also affects proper alignment of the upper extremity during the movement. Over time and with multiple repetitions, this overloading can cause pain and injury to the elbow.

Whenever one part of the body doesn’t have adequate mobility, another part will do more to allow for the movement to take place. When an exercise is performed at a high speed, high relative weight, or high repetitions, a lack of mobility can make you more susceptible to pain and injury.

Excessive mobility can have a similar effect. For example, if you’re performing an overhead lift, but your shoulders flex past 180 degrees, then the bar is too far behind your head. This causes excessive force to be placed on the shoulders and elbows. Again, this can lead to injury and pain when performed at a high speed, high relative weight, or high repetitions.

Top 7 Recommendations to alleviate Elbow Pain associated with Exercise:

Work on your Grip Strength. Practice bar hangs for time. Carry barbell plates (one in each hand) to challenge the grip strength. Don’t just work on wrist flexion or gripping exercises, but also work on wrist extension to improve grip strength and decrease your risk of lateral elbow pain. Use an exercise band (as shown below) to perform 2-3 sets of 20 repetitions. Extend the wrist up, and then slowly back down toward the floor. Be sure to move very slowly during the eccentric/muscle lengthening position (when your hand returns to the floor).
Identify the Offending Movement. If you’re experiencing elbow pain, try to identify which specific movement aggravates the elbow. Once you identify the movement, work with your coach or athletic trainer to insure proper lifting technique.
Work on your Mobility. CrossFit is not just about metabolic conditioning or strength training. You need to develop all aspects of your fitness, and this includes your flexibility. Work on upper body mobility by focusing on shoulder and thoracic mobility as well as lower body and spinal mobility. A free resource for shoulder and thoracic mobility is My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain which you can automatically download when you subscribe to my e-mail list. You will receive each week’s blog post sent directly to your e-mail making it even easier and more convenient!
Warm Up. Prior to activity, be sure to perform a cardiovascular warm up to insure that the muscles are ready to stretch and perform high level activities. Perform a dynamic warm up by taking the associated muscle (or muscles) needed for the workout through the anticipated and needed range of motion (ROM) in a quick and brisk manner. A foam roller can also be utilized as part of your warm up. For more instruction, please refer to Foam Rolling for Rehabilitation and Does Foam Rolling Help or Hurt Performance?
Static Stretch and Self-Mobilization Post Work Out. Continue to work on the immobile areas through static stretching and/or self-mobilization. Again, a foam roller can also assist. If you prefer a very comprehensive guide for improving mobility, I recommend Kelly Starrett’s Becoming a Supple Leopard.
Be Proactive. Once you start to feel pain, be aggressive with your management and self-treatment. I like to use either a tennis ball or roll PVC pipe over the forearm area, which can be an effective treatment for lateral epicondylitis (“tennis elbow”). For more ideas on how to self-mobilize, please refer to My Top 3 Household Items for Self Mobilization.
Contact your Physical Therapist. If the pain persists, seek additional help. Don’t let the pain linger. The longer it’s left untreated, the more potential for harm and damage which potentially could lead to a longer recovery. The American Physical Therapy Association (APTA) is an excellent resource for learning more about physical therapy as well as locating a physical therapist in your area.

Elbow pain can be debilitating by limiting your ability to exercise and perform daily tasks. Be proactive in your care and management. Most importantly, don’t let the pain linger. You can find more tips and strategies on managing pain and injury by simply using the search function (located on the upper right-hand sidebar).

What specifically causes your elbow pain? Which treatments have you found to be the most effective? Additional discussion can help others to manage his/her pain. Please leave your comments below.

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com. Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Posted on Wednesday, July 16, 2014

Is Running Safe?

Is physical activity, like running, safe? Most of the time, the answer is YES! The key is to rule out possible issues (especially as you age) which may make physical activity unsafe. More potential issues need to be screened the older you are and based on how healthy of a lifestyle you may have. Being well informed initially allows you to tailor an exercise program which can be safe and effective in maximizing your particular goals and needs.

How to Start?

I recommend that you take a Physical Activity Readiness Questionnaire (PAR-Q). The PAR-Q has been designed to identify the small number of adults for whom physical activity may be inappropriate or those who should have medical advice prior to initiating in physical activity.

The American College of Sports Medicine (ACSM) also offers information and a similar version of the Par-Q with clear guidelines on when a person should or should not see a physician before starting an exercise program. (When To See a Physician Before Exercising)

Assuming that you have been cleared for physical activity, let’s specifically discuss running. Let’s attempt to get one myth off the table first. Running is bad for the knees. This can be true and false. Let’s dive deeper. Running can be “hard” on the knees in certain circumstances:

If you have significant degeneration of your knees, such as severe osteoarthritis (loss of the cushion between the knee bones known as the meniscus).
You are morbidly obese.
You have some sort of bone disease, such as osteochondritis dissecans, where you experience cracking in the articular cartilage of the bone and loss of blood flow (causing the bone to die, which is known as avascular necrosis).
If you have had a prior knee injury such as a meniscus injury or surgical repair of the meniscus; micro fractures repair of the knee cartilage; or a total joint replacement in the lower extremity such as the knee, hip, or ankle.

It is possible that running may not be the best activity choice for you, but with proper training and a strong focus on technique, it is still possible.

Research indicates that running for the typical person will not cause excessive wear and tear or injury to the knee. If injury is already present, then running could possibly worsen it. It is true that running can lead to aches and pains, including conditions such as patellar femoral knee syndrome (runner’s knee). It is also true that sitting like a couch potato can also lead to knee arthritis and cardiovascular disease as well as a list of other medical conditions.

A vast majority of running related injuries can be easily avoided through proper training, proper running form, proper footwear, and proper recovery. Running is an excellent form of exercise and a wonderful stress reliever.

The key to a successful lifelong running program includes:

Proper Training – Find the right balance of volume and intensity for you. Each one of us is capable of some running. The key is to discover the right amount for you to remain healthy and engaged in the activity.
Proper Running Form – There are many different running styles and form. Some focus on a mid-foot strike while others, a heel strike. Some prefer a run/walk protocol or a power walking protocol. You may also be interested learning more about the Chi Running Technique (http://idahoezrunning.com/freedemo/). The key is to find a coach who can help you find the right technique for your particular body style and goals.
Proper Equipment and Footwear – Your feet and knees absorb a bulk of the force as you run. Ensuring that you have adequate footwear is imperative. I highly recommend visiting your local running store for a gait evaluation. These professionals will properly fit you into a real running shoe. (The quality of a shoe from a big box store will be poor in comparison.) Your shoes should be changed every 300-500 miles depending on the style of the shoe and how much wear and tear accumulated.
Cross Train – As big of a fan as I am of running, it shouldn’t be your sole form of exercise. It is an excellent form of cardiovascular exercise, but it doesn’t address strength training. Strength training is an important component to a healthy lifestyle. I cross train by performing CrossFit and through weight training multiple times per week.
Vary Your Running – Don’t run on the same surface each time, and don’t run the same speed every time. Your body loves variety, and you will, too!

Running is well worth the effort and the risk of a potential orthopaedic related issue in order to avoid the risk of cardiovascular disease, diabetes, heart disease, cancer, obesity, and osteoporosis. Seek the advice of a physical therapist or fitness coach to help you train and recover properly. If a problem occurs, you will be armed with tips and strategies to deal with it before it becomes a major issue. Happy running!

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Posted on Wednesday, June 25, 2014

Q & A: How Should I Treat Shoulder Pain and Impingement?

Q I suspect I have a left rotator cuff tear. I have severe pain especially when I move my arm outwards. It feels like a knife stabbing my left deltoid area with spasms. There is no swelling or bruising. The area is tender to touch. I have trouble lying on my left side at night due to discomfort. If I don’t move my arm, there is no pain. Ibuprofen is not effective. I have been applying ice. I haven’t seen my MD yet. When I raise my arm when I perform range of motion (ROM), I hear a cracking sound. It has been six weeks. Please advise, Dr. Ben! -Linda

A. Thanks for your question, Linda! Unfortunately, this is a fairly common scenario. Shoulder pain can be one of worst most intense pains a person can experience. It can be completely debilitating–rendering an arm almost useless in some cases. The shoulder is vital for any movement of the arm which includes the hand. It can even affect a person’s ability to utilize a computer mouse.

Linda doesn’t mention any specific causative factor which is common in these cases. She also mentions pain at night and pain with movement. Another very common symptom is where she describes the stabbing pain in the deltoid. The pain is almost always located down the arm into the deltoid area. Typically, it is located at the insertion point of the deltoid muscle. It can migrate even further to the elbow or hand.

In a situation like Linda’s, the source of the pain is rarely the deltoid and almost always the rotator cuff. The rotator cuff tends to “refer pain” into this region. Referred pain is a common phenomenon which occurs when the pain is being caused in one area of the body, but the pain is felt somewhere else. (An example of referred pain would be left arm pain or jaw pain which is present during a heart attack.)

Linda states that the pain is present when she raises her arm. This implies that she still has the ability to raise her arm, which tends to (but not always) rule out a full rotator cuff tear. Typically with a full tear, the person loses the ability to raise his/her arm. The level of pain on a full tear will vary depending on how acute or recent the tear.

To accurately diagnose Linda’s condition, I encourage her to seek treatment from her medical physician or physical therapist. Based on her reported symptoms, she is likely experiencing either a partial rotator cuff tear or shoulder impingement. Shoulder impingement can lead to an actual rotator cuff tear if it remains untreated. The key to treatment (with either a partial rotator cuff tear or an impingement) is to first address the pain and inflammation. Then the mechanical cause or causes which led to the injury must be addressed.

My Top Tips & Recommendations to Treat Shoulder Pain & Impingement include:

Reduce the Inflammation:

Use ice on the affected area (not directly on the skin) for 20 minutes per hour. Watch the skin carefully. If it looks white or blue and is non-blanching, then discontinue the use of ice. It is possible to frost bite your skin.
Rest the affected area. Stop or reduce any activities which tend to aggravate the area. This is typically overhead activities or repetitive activities.
When sleeping, try not to lie on the affected side. Hug a small pillow for comfort. This also promotes optimal blood flow to the shoulder area.
Try Mt. Capra CapraFlex. Mt. Capra, an organic goat farm in eastern Washington State, offers superior quality products primarily utilizing goat based products. Capra Flex is the best bone and joint supplement I have found. It is a blend of natural herbs and spices along with glucosamine and chondroitin. The herbal and spice formulation is designed to naturally decrease inflammation and support healing. I recommend it to anyone recovering from an injury or attempting to prevent injury when performing at a very high level. I personally use it, and in my practice, it has helped clients recover faster and prevent injury. It can interfere with some blood thinning medication, so if you are on this type of medication, please check with your physician.

Address the Mechanical Causes:

A slouched posture with a forward head and rounded shoulders can be associated with this condition. Try to keep a good postural alignment with your shoulders under your ears and the shoulder blades set in a back and down position. This is particularly important when performing any activity while using the shoulder.
Improve thoracic (upper back) mobility. The more mobility your upper back has, the less likely your shoulder will impinge when moving. Your upper back, shoulder blade, and arm must work together when moving. Tightness in the upper back will throw this system off.
Be sure to check out My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain. By subscribing to my e-mail list, you will automatically gain access to this FREE resource. Download the .pdf file, which is full of photos and exercise instructions, to get started!

Strengthen the Rotator Cuff:

The rotator cuff is a critical component to shoulder mobility. It is made up of four different muscles whose job is to make sure that the ball of the humerus (arm bone) rotates and slides properly in the socket, which is made up of the scapula. The rotator cuff allows the other major muscles of the arm, such as the deltoid and Latissimus dorsi (lats), to properly perform. When there is weakness or dysfunction, it will cause rubbing of the muscle tendon on the bone–leading to impingement or eventually fraying and tearing.
Here are my recommended Rotator Cuff Exercises using an exercise band.

Shoulder impingement or a partial rotator cuff tear can be very painful and may take many weeks to recover. My tips and recommendations are the first steps for treating and preventing shoulder impingement and pain. Many different causative factors can lead to these conditions. In most cases, shoulder impingement (or even small partial tears) can be completely rehabilitated and should (when treated properly) leave no residual effects once a person has recovered.

If your symptoms continue to worsen or you don’t improve, I highly recommend that you seek further medical treatment. Many times, a person will require medical intervention, which could include anti-inflammatory medications either orally or through an injection. A person may also need hands-on treatment from a qualified physical therapist to address other mobility issues in the shoulder, thoracic or cervical regions which are causing or contributing to the pain. Sometimes, surgical intervention is needed to repair a fraying tendon or an acromion which is hooked and causing the impingement.

Good luck, Linda! I hope you find the information to be helpful and provide some relief from the pain you’re experiencing. If you have a question that you would like featured in an upcoming blog post, please e-mail contact@thephysicaltherapyadvisor.com.

Disclaimer: The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No health care provider/patient relationship is formed. The use of information on this blog or materials linked from this blog is at your own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Do not disregard, or delay in obtaining, medical advice for any medical condition you may have. Please seek the assistance of your health care professionals for any such conditions.

Posted on Wednesday, June 11, 2014

7 Reasons Why the Squat is Fundamental to Life

If you were born and raised in an industrialized nation (like the U.S.A.), then squatting was probably something you did as a child. As soon as you became school age, you rarely squatted again. In other countries around the world, squatting is a normal part of daily life. In countries such as India and in many Asian countries, it is common to see very aged individuals who are still perfectly capable and comfortable in a full squatting position. When was the last time you saw a 75 year old man in a full squat? (A full squat will vary from person to person, but typically your hips are well below your knees and your thighs are past a parallel position.)

Here are 7 reasons why we should continue squatting as a lifelong pursuit:

1. Maintain Lower Extremity Strength: The squat activates nearly all of the muscles in the lower leg. It is particularly effective at activating the muscles in the legs referred to as the posterior chain, which includes the hamstrings, the glutes (or buttock muscles), and the hip adductors (or the groin muscles). It also activates the calves, the stabilizing muscles in the ankles, the quadriceps, as well as the core (the abdominals and lumbar extensor muscles). In short, the squat works just about every muscle in the trunk down toward the legs. These muscles are critical for all functional mobility related movements, including walking; getting up from a chair or a toilet; or picking up someone or something.

2. Maintain Lower Extremity Range of Motion (ROM): Moving into a full squat position takes quite a bit of flexibility. Most children have no problem squatting. As we age, we tend to become less flexible which is primarily due to non-use. Physiologically, muscles, tendons, and ligaments lose some elasticity and can become stiff. The squat requires good hip mobility, knee mobility, lumbar and pelvic mobility as well as ankle mobility. It requires adequate muscle length and joint range of motion in all of the major joints of the lower leg and all of the major muscles of the lower limb.

3. Maintain Bone Density: Squatting activates the major muscles of the lower limb and trunk. The pull of the muscle against the bone stimulates the bone to grow and improve its density. Squatting is also a weight-bearing exercise meaning it is against gravity. If you add any type of resistance, then that load to the bone once again stimulates bone growth. Squatting is a fundamental movement to prevent osteoporosis.

4. Maintain Balance: Squatting activates the lower leg muscles. Adequate lower leg and trunk strength is a critical component to balance. It also activates the somatosensory system. This is the integration of the neurological system (including the brain and nerves throughout the body) with the musculoskeletal system. This includes all the touch and movement nerve receptors in the muscles, tendons, and joints. (Please refer to How Do I Improve Balance? (Part I) and How Do I Improve Balance? Part II.)

5. Aids in Digestion: Many people in “civilized nations” might not know this little known fact, but incidences of constipation have increased since the advent of the toilet. This is because people are no longer squatting in the woods, over a hole, or some form of plumbing. The body’s colon has three major parts: the ascending, transvers, and descending colon. When you are in a full squat, the thighs put pressure on the ascending and descending colon, which stimulates the smooth muscles to move (this is known as peristalsis). When in the full squat position, the rectum (which is a short, muscular tube which forms the lowest portion of the large intestine and connects it to the anus) is allowed to straighten and unkink. Feces collects in the rectum until pressure on the rectal walls causes nerve impulses to pass to the brain. The brain sends messages to the voluntary muscles in the anus to relax, which permits expulsion. If you are experiencing constipation, take a walk and then spend time relaxing in a full squat position.

6. Prevents Osteoarthritis: There are many potential causes, like trauma or infection, for osteoarthritis. Trauma can be from a one-time accident or due to accumulated trauma or over-use syndrome. Just as common as over-use causing osteoarthritis is under-use. A joint cannot remain healthy if it does not move through its full available range of motion (ROM) on a regular basis. If you never move into a full squat, then you likely never take your knees or hips through their full ROM. According to osteoarthritis statistics, countries in which people still rest and spend extended time in a full squat have the lowest incidences of osteoarthritis. Squatting does not cause arthritis; it actually protects the body from it.

7. Fundamental to All Mobility: Maintaining your ability to squat, and (more importantly), come up from a squat is vital. Your ability to do so is critical to your ability to function independently. In my experience of working with seniors, there are two main reasons why a person will need additional care and support: 1. The person can no longer safely get from point A to point B (this usually involves walking). 2. The person is no longer able to stand up from a sitting position. This means he/she cannot get up and down from a chair, a toilet, or even the bed. If you cannot perform these activities safely and independently, then you will need additional care. Typically, it is a major sign of failing health when an aged and infirmed person loses the ability to care for him or her due to weakness and other factors. (This statement is not directed at someone who has suffered a spinal cord injury or has some form of paralysis which affects his/her ability to utilize lower extremities.) The squat is a critical exercise to maintain mobility and function as we age.

Squatting is one of the first abilities we develop as a child, and it needs to be one of the last ones we lose as we age. Your ability to perform a squat is fundamental to how you are able to function throughout your life. Keep squatting!

If you have a question that you would like featured in an upcoming blog post, please email contact@thephysicaltherapyadvisor.com.

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Posted on Tuesday, May 13, 2014

5 Ways to Improve Range-Of-Motion (ROM)

Most of us think stretching is stretching is stretching. Who likes it? Why do we need it? Yes, some days I’m personally still in that camp! Stretching is actually more nuanced than that. The real question is: why are you stretching in the first place?

There are potentially different reasons to stretch. One reason is to decrease pain. Stretching an ailing muscle or muscle spasm can activate internal stretch receptors in the muscle tendon unit, which helps the muscle to relax. It can also change the blood flow to the area or affect the input on the nerve–all resulting in some pain relief.

We instinctually want to stretch. Consider yawning. Our outward arm motions during a yawn are nothing more than primitive stretch reflexes. Babies begin stretching in utero! We continue to voluntarily stretch for the rest of our lives (or in the case of a yawn, involuntary). Animals (dogs, cats, horses, and even birds) also stretch daily.

Stretching releases positive endorphins and neurotransmitters in the brain which helps us to feel better. Depending on the location of the stretch and the intensity, it can cause relaxation or alertness.

Stretching is used to improve range-of-motion (ROM) of a joint, but why? The most common reason is that the joint ROM is limited and is somehow affecting performance of a desired activity.

Stretching is also used as a preventative measure. For example, if ROM is limited asymmetrically (unequally) in the hamstrings, then it could lead to a pelvic torsion and low back pain. Another example is a shoulder which has limited ROM, yet a person continues to reach up overhead or perform an overhead weight lifting technique. If the individual doesn’t have adequate ROM to perform the lift, then either he or she will perform the lift incorrectly (risking injury). The body will be forced to compensate somewhere for the lack of shoulder mobility (again, likely leading to injury).

As a physical therapist, I work weekly with people who have injuries from compensating for lack of ROM and mobility in the body. This problem is prevalent due to current American culture. We spend most of our day either sitting (driving, working on the computer, watching TV) or hunched over while sitting or standing (washing dishes, picking up children, general slouching). As a society on average, we don’t move or stretch enough to live healthfully. A joint must go through its full ROM on a daily basis to remain healthy. Without the full ROM, a nutrient rich and internally lubricating fluid known as synovial fluid cannot properly circulate and coat the joint surface. Over time, this will lead to stiffness, dysfunction, and joint deterioration such as arthritis.

One potential issue to address is that all stretching methods aren’t created equal and certainly aren’t appropriate in every circumstance. The research indicates that stretching, when done improperly or at the wrong time, can either help or inhibit performance.

Let’s review five different methods of stretching or improving ROM:

Static Stretching – Static stretching is basically holding a tissue in an elongated form. This can be performed across one joint or multiple joints, depending on the muscle or tissue being stretched. The minimum length of time should be 30 seconds to around 60 seconds at a mild to moderate discomfort. If you want to maximize results, then the stretch should be held for a longer duration of at least five minutes. Typically, this is not practical for most people. Static stretching before your athletic performance causes loss of performance. If the goal is to gain ROM, then static stretching should be performed, but only after the activity or at a separate time.

Dynamic Stretching – This is a more active type of stretching where you are moving in and out of your available range of motion. This can be progressed into ballistic stretching, which is taking a joint actively and usually quickly, through its available ROM and into a near end range stretch without exceeding the physiologic maximum ROM for the joint or muscle/tendon tissue. As a warm up, dynamic and ballistic stretching can improve performance and joint ROM. If the goal is to prepare for an activity, then a dynamic warm up should be performed. Ballistic stretching is not indicated for novice athletes or beginning stretching. It is definitely not indicated when recovering from injury.

Myofascial Release with Foam Rolling – Research is limited presently, but it indicates that foam rolling can help improve joint ROM without the deleterious effects of static stretching. It can be performed prior to athletic performance and not provide a negative effect. Clinically and personally, I find foam rolling to be an effective method in improving ROM. Foam rolling should be a frequent post-workout activity, and at times, it would be indicated as a pre-workout activity. It is also a fantastic way to release stress and tension, and it may improve recovery times. (Please refer to a recent post, Does Foam Rolling Help or Hurt Your Performance?)

Proprioceptive Neuromuscular Facilitation (PNF) – PNF stretching is a very quick and effective method of utilizing the body’s neurologic stretch receptors within the muscle and tendon units to assist in producing increased ROM. There are many different types of PNF stretches and exercises. The most basic and easiest to utilize individually is a technique known as Hold/Relax. Move the extremity and joint to a point of feeling a mild stretch, and then lightly resist any further stretch for approximately 10 seconds. After 10 seconds, progress further into the stretch and hold for approximately 30 seconds. I tend to work in sets of three to four when performing this technique. It is also important to remember that it should never result in pain, only a stretching sensation.

Neuromobilization or Neural Gliding – This is probably the least understood of all methods to improve ROM. There are many factors to consider regarding neural mobility. First, the nerves are covered in a protective sheath which is meant to be very flexible. Unfortunately, when the sheath is irritated or damaged, it tends to lose its flexibility. This typically leads to neural pain. Sciatic nerve pain from a bulging disc is an example of when this may occur. Trying to directly stretch a nerve is a bad idea as it usually makes it worse. Specific neural gliding and mobilization techniques have been developed to assist with improving ROM and pain. As a physical therapist, I use clinical signs to help guide my treatment diagnosis, which ultimately can help guide the treatment for the client. If you are experiencing neural tightness and pain, please seek medical advice to insure you are getting proper care. There are times when neural tension can be present without pain or other symptoms. It may be caused by poor spinal alignment, poor posture, or other medical illnesses.

The science of stretching is as diverse as the reasons why you may want or need to stretch. Stretching is critical to maintaining flexibility. Flexibility is a critical component to a healthy and optimally functioning body. Although flexibility and stretching are often overlooked, they are truly critical to optimize health, prevent injury, and maximize performance. Stretching should never be done to the point of causing pain. It is possible to cause injury by over aggressively stretching. The best results are usually through consistency and a mild to moderate stretching sensation.

Please email contact@thephysicaltherapyadvisor.com if you have a question that you would like featured in an upcoming blog post.

Posted on Tuesday, April 29, 2014

Does Foam Rolling Help or Hurt Your Performance?

Let’s set the stage. Imagine that you have been training hard for weeks. Your muscles are sore, and your body is achy. You are definitely pushing into your overreaching phase and fast approaching over-training. Then your overly helpful friend and neighbor mentions, “Hey, I just got this foam roller—it’s great! My buddy says it helps him run faster, jump higher, and he never hurts. You need one!”

Is foam rolling another gimmick or does it really help? All of the local gyms and sporting goods stores have them. Should you use one?

Surprisingly, the actual research on foam roller use to improve performance has been minimal. The foam roller is traditionally used as a method of self-massage or self myofascial release. By using the foam roller, it is thought that the fascial system can be changed and manipulated. Hopefully, improving either performance or recovery by affecting how the neuromusculoskeletal system functions.

The standard definition of fascia is soft and sometimes fibrous connective tissue system that penetrates and surrounds muscles, bones, organs, nerves, blood vessels and other structures and extends from head to toe, from front to back, and from surface to deep in an uninterrupted, three-dimensional web binding some tissues together while allowing others to slide smoothly over each other, though all layers are connected there are distinct layers with differing function (LeMoon, 2008, and http://en.wikipedia.org/wiki/Fascia).

Research indicates the following regarding the use of the foam roll for performance:

Foam rolling likely has a positive effect on arterial stiffness and can improve arterial and vascular function while also positively affecting joint range-of-motion (ROM).
The change in arterial and vascular function may in part be why foam rolling (after training) seems to have a positive effect in reducing muscle soreness.
Foam rolling may promote more blood flow to the area, which allows the body to eliminate waste more efficiently while providing much needed nutrients to aid in recovery.
Improved recovery is important if you plan to participate in multiple events over multiple days such as a relay or weekend tournament.
Improved recovery may also allow for more intense and frequent training while (hopefully) reducing injury.
It may aid training during certain cycles when the intensity or volume may be higher or during an overreaching phase of training. Overreaching is typically a very short and deliberate phase in your training when you have a spike in training volume for a week or two followed by a return to baseline or below which can lead to improvements in performance. Care must be taken though because overreaching can easily turn into over-training.
Foam rolling also appears to have a beneficial effect on ROM, and more importantly, it can help improve ROM without negatively affecting performance. In contrast, static stretching can impede performance.

As a physical therapist, I highly recommend using the foam roller for athletic performance because:

It appears to help improve joint ROM and doesn’t impede performance.
It can likely help with recovery, either by reducing soreness or reducing post work out tightness. By promoting improved blood flow, it allows for improved nutrient delivery which can improve recovery times.
Improving recovery may allow for more intense or frequent training sessions or prepare you for multiple events with little rest.
Alleviating soreness prior to activity can have a psychological boost, which shouldn’t be overlooked as an important outcome.

How should I use the foam roller?

I typically recommend one to three minutes of body weight rolling (if it is tolerated) per extremity, and the same for the thoracic, low back, and buttock area.
A good rule of thumb is to roll out an area that is tender and sore, or recently worked, until it no longer feels tight and sore.
Again approximately one to three minutes per area although this may vary based on your size. Increased time will be needed the more developed your muscles are.
Foam rolling is generally not advised for anyone on blood thinning medications or with blood clotting disorders.

What has been your experience with using the foam roller? Is it worth the effort? Can you notice any specific improvements in performance? Please share your comments or questions!

Posted on Wednesday, April 23, 2014

5 Lessons Learned from Running Robie Creek

Robie Creek is billed as the toughest half marathon in the northwest, 8.5 miles and up 4.6 miles down. This year the weather was beautiful, but hot! Temperatures approached 80 degrees. This was my first time running this particular race and utilizing a high intensity interval training (HIIT) and low running mileage to train for a distance effect. Racing Robie Creek taught me this:

High intensity interval training (HIIT) combined with low running mileage can be a successful way to training for a very intense half marathon. (See my TrainingPlan PDF.)
CrossFit as a form of high intensity training (HIT) is a good way to train your legs to handle a very fast and steep decent. When running downhill, your leg muscles work more in an eccentric or lengthening fashion versus the typical concentric or shorting fashion. This results in more tissue micro tearing and muscle soreness when running downhill and injuries more frequently. CrossFit training prepared my legs to handle the strenuous downhill section.
Warm temperatures are great for fans and tough on participants. With an April event, most of my training was in cool weather, but the race was in much warmer weather. This was hard on me and other participants as there were many runners who were taken off the course with heat exhaustion. Of all the race factors, the temperature was the most problematic for me. I would highly advise at least a two week acclimatization period if you’re going from cool to warm weather. Next year, I will spend at least two weeks with daily sauna exposure prior to running. I will likely over dress during outdoor sunny training days to get my body used to higher temperatures.
Train for the mid pack. In larger races or in races where there is not time corrals to help insure similar running paces, I would recommend training for this variable. Constantly changing your running pace faster or slower is more tiring than just running your preferred pace. This was the case for almost the entire race (and particularly the first five miles). One easy and effective running style to train for this variable is called the Fartlek. Fartlek is Swedish for “speed play”. It involves taking your normal forty to sixty minute run (after warm up) and intermittently changing pace from jogging (at different speeds) to sprinting. This can be performed in a structured form or randomly in true Fartlek style. One method is to pick objects in front of you and vary your running speed as you approach them. This is a critical training method if you want to improve your race time, and I should have incorporated Fartlek in my training to help prepare for Robie Creek.
You need to know how you feel in what you wear BEFORE the race. You don’t want to have chaffing on your thighs for many miles even if you look good wearing new clothes. Try out everything you plan on wearing and have a backup plan for any potential problems. (Lansinoh works great as a soothing salve for all those chaffed areas.)

Robie Creek is a nicely organized and challenging run. The scenery is beautiful, and course terrain makes it a unique race. I would highly recommend this race for anyone looking for a new challenge in the half marathon distance.

Robie Creek was a great race and a fantastic teacher. I will be sure to incorporate more of these lessons learned when training for future races. I also plan on experimenting more with high intensity training as a means to prepare for other events.

I would love to hear about the lessons and experiences you have learned either at Robie Creek or other races!