Category Archives: Low-Back

The Long Femur and Squat Mechanics

The squat is one of the best exercises to improve performance, period. Athletes incorporate the squat into their workout regimen because it increases strength and power of the entire lower extremity and significantly activates the core muscles. Unfortunately, performing the squat improperly can lead to significant injury.
Without getting into too much detail, there are 4 main reasons why a person may not be able to squat with good technique.
 
  1. Poor ankle mobility, primarily dorsiflexion
  2. Poor hip mobility, primarily hip flexion and external rotation
  3. Muscle weakness/muscle imbalance of the lumbo-pelvic-hip complex
  4. Long femur (a high femur to torso length ratio or high femur to short tibia ratio)
 Three of the above can be fixed with corrective exercise. This might shock you but there is no corrective exercise program that will lengthen the torso and shorten your femur (yes, that is sarcasm). Unless you are skilled at removing portions of the femur with a chainsaw you’re not going to fix #4.
Squatting with a long femur can lead to low back injury. In the image here you can see that the individual with the long femur has an increased forward lean. The excessive lean increases load at the low back.
I love the video here. If you move to the 3:40 mark the video shows an individual squatting with long femurs squatting.

It drives me bonkers when a provider (athletic trainer, personal trainer, therapist, etc.,) attempts to correct a client’s squat mechanics by forcing changes in items 1, 2, or 3 when the real problem is the unfixable number 4. Before you waste a client’s running them through a corrective exercise program make sure it is something that can be fixed.
If you have a long femur to short torso ratio you do have options!
  1. Widen the stance
  2. Externally rotate the legs
  3. Raise the heels
 If you continue watching the video (around the 5:30 mark) you will notice how the individual’s squat mechanics are improved by making subtle changes in body positioning.

All of these options change the lever arms and evenly distribute the weight between the low back, knees, and feet. Thus, one joint is not excessively loaded more than the others. You can try adjusting one of the above items or mix and match any three of the above.
 

The Squat: Should Your Knees Travel Past the Toes?

Should the knees migrate past the toes when performing a squat? I posted this question on downloadsocial media, and the immediate response by most was “No!”. I expected this answer from most everyone, from novice to advanced lifters. To you, I happily say, you’re wrong! The debate on proper squat mechanics will never die, but I am going to steal a line from Randy B., an athletic training, and performance enhancement peer, who answered my question: “Absolutely, [the knees] should [go past the toes]. Don’t believe urban legends or follow sports med sacred cows!” I couldn’t have said this any better! Randy is spot on. This urban legend could lead to injury. The purpose of this blog is to shed some light on the debate and provide the rationale for proper squat technique.

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Planks: You’re Doing Them Wrong

Here’s a challenge: I bet you cannot do a forward or side plank for 1 minute straight. Many people will say that is easy. So, let me rephrase: I bet you cannot do a forward or side plank properly for 1 minute straight.

Many fitness enthusiasts choose planks to work the core, but are they really working the core? When I observe clients perform the plank exercise, 9 out of 10 fail to perform the exercise properly. Take a look at the common compensation patterns that occur during the plank exercise and then challenge yourself. Can you do the exercise for 1 minute, with perfect technique, and without compensation? Continue reading

The Great Toe

When you think of the most common lower body injuries, you think ankle sprains, shin splints, runner’s knee, jumper’s knee, fasciitis, or Achilles tendinitis. When you have these injuries, you treat the injured area. We might be overlooking a little, but big deal.  Dysfunction in the big toe influences every step you take, every lunge, every jump, and every stride of every run. Ultimately, it can be a direct result in many of the aforementioned common lower body injuries. If you have dysfunction (pain, instability, or hypomobility) at the first big toe joint (MTP joint), it could wreak havoc on the entire kinetic chain.

Normal range of motion of the big toe is 40° flexion, 80-90° extension, and 10-20° abduction and adduction. Lack of motion, especially extension, will create compensatory movement at other joints. Common big toe issues such as, hallux valgus (bunion), hallux rigidus, turf toe, sesamoiditis, and gout will limit toe mobility. Below is an image of a client who demonstrates normal range or motion on the right and limited toe extension on the left.

N ROM   Limited ROM

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POS: Reduce Pain and Increase Performance

SwingDysfunction of one movement system can lead to a multitude of injuries. Treatment and care for one movement system can prevent our most common ailments. Most potential clients I interview complain of one or more of the following: sacroiliac joint (SIJ) pain and instability, non-specific low back pain (LBP), chronic hamstring strains or tightness, and peri-scapular and thoracic tightness or pain. Whether these complaints are isolated to one body part or involve many, the pain can typically be resolved by treating dysfunction of the Posterior Oblique Subsystem.

 

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Pelvic Upslip and Rotation: Evaluation and Treatment

Pop quiz: What musculoskeletal issue could result in chronic low back pain, chronic Chronic-back-pain-image muscle strains, lower extremity tendinopathies, periscapular pain and tightness, glenohumeral and shoulder girdle pain, or tension headaches? I am sure you can think of a few possibilities, but few can result in all. Often, when a patient reports to our care with one of the aforementioned we immediately think locally. Unfortunately, the real problem could be pelvic upslip, anterior pelvic innominate, or both. Despite being oft-overlooked, these malalignments are not hard to identify if you know what to look for. Continue reading

Low Back Pain in Runners: In a Battle of Muscle Supremacy, Evil Prevails

Introduction:Chronic-back-pain-image

When we think of running injuries we immediately think lower extremity, IT Band syndrome, Patellofemoral Pain Syndrome, Achilles Tendinopathy, Medial Tibial Stress Syndrome, Plantar Fasciitis, and the like.  However, one of the most common and debilitating injuries in runners is low back pain.  So why are runners so at risk of developing low back pain? Most musculoskeletal injuries are multifactorial, but more often than not many chronic injuries result from underlying movement dysfunction.

Vladamir Janda (1928-2002) revolutionized human movement dysfunction and rehabilitation in 1979 when he described three compensatory movement syndromes.  These syndromes were a result of pattern overload (i.e. running) and static posturing. Janda recognized that certain muscles were prone to weakness while others were overactive. He continually investigated these movement syndromes and later learned that the muscle imbalances were systematic, predictable, involved the entire body, and a common cause of injury. Continue reading

A Runner’s Story: From Pain to Performance

Photo_shoot_runningIn 2010, I left clinical rehabilitation and performance training. While I love my current job, I do miss the clinical aspect, which is why I seize opportunities to take on random clients with complex issues.  I’ve never written about my clients, but this case is so common, yet complex, that I thought my readers might be challenged with similar clients/athletes, or might be experiencing similar issues themselves. Here is a runner’s story that went from marathon training, to painful walking and an inability to run. Her experiences with continued failed treatment and the road we have taken to get her back to training and setting personal records. Continue reading

Treatment for Pelvic Rotation and Low Back Pain

Do you have a patient with chronic low back pain, pelvic pain or lateral hip pain? The problem could be an oft-overlooked Anterior Innominate Lesion, commonly referred to as Anterior Iliac Rotation. This malalignment is hard to identify unless the clinician is specifically evaluating for body alignment.

Simply described, anterior innominate is anterior / inferior rotation of the ASIS when compared to the contralateral ASIS. This unilateral rotational movement of is often a result repetitive movement patterns. Repetitive movement results in hypertonicity of hip flexors (primarily the rectus femoris and TFL), hypotonicity of the abdominals, hamstrings, and glutes, as well as increased laxity of the sacrotuberous ligament. The force coupling caused by the hyper/hypotonic structures yields the unilateral rotary movement of the pelvis.

The result is a chronic, dull achy pain that is unrelenting at times. Pain is typically felt across the entire low back. Focal tenderness upon palpation is commonly unremarkable. The patient may also have complaints of thoracic pain, lateral hip pain and potentially groin. Pain maybe exacerbated with athletic activity, or static postures such as prolonged sitting and standing.

As with many postural disorders, treatment for anterior rotation is best served through the use of manual therapy techniques. In my experience, there are two quick and easy treatments: muscle energy techniques (MET) and spray and stretch. Spray and stretch technique is a nice way to inhibit and elongate tonic musculature. Ischemic pressure massage to active trigger points of involved muscles followed the application of a vapocoolant spray, during a passive stretch works well. Although both treatment forms are effective, I prefer MET, as it is fast, effective, and incorporate a semi-functional component through contraction and relaxation of muscle.

When it comes to MET (or most manual therapy techniques for that matter) I often refer to anything by Leon Chaitow’s methods. In this particular instance, I have provided a video clip of a MET that can help both anterior and posterior pelvic rotation in one treatment session. I think the physiotherapists across the Atlantic do a great job of manual therapy, thus I chose a video that was made in the UK.

It is not uncommon to relieve patient pain with just one application of MET. For patients with significant malalignment this treatment may need to be performed twice daily for several weeks in conjunction with traditional functional rehabilitation designed to enhance neuromuscular efficiency.

So, if you have been a patient complaining of low back pain, be sure to observe for postural malalignment. You might find anterior innominate rotation. If so, you can utilize these techniques to resolve the problem quickly and restore optimal function.

Foot Center of Pressure Reduces Kinetic Chain Dysfunction and Chronic Pain

If you read my blog before you are well aware that I am a big proponent of identifying human movement dysfunction and correcting functional imbalances to reduce chronic pain, such as knee osteoarthritis (OA), patellofemoral pain syndrome (PFPS), and low back disorders such as sacroiliac dysfunction, facet arthropathy, or generalized lumbago.

A few years ago I read about a new neuromuscular technique called AposTherapy.  For those unfamiliar, AposTherapy corrects gait abnormalities by retraining muscles to adopt an optimal gait mechanics. The primary goal of AposTherapy is to correct the foot center of pressure (COP) during gait. This is done by wearing a unique, foot-worn biomechanical device. At the time, I heard good results about the use of AposTherapy, but data was too young to consider valid just yet or share-able, just yet.

Recently, when looking at functional rehabilitation techniques for chronic knee pain I came across an interesting study in the Journal of Biomechanics the evaluates the benefits of AposTherapy, to correct kinetic chain dysfunction responsible for the development of knee OA (1). The results of the study were significant. Following the intervention patients demonstrated significant reduction in knee adduction (valgus) moment (KAM). Several authors have demonstrated KAM to be a primary cause of knee OA, including Miyazaki, who noted KAM correlates with the progression of knee OA (2). In addition, patients who participated in AposTherapy demonstrated increased walking velocity, reduced pain, and improvement of functional living (1).

The foot-worn biomechanical device alters foot COP, allowing for proper kinetic chain alignment neuromuscular efficiency. Clark and Lucett, noted that dysfunction at one joint precipitates altered movement patterns, at adjacent joints, both proximally and distally (3). This is the foundation of AposTherapy. By correcting  foot COP during gait, altered joint mechanics up the kinetic chain are nullified and neuromuscular efficiency is enhanced. Overtime, strength gains occur allowing for optimal gait patterns. Sharma, stressed the role of neuromuscular ineffciency, suggesting that secondary to elevated joint stress with higher impact loads and altered joint mechanics facilitate the pathogenesis of the chronic joint disease (4).

Biomechanical interventions focusing on foot COP, neuromuscular development and agility, enhance functional ability, reduce pain and increase spatiotemporal patterns of gait (1).  Working knowledge of human movement dysfunction and human movement compensation patterns are prudent to health practitioners.  Health practitioners should emphasize and correct human movement dysfunction when treating clients with chronic joint pain such as and certainly not limited to knee OA, PFPS, SI pain, and other  low back disorders like facet arthropathy.  Training to enhance neuromuscular recruitment, force-coupling, as well as the correction of altered length-tension relationships and poor joint arthrokinematics will go far in reduction of pain, prevention of chronic pain, and improved functional outcomes.

What techniques do you implement to train for optimal neuromuscular efficiency?

References:

1. Haim, A, et al. Reduction in knee adduction moment via non-invasive biomechanical training: A longitudinal gait analysis study. J of Biomechanics. 45 (2012) 41–45.

2. Miyazaki, T., Wada, M., Kawahara, H., et al. Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. Annals of the Rheumatic Diseases.  2002. 61, 617–622.

3. Clark, MA, and Lucett, SC. NASM Essentrials of Corrective Exercise Training. Lippincott, WIlliams and Wilkins. 2010.

4. Sharma, L., Dunlop, D.D., Cahue, S., et al. Quadriceps strength and osteoarthritis progression in malaligned and lax knees. Annals of Internal Medicine. 2003. 138, 613–619.

The Geek’s Squat: Proper Squat Techniques for Strength and Injury Prevention

There has been much debate on proper squat techniques. Is it proper to maintain a vertical shin and prevent the knees from going beyond the toes? Is it better to squat and allow the knee to go beyond the toes? Proponents of the vertical shin technique argue it is best to save the knees and this helps increase posterior chain strength. Whereas proponents of parallel lines say, distribute the weight evenly and save the back. The purpose of this blog is to shed some light on the debate and provide the rationale for proper squat technique.

Early studies state that squatting with external loads causes undue stress and damage to soft tissue at the knee joint. This precipitated many experts to change squat mechanics. A vertical shin angle prevents excessive knee flexion, thus limiting the stress placed at the knee joint and potential damage to integral knee structures such as the meniscii, articular cartilage and ligaments. In addition, many state that maintaining a vertical shin angle allows for enhanced strengthening of the posterior chain (hamstrings, glutes, low back).

I agree it is important to protect the knees. However, the lower back is much more important, in my opinion. Low-back pain is one of the major forms of musculoskeletal degeneration seen in the adult population, affecting nearly 80% of all adults (1). It has been estimated that the annual costs attributable to low-back pain in the United States are greater than $26 billion (2). In addition, 6 to 15% of athletes experience low-back pain in a given year (3, 4). The body is an interconnected chain, and compensation or dysfunction in the LPHC region can lead to dysfunctions in other areas of the body (5). So why do we squat to protect the knees? How should we squat?

Proper squat mechanics requires optimal flexibility at the ankle, knees, and hips during the descent of the squat. When these joints are moving together, forces will be disturbed optimally and equally throughout the kinetic chain. If one of the joints has limited ability to move, another joint must compensate to make up for the lost movement. For example, if you are trying to pick something off of the floor and do not bend your knees you must bend at the back. Using this example, if we squat like this (limiting knee flexion or ankle dorsiflexion) we are asking the lower back to lift weight in a biomechanically disadvantaged position. You know the phrase “lift with your legs not your back.”

Do a quick check and test your squat mechanics. Evaluate your technique by watching in a mirror.  At the bottom of the squat the torso and tibia should be parallel to each other (See image below).  Have you ever noticed how a baby squats? Do a quick google search for baby squat. You will be amazed at their technique. They lift properly, because they have the flexibility to get in to a deep squat without excessive leaning at the low back. It does not matter if the knees go past the toes. The most important thing to ask: is the back parallel with the shin?

Fry et al. (2003) examined the hip and knee torque forces of variations of parallel squats and concluded appropriate joint loading during this exercise may require the knees to move slightly past the toes. Restricting squats created significant increases of excessive forward lean and subsequent increased torque loads at the low back and hip (6). Maintaining a vertical shank did not yield change knee torque significantly (6).

Torque is a measure of rotational force about an axis of rotation.  Simply put torque is a product of force and lever length from the axis of rotation to point of force of application (Τ = r x F) where Τ is linear torque, r is the displacement vector and F is force. Look at the two images below and notice the Torque values at the knee and low back:

Squatting with a Vertical Shin

Squatting with vertical shin:

Measurements:
αlb= 78° αk= 102° F = 135lbs (600.5 Newtons)
B to C= 19 inches (.48 meters). A to B = 2.75 inches (0.07 meters).  A to C = 16.25 inches (0.41meters)

Linear Torque Low Back:
Τlb = r x F
Τlb = 0.41m x (600.5N)
Τlb = 246.2 N·m

Linear Torque at the Knee:
Τk = r x F
Τk = 0.07m x (600.5N)
Τk = 42.04 N·m

Squatting to allow toes go beyond the knees

Squatting with parallel lines 
Measurements:
αlb= 90° αk= 90° F = 135lbs (600.5 Newtons)
B to C= 19 inches (0.48 meters) A to B = 9.5 inches (0.24 meters) A to C = 9.5 inches (0.24 meters)

Linear Torque Low back:
Τlb = r x F
Τlb = 0.24m x (600.5N)
Τlb = 144.12 N·mLinear Torque Knee:
Τk = r x F
Τk = 0.24m x (600.5N)
Τk = 144.12 N·m
You can clearly see that squatting with a vertical shin reduces stress placed on the knee, but significantly increases torque on the low back. Do we really want to place an increased load at the lower back, when it is so prone to injury? The most important thing to consider is overall exercise technique. Lifting with ideal posture is paramount for injury prevention. When this occurs forces will be distributed equally throughout the kinetic chain.

References:

1. Walker BF, Muller R, Grant WD. Low back pain in Australian adults: prevalence and associated disability. J Manipulative Physiol Ther 2004;27:238–44

2. Luo X, Pietrobon R, Sun SX, Liu GG, Hey L. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine 2004;29:79–86.

3. Nadler SF, Malanga GA, DePrince M, Stitik TP, Feinberg JH. The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes. Clin J Sport Med 2000;10:89–97.

4. Nadler SF, Malanga GA, Feinberg JH, Rubanni M, Moley P, Foye P. Functional performance deficits in athletes with previous lower extremity injury. Clin J Sport Med 2002;12:73–8.

5. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther 2003;33(11):639–46.

6. Fry, A.C., J.C. Smith, and B.K. Schilling. Effect of knee position on hip and knee torques during the barbell squat. J. Strength Cond. Res. 17(4):629–633. 2003

Improve Your Golf Game and Reduce Injury

Injuries in golf occur as they do during participation in any athletic orientated activity. Research indicates injuries in golf relate to functions of age, skill level, and frequency of play. According to Gosheger et al., over 80% of golf-related injuries are due to overuse (1). The most common injury experienced by professional golfers is low-back dysfunction. Low-back golf injuries can be chronic in nature due to poor swing mechanics, poor conditioning, or overuse. Research has shown that golfers who have low-back pain demonstrate a decrease in range of motion for hip internal rotation on the lead leg, decreased lumbar extension, decreased activation and/or timing of the abdominal obliques, spinal erectors, and knee extensors (2-4). A common low back disorder of golfer’s is sacroiliac joint (SIJ) dysfunction.

When loads are transferred between the trunk and legs, the flat surfaces of the pelvis bones (sacrum and ilium) make the SIJ subject to considerable forces. If SIJ stability is not maintained, loads cannot be transferred efficiently between the trunk and legs, which may result in abnormal loading joint tissue and the development of pain (5). The transverse abdominis and internal oblique muscles play a significant role in resisting shear loads across the SIJ and maintaining stability (5). Proper execution of an abdominal drawing-in maneuver during performance should enhance the stability of the SIJ joint and allow for the most efficient transfer of forces between the trunk and legs.

Exercise is believed to be a vital component in preventing the occurrence of low-back pain and injury. What is unclear, however, is the type of exercises that should be performed as part of a low-back pain prevention and rehabilitation program. Liddle, et al. concluded that strengthening exercises targeting the lumbar spine, lower limbs, and abdominal muscles were the predominant exercises performed in successful exercise programs that decreased pain and improved function (6).  Conversely, Hayden, et al concluded in a systematic review that programs that strengthened the trunk stabilizing muscles were most effective. A separate meta-analysis, (7) indicated that the most effective programs consist of a supervised, individually designed set of stretching and strengthening exercises.

I am in agreement with the observations and recommendations from the scientific literature noted above. The best approach to developing a low-back injury prevention program includes a variety of inhibitory and lengthening exercises aimed at improving flexibility of tight and overactive muscles, isolated strengthening exercises for weak and inhibited muscles, and improving neuromuscular control through integrated exercise is recommended.

Golfer’s with SIJ dysfunction commonly have overactive and underactive muscles. The overactive muscles include the Tensor Fascia Latte, IT Band, Hip adductors and Piriformis. Underactive muscles include the glute medius and minuimus as well as intrinsic core stabilizers (multifidus, transverse abdominus and obliques). Inhibiting and improving flexibility of the overactive muscles followed by strengthening of the underactive muscles will help reduce or prevent low-back pain and could improve your golf swing.

References:

1. Gosheger G, Liem D, Ludwig K, Greshake O, Winkelmann W. Injuries and overuse syndromes in golf. Am J Sports Med. 2003;31(3):438-443.

2. Horton JF, Lindsay DM, Macintosh BR. Abdominal muscle activation of elite male golfers with chronic low back pain. Med Sci Sports Exerc. 2001;33(10):1647-1654.

3. Lindsay D, Horton J. Comparison of spine motion in elite golfers with and without low back pain. J Sports Sci. 2002;20(8):599-605.

4. Vad VB, Bhat AL, Basrai D, Gebeh A, Aspergren DD, Andrews JR. Low back pain in professional golfers: The role of associated hip and low back range-of-motion deficits. Am J Sports Med. 2004;32(2):494-497.

5. Snijders CJ, Ribbers MT, de Bakker HV, Stoeckart R, Stam HJ. EMG recordings of abdominal and back muscles in various standing postures: validation of a biomechanical model on sacroiliac joint stability. J Electromyogr Kinesiol. 1998; 8:205-14.

6.  Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low back pain: what works? Pain. 2004; 107:176-90.

7. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005:CD000335.