Do YOU have Chronically Tight Muscles?

If I had a dollar for every time someone said to me “I’ve just got really tight muscles” I’d be pretty rich by now. Many people also believe, wrongly (no offense, but it’s true), that tight muscles are either 1) something that is genetic or, rather, just how their body is, 2) tight muscles don’t contribute to their injury risk and/or 3) they will always be tight – as in they can’t do anything to decrease the tightness.

So in order to understand why the above thinking is wrong, we need to understand some neurophysiology and anatomy. The first truth that I am going to lay out is SUPER important and something that you’ll see in many of my posts. That is, the brain controls EVERYTHING. And by everything, I mean EVERYTHING. But for the sake of this post, every muscle contraction/activation or lack of contraction/activation is controlled by the brain – can we all agree on that? Good.

Since the brain controls everything, then at the basis, if we can get the brain to turn off the tight muscles, theoretically those muscles should not be tight anymore – right? So the question isn’t “why are my muscles so tight” but rather “why is my brain keeping my muscle(s) tight?”  And if we can figure out that answer, we’ll be golden.

The brain is a creature of habit and likes to take the path of least resistance (i.e. the easy way out). If it can get out of recruiting the biceps at 100% during a biceps curl, it will. It may recruit the deltoids and pecs (to stabilize) at an increased rate of 20% and decrease full on biceps recruitment to, say, 80%. This example may result in a bicep curl that looks more like the whole arm is moving a bit more, than a straight up bicep curl; instead of seeing just the elbow bend, it may look like the person is leaning back, their shoulder may move forward a bit etc… Don’t get bogged down by the numbers I just listed – I made those up, but the concept is still accurate. So, depending on your age, your brain will have created hundreds of thousands/millions of movement patterns (i.e. muscle memory) and stored them in a bank where it will draw upon them when necessary.

Now, oftentimes, the brain usually will keep a muscle – or muscles – tight for one of the following reasons (yes, there are other reasons the brain might do this, but these are the most common):

  1. To keep in the body in a protective state. So the follow-up question to this is “why does my body want to protect ‘x’?” It could be that the tight muscle is turned on due to inhibition or weakness in another part of the body. So rather than fix the problem (which would take actual work!), the brain does what’s easiest, keep a muscle tight. Example: Many times (certainly not the only times), tight hamstring(s) can be holding on to the pelvis for dear life because the core muscles are inhibited. So the solution wouldn’t be to stretch the hamstrings till the cows come home (bc, hopefully you’ve guessed it by now, the hamstrings will come back tighter the next day or a few hours later), but rather to figure out why the core is not efficient (I utilize NKT to figure out what muscles are facilitated/inhibited)
  2. Another reason the brain keeps a muscle turned on is because of over utilization. If you go to the gym and only work your chest, well guess what? The muscles utilized in all of those exercises (pec major/minor, some anterior delt, some biceps, some neck muscles etc…) will be overworked (and even more depending on if you had any compensations to begin with). With each repetition, your body is RECORDING that movement and the muscle activation patterns required – and saving them to your hard drive. Overtime, these muscles that are over utilized become …. well…. tight. And if something is tight or overworked, it can be facilitated or inhibited – NKT helps me in my assessment process. So the lesson here is, make sure you work ALL muscle groups, the back and the front!

One thing I want to clarify – compensations aren’t all BAD! This is something I’ll elaborate in a future post. But know that our bodies compensate all the time, it’s called adapting to life! It’s when a compensation has served it’s purpose, but still sticks around and is no longer aiding your body in anything in particular, that it becomes a “problem”. This is a loaded topic that can’t be expanded upon in this particular post, but I promise, I’ll get to it in the future. Just know, I may be addressing compensations in a negative light right now, but that they aren’t all bad!

All in all, we have to re-frame our mindset and the questions we ask. Instead of “Why are my muscles tight?”, ask yourself “Why is my brain keeping my muscles tight?”. This allows you to trace the problem back to the source. While I don’t know the specifics of your problem, hopefully with these pointers, you’ve realized that tight muscles 1) don’t resolve on their on 2) don’t resolve with constant stretching alone, and 3) you should see a clinician (I would love to help you!) if your problem doesn’t resolve.

 

5 Things You Should Do If You Have A Desk Job

If you have a desk job, you know that it can be a pain … literally. Sitting all day can make you feel stiff/tight/sore etc… all over! Therefore, sitting must be BAD, right? WRONG! Any posture sustained for a prolonged period of time will create stiffness/tightness/soreness etc… That’s why when those with desk jobs switch to a standing desk, their problems still don’t go away! That’s because standing for 8-10 hours a day can be just as problematic! **MIND BLOWN**

But, there are things you can do – AT YOUR DESK – that can help ease the pain and stiffness.

1. Neck Range of Motion

This means that you should be moving your neck through it’s full Range of Motion … OFTEN. Look up towards the ceiling (extension), look down towards your chest (flexion), look to your left/right (rotation), and combine these motions (i.e. draw some circles with your head/neck). Do this often, and you won’t get stiffness in your neck at the end of the day! This is because the articular cartilage (cartilage on the joint surfaces of your spinal segments) will be getting the nutrients it needs from the synovial fluid around it to stay happy!

neck spine.jpg
Cervical spine side view (neck)

The above video is just one example of how to do some gentle neck range of motion (ROM) exercises in a seated position.

2. Levator/Upper trap stretch

Your upper traps tend to get tight after sitting at a computer/desk for a long time. This muscle is what people commonly point to as “top of their shoulder”. It actually starts up at the base of your skull, runs down one side of the spine and across the region between your shoulder and neck. Your levator scap muscle starts on the top corner of your shoulder blade and runs up towards your skull and attaches on the cervical spine (neck). These two muscles will get tight and start to elevate your shoulders up towards your ears. They can also be common causes of neck and/or shoulder pain.

To stretch your upper trap, sit on the hand of the side that you want to stretch (this will keep your shoulder from rising up). Keep your gaze forward. Take your other hand and put it on the side of your head that you’re looking to stretch, and gently pull away.

upper trap stretch

To stretch your levator scap, your starting position will be similar – sit on the hand of the side that you are looking to stretch. Now look away from that side and down towards the opposite arm pit. With your opposite hand, place it on the top/back part of your skull. The motion will be one of pulling the skull down AND away from the body. Commonly individuals will say they feel this stretch go down their neck and into their shoulder blade when performed correctly.

levator stretch

3. T-spine Range of Motion

Your T spine (thoracic spine) is the section of your spine that is known as your mid/upper back (just above your low back). It is connected to your neck (duh, your entire spine is connected!), and many times this area can feel tight after sitting or standing for a long period of time – mainly due to the misconception that there is such thing as “good posture”. Short answer – there is no such thing. Long answer – topic for another post. But “good posture” (I hate calling it that, but everyone immediately knows what I’m talking about when I say that) puts your T spine in mainly an extended position (upright/straight). Below you’ll see ways to incorporate increased flexion (bending/rounding of the spine) while at your desk. Using your desk to support you, round through your shoulders, bring your chin to your chest, and round out your back while sitting (or standing!). Then arch through your back and look up towards the ceiling (increasing extension)

seated cat cow

4. Get up … Often

This seems like a no brainer, but I am willing to bet that you don’t do this often. If you’re sitting for a long period of time, not only will your spine become “compressed” and stiff, your hips will feel tight in that flexed position. I recommend that you at least stand up and stretch every 30min for 15sec, but if possible, stand up and walk around for a few min ever 30-45min. However even just standing up and stretching can decrease the tension on your hips. This is also a fairly non disruptive movement in the office work environment but SO SO SO helpful to keeping your body happy and improving your employees’ longevity in the work place.

5. Breathe

Another super simple tip. When I say breathe, I don’t mean … breathe. That sounds confusing. I mean that you should, every hour, take some MINDFUL, deep breaths. Sometimes it helps to close your eyes to take away all visual distractions (similar to meditating) and take 3 FULL breaths at a slow pace. Whether you’re standing or sitting, you may notice that after a while at your desk, your shoulders will have crept up to your ears creating some of that neck tightness we talked about earlier. Aside from stretching your upper traps and levator scap, mindful deep breaths can help you become more aware of the tension in your shoulders and focus your attention on relaxing them. Doing this every hour (at some point) can help decrease overall tension and stiffness that would, otherwise, build up by the end of the day.

Give these a try tomorrow at work and hope you feel great!

Return to Sport

Hot topic of the day – Kevin Durant’s lower leg injury (suspected R achilles tendon rupture) from last night’s Game 5 of the NBA finals.

Here are some things to know prior to passing judgement and assessment of his injury:

  1. Mechanism of Injury: Usually results from sudden forceful increased stress on the Achilles tendon – in Kevin Durant’s case, he was planting with his R leg as well as making a move to his L, forcing increased dorsiflexion into his ankle (relative forced stretch of the achilles).
  2. He had not played in the 9 games prior to this game due to a R calf strain.

So this begs the question(s): Are his two injures (calf strain and now achilles rupture) related? And, did he return too soon? We’ll take a look at both of these questions.

First – Are his two injuries related. Absolutely. Everything in the body is connected and if you think that anything in the body functions independently of any other part in the body then … you’re wrong. This is an absolute truth and there’s no room for argument. Now, how are his two injuries related? There are a couple of parts we need to examine. It’s easy to see that he had strained his R calf and now he has a ruptured R achilles tendon. Your calf muscle (gastrocnemius and soleus) tendons turn into the achilles tendon and insert onto the back of your calcaneus (heel bone):

Gastrocnemius-Muscle

With the way I practice – utilizing NeuroKinetic Therapy (NKT) – his R calf (gastrocnemius or soleus, medial or lateral) would have been found to be either inhibited or facilitated. It’s important, then, to figure out the other half of that equation – if it’s inhibited, what’s facilitated and inhibiting the muscle? If it’s facilitated, what is it inhibited? This is VERY important to figure out because after an injury (ANY injury), the body will go into a protective state and start to compensate. Compensations are not bad inherently – in fact our bodies constantly will compensate when we start off learning a new movement pattern or if it’s a short term pattern. However, once the compensation has done its job, are our bodies able to let go of that pattern? If not, that’s when – given enough time – the compensation pattern can become a problem.

If his R calf was either facilitated or inhibited – it has become inefficient. Now, with inefficiency the muscle can be either tight or not and either one can lead to this injury we now see that he’s suffered because inefficiency just means that the muscle can’t do it’s job at 100%. I recently read a quote from Perry Nickleston, DC who wrote “we mistake being able to function for healthy”. Kevin Durant may not have had any more pain (or he may still have had discomfort, it is the NBA finals and athletes can be stubborn), or he may have been able to walk/run with no limp, or he may have passed all of his return to sport tests – but our bodies are amazing at compensating and hiding dysfunctions. Professional athletes are EVEN better at it. But just because he was able to pass these tests or run with no visual impairments doesn’t mean he was 100% healthy.

This leads to the second question: Did he return to sport too soon? In my opinion yes. He only practiced once at full speed prior to last night’s game. However, there’s much more to it. Having worked with professional athletes and teams in the past (Boston Blades, professional women’s hockey 2016-2017), something that many in the rehab world fail to understand (unless you’ve worked with athletes of this caliber before) is the athlete’s mentality. With regards to rehabbing an athlete (amateur or professional) I always followed the mantra of “Maintenance during the season, rehab in the off season”. This means that during the season, there’s not much you can do (or should do – a post for another time, but in short there’s always a learning curve with movement patterns and that takes TIME, which athletes in season don’t always have) but to keep them healthy enough to play with any means necessary (usually this means symptom treatment, taping etc…). But the key here is what part of the season are we in? If this were the regular season, I’m sure Kevin Durant would have sat out until he was completely healthy since Golden State was going to the make the playoffs anyway, and there’s more TIME. Post season, it’s do-or-die for the athlete. If this was a first round, though, Golden State may feel confident enough to not play him and still win. However, this is the NBA FINALS. There’s a lot on the line. Him and his team have worked hard all season to get to this point. I’m sure Kevin Durant was willing to do anything if it meant winning last night to keep their season alive (they were down 3-1 in the best of 7 series going into that game).

Kevin Durant left it all out on the court last night – ending his season to help keep his team’s season alive. He did it because he didn’t want to let his team down. Did he know he wasn’t 100% – absolutely. But to him, he wanted to end his contract with GSW on a high note, even though now he is injured and free agency is only days away. That is the mentality of an athlete – to do WHATEVER it takes for your brothers, your team. Not everyone will understand that unless you’ve participated in team sports at a high enough level.

So do I think he returned too early? Yes. Do I understand why he came back early? Yes. And the latter is more important in this case than the logical/obvious answer. Because to him, this was worth it at the time. So before we start to judge Kevin’s decision, or his medical staffs’ abilities, understand that this is the athlete’s mentality in season.

I welcome any comments you may have on this topic.

 

What We Say Matters

In the physical therapy world, we do a lot of listening (or we should … if you don’t, then you should start – there will be a post in the future about listening), but we also do plenty of talking – mostly educating our clients. However, not all words are created equal. We, as professionals, have to be very careful with our word selection because that can directly influence our outcomes with the client.

Words and language are a form of external, auditory stimulus. All stimuli (external, physical, etc…) are processed in the brain and then a response is sent out. If the stimulus is a touch of another person’s hand, the output response is that it is human touch. If the stimulus is a paper cut, the output response is pain. The same works for auditory stimuli – the brain has to decide how to respond to certain words and phrases. The output is usually emotion – how we feel towards hearing these words; do we feel happy/sad/neutral?

pain words

Think about this scenario: if you were a client (no healthcare background, unfamiliar with medical conditions or rehab guidelines in general like much of the populations we serve) and you found out you had a rotator cuff tear. You get an MRI and the MD tells you that you tore your RTC, you may need surgery, you may not be able to lift your arm without pain, they may ask “how much pain are you in?” etc… The same can be said of chronic pain clients. When these words are processed by the client, the brain’s output of emotion is negative and can heighten the pt’s perception of pain. There is an article published by Thomsen, R. et al in 2011 “Impact of emotion on consciousness” where they found that “participants were more confident and accurate when consciously seeing happy versus sad/neutral faces and words” with “evidence of interaction between emotion and conscious experience”.

If the client is predisposed towards having negative emotions with regards to their injury, we have to do better as PTs to change their overall outlook. We interact with the client on a more consistent and frequent basis than the MD does, so what we say matters more – if we are consistently conscious of our language use around the client, it can re-shape how they perceive pain. However, if we are consistently asking the client “how bad is your pain today?” or “do you have pain with overhead lifting?” or “don’t run/don’t lift heavy objects” – we are feeding into the client’s negative emotions towards their injury. Instead, ask these questions with different phrasing such as: “how’re you feeling today?”, “Are you able to perform any overhead lifting?”, “Modifying your run schedule or working on pacing during your run can decrease your discomfort”.

pain

By turning some of these questions into “open-ended” ones, the client is forced to become more aware and mindful of their current status – over time, the client may start responding in a more positive manner. They may say “I still get a little pinching with overhead lifting” to which you can respond “that’s a positive improvement, when you started overhead lifting was a very difficult movement for you!” Positive language can help your client become more mindful of their current status. Luiggi-Hernandez et al published a paper in 2017 on mindfulness for chronic low back pain where they found that mindfulness helped participants decrease negative emotions towards chronic low back pain, decrease fear of pain, reduced significance of pain etc…

During a client’s first evaluation (especially chronic pain clients), I set the expectations very clearly – I know that pain will persist for a while, however, I don’t want the client to search for improvements on a day-to-day basis. Even if they still have the same level of “pain” or “discomfort” what I want them to look for, weekly/bi weekly, is if they can perform more functional tasks – tasks that they weren’t able to do prior to starting PT. This, in itself, is improvement. This sets the tone for all of my future sessions because the client won’t focus on the pain – they know it’ll still be there. Once they begin to follow through with my plan of care, they will – all of a sudden, usually – realize they have less pain with movements and it becomes an “A-HA!” moment for them.

Now, I don’t want people to read this post and think they can talk someone out of pain. The idea is to be aware of our choice of words and use guided mindfulness to decrease the client’s sensitivity and allow you, the PT, to treat their impairments and dysfunction. You still have to address their deficits and strengthen weak areas, cue proper movement patterns etc… but having the right word choice can open up new opportunities for gains.

5 Principles To Better Treatment

We interrupt our regularly scheduled topic series (I promise Part 3: Interventions for tight hamstrings will be posted soon!) to bring you this article on principles for better treatment. This post is geared towards both new grads and veteran PTs alike, as I feel that even those of us who have been treating for a while could benefit from a refresher. Certainly this is not an end all be all guideline, but I felt that these 5 principles are a good foundation for improving your treatment outcomes with clients.

This post came about after much thought and reflection on what I felt made me successful with certain clients and what I could have done better with other clients. Enjoy!

1. Maximizing Your 1-on-1 Time

This is important, and all physical therapists know it, but it isn’t always executed well. With the pressure of increased productivity and decreased time spent with clients (i.e. traditional outpatient ortho clinics), it’s hard to perform a truly comprehensive on-going assessment/evaluation throughout your plan of care. And as a result, many times diagnoses are missed or you start on the wrong treatment path and have to back track.

Many clinics attempt to advertise that they find the “cause”/”source” of their client’s problem, however what I’ve seen in many clinics is that the therapist does not actually have time to find the source of the pain, and the client returns not too long after discharge and becomes a “frequent flyer”. So how are you supposed to find the source if you only end up with 20min of 1-on-1 time with the client?

When I worked in an insurance based model, I always tried to maximize my 1-on-1 time with clients. I had a check list of things I needed to check and each session I may only be able to check 1 thing, but I made sure to do it so that I would not have to back track. Here’s my list of items I need to check always when treating a client

  • Check above and below the site of pain: Often times, unless there’s direct trauma to the area, the site of pain is not necessarily the source of pain. Don’t settle for only 1 joint above and below – make sure to treat holistically! Each session, test/check an area that could be influenced/influencing your client’s complaint. A good way to do this is to take a CEU on assessment; there are many out there, and I don’t believe that there is one that is better than all others, but the important thing is to use the assessment to it’s fullest potential. I use the SFMA and PRI for my assessments, but there are many out there such as Mckenzie, DNS, NKT etc…
  • Don’t make it all biomechanical: what I mean by this is that as physical thearpists (read: movement experts) we HAVE to address the nervous system because the nervous system is what creates the movement patterns we see and treat. While we have to address the biomechanical side of issues, don’t get hung up on the roll/glide of specific joints, focus on the overall quality of movement and functional strength/patterns. Most/majority of injuries aren’t purely biomechanical in nature.
  • “Every back has a front”: These wise words were spoken by my program’s director Dr. Kapasi, PT, Ph.D back on my first day of PT school in Anatomy. Remember, we are dealing with HUMANS, therefore not everything is about the bones and muscles. Sometimes back pain can be caused by inflamed kidneys, and it is important to know when to refer out. Utilize your differential diagnosis skills – the jump from a Master’s to a Doctorate was partly based on improving/increasing the differential diagnosis skills of clinicians. Don’t perseverate on a pure biomechanical model.
  • Test/Re-test: Lastly, you need to know you’re on the right track, so make sure to test/re-test OFTEN! Not just on 30-day re-evals. Every session, you should be assessing and checking to see how your client is progressing, even through simple observation – it doesn’t have to be a formal objective test!

differential dx memes.jpg

2. Motivational Interviewing/Listening

Many times as a PT I feel like I’m my client’s counselor more than a PT. However, part of our job is to LISTEN to our clients and their story. Knowing the right questions to ask and actively listening to their answers will lead us to the “why” of their problems. Our clients are very smart, and they will unknowingly give us the missing piece that we’re searching for. Make sure to always ask “how” and “what/when” questions – the “why” is for us to figure out. “How did you hurt yourself”, “When did this all start?”, “What makes it feel better/worse?”, “How are you coping with this, currently?”.

Sometimes we need to ask questions (through conversation, don’t be weird about it!) not directly related to their injury – are they currently dealing with any external stressors in their life?, any previous injuries growing up?, any pertinent past medical history (this is important because often times clients will only report history that is related to muscles/bones when they come to see a physical therapist).

And above all – LISTEN to their answers. A wise man (Dr. Kapasi, again) once said “God gave us 2 ears and 1 mouth for a reason – so we can do twice as much listening as talking”.

counseling meme.png

3. The Power of Positive Language

positive language

What we say to our clients matter! And directly affects their perception of their injury. This is especially important when dealing with chronic pain diagnoses. When I treat, I always try to re-direct my client’s focus from “pain” and what they can’t do towards positive outcomes such as functional improvement and what they are able to do now, even with the same level of pain (still demonstrates positive progress though pain is still present). When clients meet with MDs and they receive a “medical diagnosis”, many will research it on WebMD, and come in to our clinics with anxiety and fear due to what they’ve found on the internet – we need to break their pre-conceived notions!

Above, I mentioned that we need to address and treat the client’s nervous system (think biopsychosocial model). Using positive language/imagery/visualization can decrease our client’s anxiety levels, decrease their fear of movement, and subsequently change their outlook on their condition. Negative thoughts can indirectly increase pain perception, and therefore, the physical manifestation of pain within our client.

 

4. Don’t Over Treat

I think this one pertains more to new grads, though seasoned therapists could benefit from this one as well. When I was a new grad, I felt that every client needed manual therapy, every session. This is not the case. In fact, this leads to over treatment and can aggravate a client’s symptoms. Sometimes clients only need tactile cueing and proper movement coaching to improve. When a client is close to discharge, they should not require 30min of manual therapy – should they really be discharged if you have to “mobilize the distal tib/fib and tibiofemoral joints for an entire session?” (this is not including discharge for insurance reasons…). How do we know if we’re about to over treat? TEST/RE-TEST!

5. Confidence vs. Arrogance

Lastly, know the difference between confidence and arrogance. Clients can tell the difference, don’t be arrogant. You can be confident and assertive without sounding arrogant and pretentious. Again, verbal and body language matter. Make sure to not hold yourself as if you’re “better” than the client, build rapport and earn their trust – don’t be demanding, be empathetic. This can be frustrating when dealing with tough clients who aren’t adherent with your plan of care – where you know they could be progressing if they just followed through with your plan. Maybe you need to try another approach, maybe you need to find out why they aren’t adherent – what are their barriers to compliance? Don’t just assume that the client does not want to participate (you may have some who fall under this category but that should be a small percentage).

As an added bonus – don’t put down other professions to prove your point. It makes us (PTs) as a profession seem petty and desperate. Let your results speak for yourself!

 

 

Do you think you have tight hamstrings? Part 2: Low back and Hip pain

Almost everyone, nowadays, you meet will say “I have tight hamstrings” and when you ask them to bend forward and touch their toes they’ll say “I’ve never been able to do that”. Many of these people will concurrently experience some form of low back pain – it may not be severely debilitating, but if it’s achy or intermittent, it’s still low back pain. In PT school, we were taught to always check directly above and below the affected target zone because it could be coming from elsewhere. Now, in my clinical practice I take it much further than just above and below 1 joint, but the idea is still the same – always find the source, don’t perseverate on the location of the pain!

lbp.jpg

I understand that in school and throughout the orthopedic world there are different classifications of LBP (i.e. extension/flexion based exercises, lateral shift, traction/manipulation etc…) but this post is meant to give a general insight into back pain and how hamstrings being tight might be playing a role.

Now, back to the topic at hand. Since we’re talking about tight hamstrings in this topic series, we’re going to work backwards and discuss how having these supposedly “tight” hamstrings can contribute to common ailments such as low back pain or hip pain (most notable FAI – which you can read about in the most recent topic series here).

Low Back Pain

I am about to explain one scenario in which low back pain exists, there are many findings and ways to develop LBP – this is not an end all be all.

The lumbar spine is connected directly to the sacrum, which is wedged between the two innominate bones on either side. So logically, there would exist a direct relationship between the L spine and the Pelvis. In fact, PTs talk about lumbopelvic rhythm, lumbopelvic stability, lumbopelvic ROM etc… By grouping them together many PTs would consider, and treat, this area as one area, which may cause some to miss the subtle influences that the pelvis may have on the L spine.

In the previous post, we discussed anatomical relationships of the hamstrings, internal/external obliques, and transversus abdominis. Addtional muscles that need to be added to the mix are the psoas, iliacus, adductor magnus, rectus femoris, and TFL.

 

The Psoas and iliacus muscles are often grouped together as the iliopsoas, but they are separate until their insertion. The psoas originate from the from of the vertebral bodies of T12-L5, and the iliacus covers the majority of the medial side of the iliac foss and joins the psoas on the lesser trochanter assisting in hip flexion and medial rotation. The adductor magnus is one that many tend to forget, it has an extension component because it starts on the ischial tuberosity and inserts into the linea aspera as well as the adductor tubercle. The TFL and rectus femoris assist in hip flexion due to their origin on the iliac crest and ASIS respectively.

As humans, many of us spend the majority of our days sitting at a desk leading to tight hip flexors (our nervous system adapts and overtime will allow us to assume this posture efficiently by effectively shortening certain muscles and lengthening others) and poor core engagement (how many people actually engage their core while sitting after 10 hours?). Take a minute and review the anatomy of the core muscles we discussed in the previous post and visualize how an anterior tilt can put these muscles on stretch and at a poor length-tension relationship.

With increased tightness (read: overactive, or increased neural activation of…) developing in your hip flexors pulling your pelvis into an anterior tilt, the glutes stop being as effective (or can also be overworked inefficiently trying to overcome the activation of hip flexors anteriorly) and the erectors posteriorly begin overworking for the lack of hip extension – effectively shortening and resulting in increased lumbar lordosis. This definitely makes sense visually and Smith et al (2016) found that there was increased activation of erector spinae during walking activities in those who were asymptomatic but had a history of LBP. They also found reduced endurance of the deep fibers of multifidus. The posterior wall of your core is not able to sustain a contraction for as long when you start having low back pain – this one piece should cue you into that the overall functional of an individual’s core is altered if htey have a history of LBP or are currently experiencing LBP.

What does this have to do with the hamstrings being tight? Remember that the hamstrings attach to the ischial tuberosity – an anterior tilt will result in the hamstrings on stretch while at rest. It also puts the hamstrings outside of their optimal length-tension (I warned you that this was a very important principle) for contracting and holding the pelvis in a neutral position. As a result, the hip flexors and erector spinae will dominate and result in a non-neutral spine; increasing the compressive forces through the spine, thus low back pain. The hamstrings are not the only muscles affected, the adductor magnus also attaches at the ischial tuberosity, so the extension AND adduction fibers are also affected.

Hip pain

After the previous discussion on low back pain – you may notice that many of the muscles mentioned have an attachment at the hip, and so you can imagine that there would be a direct relationship between low back pain and hip pain.

An anteriorly rotated pelvis (think the tight hamstrings we discussed just above) will disrupt the relationship between the femur and acetabulum. We will now skip to a tangent principle that is just as important as the length tension relationship mentioned in the previous post. It’s called Wolff’s Law. It essentially states that our body is constantly taking up and laying down new bone in accordance with where stress is. It’s our body’s way of adapting to the daily stresses we put our body through. As a result, if one side of a joint is consistently under more stress than the other, that particular side of the joint may become thicker overtime due to this principle. This can lead to potential problems over time however.

fai-image

Picture this: A soccer player with tight hamstrings presents with groin pain. You find that they have an anteriorly rotated pelvis with excessive lordosis. The anteriorly rotated pelvis disrupts the relationship of the acetabulum and femur, and with the repetitive nature of soccer (running and forced/explosive hip flexion while shooting), the superior/anterior portion of the femur will bump into the acetabulum. Overtime, the body will adapt and the irritated part of the femur will become thicker with increased bone lay down. Now the femoral head is no longer spherical and the shear forces between the femoral head and acetabulum begin to wear away the cartilage – the athlete now has a Cam impingement and potentially the development of hip arthritis.

Many may argue that this post is focused on being able to achieve neutral, but life does not occur in a neutral spine or hip. I completely agree with that statement. However, because life is so dynamic, we must be able to achieve neutral before we can become dynamic. Otherwise we are perpetuating the dysfunction through inefficient movement. Life is about being able to move into and out of neutral, thus creating the dynamic nature of movement we see.

The third part of this series will focus on basic movement dills to help your athlete achieve neutral and then progress them into more dynamic exercises.

References:

Smith, J. A. PT, PhD, Kornelia, K. PT, PhD Altered multifidus recruitment during walking in young asymptomatic individuals with a history of low back pain. JOSPT 46(5) 365-374; 2016

Harris-Hayes, M. PT, DPT, MSCI, OCS et al. Persons with chronic hip joint pain exhibit reduced hip muscle strength. JOSPT 44(11) 890-898; 2014

Prather, H. DO et al. Hip and lumbar spine physical examination findings in people presenting with low back pain, with or without lower extremity pain. JOSPT 47(3) 163-172; 2017

Megan Sions, J. DPT, PhD et al. Trunk muscle characteristics of the multifidi, erector spinae, psoas, and quadratus lumborum in older adults with and without chronic low back pain. JOSPT 47(3) 173-179; 2017

Ishizuka, T. et al  Instantaneous changes in respiratory function induced by passive pelvic suspension in the supine position in relation to increased diaphragm excursion. J phys ther sci. Mar;29(3):432-437; 2017

Workman, J. C. et al. Influence of pelvis position on the activation of abdominal and hip flexor muscles. J strength cond res. Sep;22(5):1563-9; 2008.

Teichtal, A. J. et al. Wolff’s Law in action: a mechanism for early knee osteoarthritis. Arthritis Res. Ther. Sept;17(207); 2015

Do you think you have tight hamstrings?, Part 1: Understanding Anatomy

This topic series is meant to be applied holistically to any group of “tight” muscles. In this topic series we will be exploring why a muscle may develop tightness, using the hamstrings as an example.

Has a client told you that they have tight hamstrings before? Are your clients unable to bend forward and touch their toes because of “tight” hamstrings? What if I told you that the hamstrings may not be “tight”, but rather they are overstretched and compensating for dysfunction else where?

In order to understand why the hamstrings get “tight” we need to understand it’s anatomy first.

hamstring

The hamstring is a group of muscles including the biceps femoris (long and short head), semitendinosus, semimembranosus. All aspects of the hamstring originate off of the ischial tuberosity except for the short head of the biceps femoris, which originates from the linea aspera of the femur.  The semitendinosus and semimembranosus run along the medial portion of the posterior leg and attach to the medial portion of the knee. The biceps femoris attach to the lateral aspect of the fibular head.

When other muscles in the hip get tight, they can anteriorly rotated our pelvis and put our hamstrings on stretch at rest. Our muscles can operate and contract throughout an entire range, but work optimally within a certain range. When our muscles are too stretched out they are ineffective and when they are too contracted, they become inefficient. This is called the length-tension relationship.

length tension relationship.jpg

In the above graph, 3 and 4 represent ranges where the muscle is too stretched out – the myosin and actin fibers do not overlap enough to pull effectively – and cannot contract effectively. 1 represents ranges where the muscle is already contracted – too much overlap between the myosin and actin, so it is not able to contract any further – this is often an explanation for muscle cramps; your muscles are already operating in a shortened range and it is unable to further contract, therefore it cramps up during a movement. 2 represents the optimal range for muscle contraction. This concept of “optimal muscle length” is an important one for all movement and can sometimes be forgotten in the clinical world while treating clients.

lateral ant tilt view

This is a lateral view where the L is “anterior” and the R is “posterior”. The image on the Left is normal pelvis positioning (neutral). The image on the Right is a forwardly tipped pelvis (anteriorly rotated). In the image on the Right, the hamstrings already “pre-stretched”. Many people judge whether or not they have tight hamstrings based on whether or not they can bend forward and touch their toes or sit with their legs in front of them and try to touch their toes. If they can’t, they deem themselves as having “tight” hamstrings. But what if your pelvis was rotated forward? Your hamstrings would be “stretched” at the start before your bend forward, and therefore it is unable to stretch much further.

IF you continue to stretch an already lengthened you may be weakening your hamstrings and creating an “over stretched” muscle – that will likely become ineffective at stabilizing your pelvis.

IO pelvisTA pelvisppt

When your pelvis is rotated forward, your “core” and abdominal wall are stretched and not contracting well (think zone 3 and/or 4 in the previous image) and this can affect your overall movement (your core is where every movement begins) and it can affect your diaphragm/breathing (a post for another day!). The above images demonstrate how the core is involved. The top two pictures are of the Internal Obliques and Transverse Abdominis, and both attach to a substantial portion of your rib cage as well as the pelvis on either side. Together with the External Obliques (not pictured) they can help rotate your pelvis posteriorly (backwards). In the bottom image above, the middle figure is a posteriorly rotated pelvis. Knowing the attachments of these muscles, including the hamstrings, if contracted together, you can target the innominate and posteriorly rotated it.

The following posts will discuss exercise interventions – such as activating your muscles properly to control your pelvic range better – as well as how this poor pelvic positioning may influence other ailments you may have including low back pain, hip impingement, or knee pain.

 

Femoroacetabular Impingment (FAI) series, Part 3: Mobility Drills

The first two posts dealt mostly with understanding FAI as a pathology as well as assessing/differentially diagnosing the dysfunction. This post will serve to discuss mobility drills and interventions that can be implemented day one for the athlete with the limitations listed previously. This is not an all-inclusive list, just a few drills I like to give to help increase mobility of the hip. There are many aspects of the athlete that need to be addressed such as glute loading patterns, ankle mobility drills, and lumbopelvic motor control – these will be discussed in future posts separately, apart from diagnoses.

I’d like to also give a shout out to AnyTime Fitness in Quincy for letting me use their space for these photos.

Banded Hip Mobilization – Flexion

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This is a great drill – and there are variations (one that is shown below) – that is great for increasing external proprioceptive input into the neuromuscular system. It can also serve to progressively increase motor recruitment for an athlete having a hard time with active hip flexion. This drill can also be progressed to other positions such as quadruped, tall kneeling, and standing (a la SFMA 4×4 progressions).

To start, have the client lay supine and take a resistance band (thera-band, j band, etc… get creative!) and anchor one end onto something sturdy and the other wrapped around the proximal femur of the affected joint. Have the patient bring the target extremity into 90/90 hip flexion/knee flexion. Make sure the client does not go into increased lumbar extension/lordosis – a verbal cue I give to clients is to make sure their back is flat against the ground; this will help increase deep core activation and put the client into a bit of a posterior pelvic tilt. Once they are able to assume the starting position, have the client bring their knee towards their chest into hip flexion – I also cue them to allow the band to “sink in” and pull down on their femur to increase inferior gliding; ultimately aiding them into hip flexion. Usually I’ll have them perform 10 repetitions and 2 sets at an even, slow pace – retest the client and see if there’s an increase in mobility.

Another reason I like this drill (and other banded mobilizations) is that the client is taught how to perform self-care at home and it allows them to take ownership of their rehab. This will result in increased compliance and improved overall outcomes.

Banded Hip Mobilizations – IR

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This is a nice variation of the above banded hip mobilization. Same position as above, but now rotated 90deg to the R. Now the band is pulling laterally instead of inferiorly, which will aid in hip IR. There are two ways to perform this exercise. 1) Assume 90/90 of hip/knee and have the client internally rotate their leg while also allowing the band to “sink into” their medial femur and pull the proximal aspect laterally (gapping the joint and aiding in overall increased IR). 2) Have the client assume 90/90 and, just like the above drill, have them flex their hip and knee towards their chest and then internally rotate once max hip flexion is achieved. The first way is easier than the second, especially in the presence of progressive FAI.

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Many times you’ll also find upon assessment that the anterior hip is restricted due to over activation of the hip flexors. Have the client assume a half kneeling position (airex pad is for comfort) with the target hip on the pad. Cue the client to keep their hips and shoulders square, drive the front knee over the 2nd and 3rd toes so that they feel a stretch in the anterior portion of the target hip. Now in this position, sometimes I’ll even have the client hold and perform a glute set with a 30sec hold to increase neural inhibition of the hip flexors.

The final image demonstrates another progression of the drill, where the client performs IR at end range hip extension and focuses driving the motion with their hips. I would instruct the client to rotate to their end range, or just before pain onset, hold for 10sec and then return to the starting position. Have the client perform sets of 10, and with each rep ask the client to see if they can push a little further.

The above mobility drills are designed to be implemented on the first day and the client should monitor their overall mobility in a long term fashion – results (as with all rehab) don’t happen overnight. As mentioned above, there are many, many other aspects of their dysfunction that would need to be addressed, but I will be saving those for future posts. For now, these mobility drills should help you get started in improving symptoms of FAI.

Femoroacetabular Impingement (FAI) series, Part 2: Differential Diagnosis and Assessment

In this post, I will be covering some differential diagnosis and key aspects of the assessment when treating athletes with anterior groin pain that may be FAI. As mentioned in the previous post, there are a number of things that can cause “anterior groin pain” including athletic pubalgia (sports hernia) and trigger point referral patterns. So in order to differentiate FAI from these other diagnoses, you have to understand these other pathologies as well. I won’t be going into detail with each of the diagnoses but will provide succinct information as to the etiology of each.

Athletic pubalgia, also known as a sports hernia, is not a true “hernia” by medical definition. It can be a result of multiple injuries but most commonly it involves micro tearing in the rectus abdominis (lower portion, near attachment on public symphysis) and adductors (again, near their attachment on the pubis). Athletic pubalgia has commonly been viewed as sport and position specific, with the three more common sports being football, soccer, and hockey. Clients often will present with groin pain (often chronic), that increases with any exertional activity, and subsides with rest. Males are more commonly affected than females.

Muscle trigger points (MTrPs) can also cause referred pain patterns into the anterior hip. Due to their proximal attachments, the iliopsoas group/adductor longus and magnus can refer pain into the anterior groin. These can be present in an athlete with FAI as well due to their inefficient movement patterns and over compensation with certain muscles. However, it will be important to perform an in-depth assessment and not stop when you find MTrPs so that you don’t miss something more serious like athletic pubalgia or FAI.

iliopsoas-referral-pattern

adductor-longus-referral-pattern

Often times FAI can be traced by to some sort of non-specific groin strain, leading to muscular imbalances later in life, though there can be an acute precipitating episode as well. The athlete may recount “not being as flexible for as long as they can remember”. Though Dr. Byrd found that rarely is the flexibility a true impairment, as the lumbosacral and pelvic motions are increased to compensate for hypomobile hip joints. Most commonly athletes will use the “C sign” to describe the location of their pain when it’s deep.

c-sign
C sign. When asked to locate their pain, the athlete often times will describe it as a wrapping discomfort from lateral to anterior and deep.

I have mixed feelings about objective/special tests and the data that I can gather from them. I still perform them during my assessment because I feel that the more data you can gather on the initial visit, the better tailored your POC will be for that specific client. However, if a client comes in with an irritated hip, almost any test will surely increase their pain. Another thing to keep in mind is that while the client may have unilateral symptoms, the bony morphology may also be present on the asymptomatic side. The biggest deficit that should be spotted upon initial assessment is that the athlete will lack IR on the symptomatic side – however since I mentioned that the structural changes may also be present on the asymptomatic side, there will be cases where you will find no change side to side. You will need to continue to ask leading questions and find out if it reproduces THEIR pain or if the movement is just uncomfortable. Special tests that can be useful in cases of suspected FAI are the hip scour (if there is intra-articular damage already), passive flexion/adduction/IR (FADDIR), log roll test (IR and ER), ASLR*, as well as AROM/PROM and palpation.

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Log roll test. Positive test when ER > IR. No stress is placed on the femoralacetabular joint in the supine position, therefore should not be painful unless intra-articular damage has already occurred (muscle guarding and acuity will dictate pain levels as well).

ASLR has an * next to it because I don’t use it the way others do and it’s not necessarily validated by research (at least I haven’t found any – but who knows, I haven’t been looking too hard for that), just a clinical pearl. The classic ASLR test usually tests for lumbar disc pathology and/or posterior chain tension. Now, as I mentioned earlier, with any hip pathology that’s acute or moderate/highly irritable, movement WILL create pain for the athlete. I’ve found that those who aren’t symptomatic at rest but have some sort of FAI confirmed with other tests later, will have a positive ASLR with pain onset between 30-90 deg (large range based on severity and acuity of symptoms). It’s similar to the shoulders when you get an athlete with shoulder impingement and a painful arc. Now this is just something I’ve noticed in the clinic, so don’t quote me in your next presentation with this information, but give it a try and see what happens on your next assessment.

Some other things you may find upon initial evaluation is that they don’t really want to load the hip that is affected. With FAI, if it is in it’s early stages, the athlete may not have much trouble with weight bearing activities like walking but more explosive activities such as running and jumping may increase irritation. Therefore, the athlete may not have much pain when walking into your clinic. But in later stages the athlete may ambulate with an antalgic gait because they do not want to load the hip and want to get on and off of it quickly – effectively creating a functional leg length discrepancy during gait and can lead to lumbar spine problems if not corrected early on.

In athletes playing high risk sports (i.e. hockey, soccer, football etc…) some leading questions I like to ask include “when does the pain come on” during activity as well as “what movements exacerbate it”. Often times, the pain comes on during the swing phase of running (due to hip flexion ROM) or cutting away from the painful side. For hockey players pain can come on during their push off while skating AND when they bring the leg through. Pain during push off is usually noted when they are skating around a corner in the direction towards their painful side – i.e. L hip pain, when they push off to skate around a corner to their L. This is because they are adducting and IR their inside leg to stay in line while skating and can increase pain/pressure on that hip. Often times I will also ask the athlete to demonstrate the movement that brings on their pain.

hockey IR hip.jpg
Forced Hip IR/Adduction while going around a corner on skates. In this image, if the R side were painful, the player would have pain during push off while going around this corner.

If the patient has had radiographic imaging, you may be able to identify the lesion and type from the X-ray. You may also find other signs on the radiograph like the “cross-over sign”. The cross over sign indicates acetabular retroversion and is present when the anterior/superior border of the acetebulum extends more laterally past the posterior/superior border.

cross over sign
Cross over sign on radiographic imaging. The white line traces the anterior portion of the acetabulum and the black line traces the posterior aspect of the acetabulum. As you can see, the anterior/superior border extends laterally past the posterior superior aspect.

However – with all of these tests, no single test will tell you that the athlete has FAI, you will need to utilize a combination of tests, ROM, palpation, and most importantly history. If you ask the right questions, the athlete will, with out knowing, point you in the right direction. Palpation can often times help localize tender areas, but as mentioned before, your athlete may have a combination of impairments contributing to their symptoms, not just FAI (MTrPs, strain, articular damage etc…).

References:

Ames, P. S. PT, SCS and Heikes, C., S. MD. Femoroacetabular impingement in the running athlete. JOSPT 40(2). Feb 2010

Austin, A. B. DPT, Souza, R. DPT, Meyer, J. L. DPT, Powers, C. M. PT, PhD. Identification of abnormal hip motion associated with acetabular labral pathology. JOSPT 38 (9). Sept. 2008

Byrd, J. W. T. MD. Femoroacetabular impingement in athletes Part 1: Cause and Assessment. SportsHealth 2(4) 2010

Rabe, S. B. MS, ATC, LAT et al Athletic pubalgia: Recognition, Treatment, and Prevention. ATSHC 2(1) 2010