One of the most commonly injured body regions that we encounter are the knees! We get asked all the time the best stretches, mobilizations, or treatments for the knee and the truth is… the knee more often than not the VICTIM, not the cause of your pain. This means that the best treatment for the knee is to address the ACTUAL cause, whether that be the mobility of your hips or ankles, strength imbalances, or movement impairments. Sure, issues will likely occur at the knee itself, which we’ll cover in a moment, but if you ONLY address the knee, you likely won’t get the results you’re looking for!
Let’s start with talking about some anatomy. The knee is a simple hinge joint, much different than the hip, which is a ball and socket joint. Ball and socket joints afford much more motion than hinge joints. Think of all the ways your hip can move - it can rotate, move forward, back, out to the side, across your body… just to name a few. Hinge joints do exactly what it sounds like, they hinge back and forth much like a door on a hinge at your house. While hinging back and forth is the main motion of the knee, there actually is a small amount of rotation that occurs as well. When that rotation becomes excessive, it leads to pain. More specifically, we see excessive rotation into external rotation and a lack of rotation into internal rotation. This is most often seen as the inward collapse of your knees in relation to your hips and ankles or outward pointing of your toes when going up and down stairs, standing up from a chair, or squatting. Reducing this excessive knee rotation into external rotation can significantly speed up recovery! These are our top 5 exercises to address this common issue!
In addition to implementing these 5 exercises above into your weekly routine, you’ll want to improve your movement patterns for long term success. Avoiding excess valgus movements is KEY. It’s this movement pattern that, when done repeatedly, leads to the most common root cause of knee pain - excessive tibial external rotation. Check out this blog, Top 5 Reasons Knee Valgus is Bad for You to learn more about this movement pattern.
I also want to mention that it’s okay, infact recommended, to allow your knees to translate over your toes when squatting. This is a normal motion that is needed to perform a healthy, pain free squat. BUT, you have to have the mobility and strength to do so. By addressing the impairments that cause you to move into valgus and prevent your knees from translating over your toes, you’ll be on your way to restoring health in your knee.
Lastly, be sure to train through full ranges of motion (ie. squatting below parallel). Joints that are not trained through their full range will become stiffer, and weaker over time. Have noisy knees? The term “motion is lotion” holds true and applies here as well! Now, noisy knees aren't usually a cause for concern, check out this blog to learn more - My joints crack and pop. Is that bad? But, the more movement and deeper ranges of motion you can perform without pain, the more lubrication and nutrition you’ll diffuse into your knees. The muscles, tendons, and ligaments surrounding the knee joint will become stronger if you use them to their full potential!!
If you’re experiencing knee pain, you’re not alone. This is a COMMON issue that CAN be addressed. (NO, bad knees are NOT genetic). Start implementing the info from above right away to get you on the right path. While this is the most common movement impairment in the knee, it’s not a one size fits all approach. If you’d like a more individualized evaluation, game plan, and customized treatment, don’t hesitate to reach out! We work with athletes just like you everyday (locally and around the country) and specialize in getting athletes back to their sport without limitations! We’d love to help!
Thanks for reading!
“The Doc told me I have a herniated disc! Now What??” Budging or herniated discs are consistently some of the most feared diagnoses out there, especially in athletes. They see the MD for their back pain, get an x-ray or MRI, and they’re told one of the following. “Imaging is showing disc desiccation, disc prolapse, disc protrusion, disc fissure, disc bulging, a herniated disc, degenerative disc disease, foraminal encroachment, nerve root compression (or impingement), or stenosis. At this point you’re as white as a piece of paper and picture the worst-case scenario. Medical background or not, those are some pretty terrible descriptions of a picture taken of your spine. But here’s the truth behind it: 99% of the time, you’re going to be just fine. Stick with me as I dive into what the research says about your back and a bulging disc (Hint: surgery is not typically the answer).
Let’s kick this off talking about imaging, aka x-rays, MRIs, and CT scans. Imaging is a powerful tool to show providers a glimpse of what’s going on internally within the body. MRI’s in particular can show incredible detail relating towards inflamed or degenerated tissue. Oftentimes, imaging shows us so much detail that we will have “abnormal” findings that may not even correlate to the symptoms. Therefore, without a thorough examination, just using the picture to diagnose a problem isn’t enough. We simply don’t know if the findings are related to the patients symptoms, OR, if they are just age-related changes…. like grey hair. Let me explain further. Take a look at the graphic below, which shows common findings from images of the spine in individuals with NO BACK PAIN AT ALL!
There are 2 massive takeaways here.
1) Look at the 30’s group. 50% of people in this group showed disk degeneration and 40% showed a disc bulge. 50%! These numbers are HUGE. I sure didn’t think about bulging discs in my back at 30, and most people would consider this very rare for a 30 something year old to have a pain from a bulging disc.
2) The number of “positive” findings exponentially increases in each age group. So, the older you are when you start to experience any sort of back pain, the higher the chance you would show positive findings in the event you get an MRI or CT scan. This is why face-to-face examinations are SO important – they can help to delineate whether or not your back pain is truly from a disc issue, or something totally different (joints, muscles, etc.)
So, what signs and symptoms would you have that indicate a herniated disc? Let’s discuss. First things first, because of how close the disc sits in proximity to the nerve, we are always looking out for some major red flags regarding this anatomical relationship. Two red flags that require immediate physician attention are the loss of the ability to walk, or the loss of control over your bowel and bladder. These indicate that the spinal cord itself is being compressed. No bueno. Let me repeat, if you’re having these symptoms it is an emergency and please call 911 to safely get to the Emergency Room rather than reach out to us!
Other more common symptoms of a herniated disc, that are less severe and not a medical emergency, include nerve pain down one or both legs (that may include numbness and tingling or weakness), significant muscle weakness, loss of sensation on the skin, pain with unloaded flexion (lying on your back and bringing both knees to chest increases pain), increased pain with coughing or sneezing, pain significantly worse in the morning, and pain worsened by repeated bending forward. If you don’t have ALL of these lesser symptoms, your pain is most likely related to something other than herniated disc….. Let that sink in. That’s a decent sized collection of specific symptoms that must ALL be present. Considering this, the reality is that a true disc herniation being the cause of your pain is actually pretty rare.
toSo, the doc has diagnosed you with a herniated or bulging disc, and what are your next steps? Let’s start here with a statement from the American Academy of Neurological Surgeons:
“The initial treatment for a herniated disc is usually conservative and nonsurgical. A doctor may advise the patient to maintain a low, painless activity level for a few days to several weeks. This helps the spinal nerve inflammation to decrease. Bedrest is not recommended.The doctor may recommend physical therapy. The therapist will perform an in-depth evaluation, which, combined with the doctor's diagnosis, dictates a treatment specifically designed for patients with herniated discs.”
If you go by what Dr. Google has to say about exercises to do, here's what you'll find:
Now, here's what physical therapy SHOULD look like for your low back pain. During the initial evaluation we discuss the history of your low back pain including onset and what gives you relief or increases pain. We also begin to address other significant factors that play a role in the development of low back issues such as: sleeping positions, postures you spend all your time in at work, and workout history/current programming. Then, it’s time to get you up and moving. We look at how you move through a handful of different functional motions to get an idea of any areas with mobility and strength imbalances and restrictions contributing to your pain. After that, we go through a more in depth assessment of each involved joint for mobility restrictions. In the presence of low back pain, we have to look at the Spine, SI Joint, Hips, Knees and Ankles as they all can play a role in having back pain while working out. From the collection of information we gathered regarding your injury to this point, we then educate you on where the pain is coming from, what we plan to do about it, and how to keep it coming back. This also includes discussing workouts and how to modify (Not just rest!) so that you can continue working out around the pain! After all the evaluation, the rest of the time remaining in the first visit is treatment to purely get you some pain relief and walking away from the clinic feeling better that day!
These are some common exercises we use after that first visit to start getting you moving again and getting the pain to calm down outside of the clinic. Notice, we keep the spine in a drastically different position than Dr. Google. The majority of time, with low back pain, moving into back extension such as the cobra pose only makes the pain much much worse!
So, we now know that full blown symptomatic disc herniations are actually pretty rare, that imaging will tend to show you some sort of disc related condition (even without back pain), and the first line of treatment is physical therapy. Unfortunately, not all physical therapy is the same. If you’ve seen a PT for low back pain in the past, here we do things quite a bit different. At The Charlotte Athlete, low back pain is the number one most common body region we treat, and the key to treatment in this region of the body is getting down to the root cause of why the pain occurs. Taking this approach, and addressing how you move, allows us to have excellent outcomes and even help some people who have had decades of low back issues. If this sounds like you, even if your skeptical of if we can help, take advantage of our free 20 minute phone call with one of our Doctors of Physical Therapy to see if we are good fit for you!
Thanks For Reading!!
- Dr. Mike
If you read our previous blog post on posture, you’ll remember we mentioned that about half of the population have an excessively flat thoracic spine or upper back while the other half have an excessively rounded thoracic spine. If you DIDN’T fall into the “excessively flat” category, this blog is for you and will teach you exactly how to fix that rounded, hunchback-like posture!
While a normal thoracic spine SHOULD have some curvature to it, an excessive amount can be detrimental! Your thoracic spine is the foundation for your neck and shoulders. If your thoracic spine can’t move well or is in a less than ideal position, there’s limited possibility of your shoulder blades and neck moving properly which could potentially lead to pain.
As you can see from the graphics below, this excessive curvature can lead to extreme forward head posture so that the muscles responsible for holding the head and neck in a good position become strained and/or overworked from trying to maintain a position that they just can’t handle. Excessive curvature of the thoracic spine can also cause your shoulder blades to sit in a poor position making overhead activities difficult and potentially even painful so that the muscles in and around the shoulder joint get beat up from trying to compensate.
If this sounds like you and you’ve been dealing with neck, thoracic spine (upper back), and/or shoulder pain, then definitely give these next few exercises a try. OR.. even if you don’t have pain and just feel like that desk job is finally taking a toll on your posture, then these exercises are for you too!
1. Weighted Thoracic Extension
Place your upper back on a bench and while keeping the hips low to the ground, extend the weight over your head. Hold for 2-3 seconds and repeat 10x.
Extension (arching backward) is probably one of the most popular directions that we see people work on. While extension is needed and important, we can’t negate the benefits of rotational exercises on mobility of the thoracic spine. The anatomy of these joints are made to move more readily into rotation than extension, so the rotational exercises coupled with extension exercises will actually give you greater results!
2. Half Kneeling Thoracic Wall Circles
Kneel close to a wall with your outer knee up. Perform a big circle with the outer arm and try to stay in contact with the wall throughout the range. Perform 10-12 reps per side.
Now that we’ve mobilized the thoracic spine, to create lasting changes, we must strengthen! This exercise below activates and strengthens the important postural muscles in the upper back while also improving the position of your shoulder blades.
3. Wall Angels
Lean up against a wall and press your lower back flat. With both arms bent to 90 degrees and the pinky side of your hands on the wall, raise your arms up as high as you can until you feel a restriction. At that highest point, slide your pinkies up and down as fast as you can. Shoot for 1 minute!
Lastly, reel in that forward head posture by performing chin tucks and strengthening the muscles in the front of the neck.
Perform the 4 exercises above, 2x per day, over the next 2 weeks and you’ll notice a dramatic difference. Not only will your posture improve, but your neck and shoulders will feel and perform better as well. With that being said, you have to start now! Posture becomes much more difficult to improve the longer you put it off.
Thanks for reading!
- Dr. Aerial
What the Heck is Blood Flow Restriction Training?? The Ultimate Guide to it’s Use and Effectiveness!!
Sounds crazy, right? NOPE! It’s incredibly safe AND can produce some wild gains! Let’s jump right in. Blood Flow Restriction Training (BFRT) is a common treatment method with over 20 years of research, but has only recently started to become a staple in performance PT practice. The primary purpose behind BFRT is to stimulate muscle hypertrophy (muscle growth) which ultimately allows the muscle to become stronger. In the next few paragraphs, I’m going to cover what exactly it is, how it works on the muscles, and how it can work for your athletic and fitness goals!
What is BFRT?
BFRT utilizes a band or cuff placed tightly around a limb to reduce blood flow while you exercise. It doesn’t completely cut off blood flow, but just enough to allow blood flow into a limb, and prevent the flow back out to the heart. These changes in blood flow allow the muscles to use up all of the oxygen available. This creates an advantageous environment which allows us to use low intensity exercise, but still get the benefits of higher intensity training!
Yeah, yeah I know…. train at low intensity and get the benefit of training at high intensity, it sounds like a gimmick. Even I was skeptical of its benefits at first. But after diving into the science and research behind it, it was easy to see how this has made its way into the rehab and performance realm! So, let’s take a look at how it works!
How Does BFRT Work?
The starting point for how BFRT works actually begins at the muscle. How does a normal muscle get bigger and stronger? I could put you to sleep reviewing all the different physiologic pathways involved with muscle growth, but simply put, it’s a combination of mechanical load (how heavy weights are), volume (how many times you lift those weights), neural stimulus (high vs low intensity), and metabolic processes (protein consumption and hormonal changes).
In terms of muscle growth, the hormones and metabolites created from exercise are the key. Big, multi-joint exercises (ex: squats, deadlifts, or push ups), high load (heavy weights), and high intensity, yield high releases of muscle growth hormones such as testosterone, and human growth hormone among others. The important word though is “high load.” However, there's a second piece to the puzzle. Just like you need lumber for a contractor to build a house, these hormones need protein to build muscles. To ensure the desired muscle growth, there must be adequate protein intake to allow for more muscle building than muscle breakdown from exercise.
The heavier you lift, for more reps, using less rest, results in larger muscle gains. Easy right? Except we said previously that BFRT works best at low intensities, which wouldn’t fit the bill for muscle growth… so we need to dive a little deeper into the metabolic processes involved here to learn how BFRT really works!!
So, BFRT reduces the amount of blood flowing to limbs, which limits the amount of oxygen to the muscles. Think of oxygen as the fuel to the muscle. So, when the muscles work while under blood flow restriction, we start to use up all that fuel. As the fuel supplies reduce, it accelerates fatigue (burn, baby burn!) and it becomes an “all hands-on deck” situation for the muscle causing it to recruit more and more motor units (more muscle) to complete the movement!
Ready for the cool part? By restricting blood flow and creating this “all hands-on deck” situation for the muscle, we stimulate those same protein synthesis pathways that are involved in muscle building after heavy workload days.
This results in the increased release of the hormones and metabolites mentioned above that are coming to repair and rebuild muscle. You only have to use BFRT once to know this, because you will 100% feel it as an insane pump!
Here’s the even better part: BFRT results in significantly less muscle breakdown during the session as traditional high load training. So those same metabolites and hormones brought to the area have less repair to complete and get to focus more on building. It also means that BFRT should result in less delayed onset muscle soreness (DOMS) #gamechanger.
Remember this equation? Well, BFRT ramps up the muscle growth side, and decreases the muscle breakdown side. I may not be the best at math, but I do know that those changes to the equation will result in bigger gainz!
Now… here’s the disclaimer. BFRT used alone without heavy lifting is inferior to high load training alone. In the words of Mr. Olympia Ronnie Coleman “Everyone wants to be a bodybuilder, but don’t nobody wanna lift heavy a** weight.” This still holds true even with the introduction of BFRT. Don’t be discouraged though, the next section goes through who will benefit the most from BFRT (Hint: Mostly everybody!)
Who can benefit from BFRT if it doesn’t replace high load training?
1. Those who currently can't lift heavy:
2. Fully healthy CrossFit, Olympic Weightlifter, bodybuilder, ball/stick sport, and endurance athletes:
The previous section highlights the most common uses of BFRT, but certainly isn’t fully comprehensive.
Here’s a quick recap of important points to remember:
We’re incredibly blessed to have this equipment to use with our patients at The Charlotte Athlete. Just over a year ago, I completed a BFRT certification course to further my knowledge on the benefits, effects, as well as experience firsthand use of the blood flow restriction cuffs. Since then, I’ve truly seen BFRT become a game changer within the rehab process AND performance training. If you have any questions, or are local and want to give it a try, hit the comment section and let us know!
First, congrats to you if you’re pregnant! And kudos to you if you’re still trying to workout while pregnant! If you are like me, you’re probably experiencing a whirlwind of emotions and thoughts and just want the best for your baby, which is why you’ve ended up here. You’re trying to maintain your physical fitness so you can give your growing baby the best environment to develop in. However, it’s tough to know what is and isn’t safe or what the best recommendations are and the lack of evidence/controversial research doesn’t make it any easier. BUT, hopefully this blog will provide some clarity to your situation!
There are A LOT of changes that occur in the human body when pregnant. To accommodate the growing baby and the enlarging uterus, your organs have to do some moving around. As the baby grows, the lungs get pushed upwards, your intestines/bladder get squished, and your abdominal muscles have to stretch and may even separate. You may also start to experience various aches and pains and even changes in balance and posture. With all of these changes occurring in the body, I bet you’re wondering if there’s anything that we can do to affect this process or if it’s all inevitable. Well, you’re in luck! Your actions during pregnancy CAN influence some of these symptoms, which is why I’d like to talk about performing abdominal exercises while pregnant. This is one of the most controversial topics relating to pregnant women. Thankfully, working out while pregnant is becoming a little more accepted,(1) but core exercises on the other hand… a much touchier subject! Are they safe to do? Are they healthy to do? How do I know which exercises are safe and which exercises aren’t? Am I putting my body or baby at risk? Keep reading for answers!!
If you haven’t already, I would make sure you have an OBGYN and physical therapist that you trust! Ideally, they’d both work closely together to give you the best advice for YOUR individual body at each stage of your pregnancy. You want to make sure whoever you’re taking advice from is active and knows about the sport/hobbies you are interested in so they can help guide you on this journey. I would advise AGAINST someone who gives you the same cookie cutter advice they give all moms. For instance, I’ve been active in sports my whole life, played college soccer, have been competing in Crossfit for 5 years, and then got pregnant. My first OB told me I should take it easy, only do light to moderate activity, not elevate my heart rate, not lift over 35 pounds, and definitely NO core exercises. *News Flash*: this is OLD advice that is very outdated! And if you don’t know any better and don’t do your own research, then how would you know??
9 times out of 10, if you’ve been working out or doing the activity consistently BEFORE getting pregnant, then you’re likely going to be able to continue doing that activity WHILE pregnant, as long as you’re being safe and smart.(2) Ask yourself, “Does the risk outweigh the reward?” When it comes to core exercises while pregnant, the reward IS there and here’s why!
As I mentioned previously, many changes that occur in the body while pregnant are stretching of the abdominal wall, aches and pains (usually in the back), and changes in balance and posture. ALL of these changes can be influenced by the STABILITY/STRENGTH of your core! The weaker your muscles are, the more apt they are to stretching, which can lead to Diastasis Recti. This then affects your posture and will likely increase the amount of aches and pains that you experience during pregnancy, especially in your back.
What is Diastasis Recti?
Diastasis recti occurs when the uterus stretches the muscles in the abdomen to accommodate your growing baby and ends up creating a space between your abdominal muscles. This separation is actually a common occurrence and 2 out of 3 pregnant women will experience this. In many cases, the linea alba (the midline of your abs) naturally regains tension after pregnancy and the gap separating the two abdominal muscles closes on its own. But, when the space doesn’t close and is bigger than 2 finger widths wide, it could become a problem and make recovery tough. According to research, women are at an increased risk for developing this excessive separation if they are over the age of 35, obese, have had multiple births, or have a WEAK CORE. Maintaining a strong core and healthy weight with exercise before, during, and after pregnancy is undoubtedly the BEST method to avoid diastasis recti.(3)
No, not ALL core exercises are safe or recommended while pregnant, but it is beneficial for you to find the ones that are…and here’s how: It’s important to understand that there’s a difference between core STRENGTHENING and core STABILITY and core STABILITY is what’s needed when growing a tiny human!
Lots of programs and exercises “strengthen” the core. These are the exercises that we’re probably most familiar with and involve direct movement within the core. They’re the exercises that most of us commonly do to build a 6-pack such as russian twists, sit ups, crunches, V-ups, leg raises, reverse crunches, and GHD sit ups. “Stability” is different and is often a component that is lacking from most programs because the exercises aren’t as glamorous. They’re exercises that don’t involve movement of your abs, such as a standard plank, side plank, med ball stirs, and pallof variations (see videos below). These exercises are much safer alternatives to perform while pregnant as they do not cause excessive strain to the rectus abdominis (your 6-pack muscles) and focus on 360 degree core stability.(4) They’re also the exercises that will help ward off pain, excessive changes in posture and muscle length, and even constipation, bloating, and urine leakage.
However, it’s still important that you know what your body can and can’t handle. For instance, just because someone else is pregnant and can perform a plank, doesn’t mean that everyone else that is pregnant can and vice versa! It’s important that you know what to be aware of while performing these exercises (and any other activities).
Be sure to avoid excessive coning, bulging, the feeling that you’re unable to control your core, an increase in the amount of pressure in your pelvic floor, or an increased need to pee (to name a few). If any of this occurs, alter the movement. Simple as that. The coning is our body’s way of giving us feedback and just tells us where the pressure distribution is in our body. Now, excessive coning done repeatedly over time is what could lead to an abnormal widening of your abdominal muscles and could make recovery a lot tougher. For this reason, I recommend adjusting each exercise as necessary so you can then successfully avoid the coning.
With all that being said, I do NOT recommend that you start up a strengthening program for the first time while pregnant and it is ALWAYS recommended that you consult with your doctor or a medical professional before doing anything! This post is NOT intended to be a prescription for what you should or shouldn’t do during pregnancy. You need an individualized program tailored toward your body! What this post IS intended for is to empower you and make you aware of some of the changes that are likely to occur throughout your pregnancy and hopefully give you a sigh of relief because now you know you can do something about it!
Thanks for reading!
- Dr. Aerial
1. Hammer, R. L., Perkins, J., & Parr, R. (2000). Exercise during the childbearing year. Journal of Perinatal Education, 9(1), 1–13. https://doi.org/10.1624/105812400x87455
2. Physical activity and exercise during pregnancy and the postpartum period. (2020). Obstetrics & Gynecology, 135(4). https://doi.org/10.1097/aog.0000000000003772
3. Rebelle, T. (n.d.). How to prevent Diastasis Recti (with crunches). NASM. Retrieved March 2, 2022, from https://blog.nasm.org/womens-fitness/how-to-prevent-diastasis-recti-with-crunches
4. Chiarello, C. M., Falzone, L. A., McCaslin, K. E., Patel, M. N., & Ulery, K. R. (2005). The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women's Health Physical Therapy, 29(1), 11–16. https://doi.org/10.1097/01274882-200529010-00003
Typically, when we think about improving our posture we think of this:
While exercises geared toward opening up the chest and extending the back work great for many people, in some instances it can actually make things worse. Especially in athletes and those under 40. One of the biggest misconceptions out there is that everyone is stiff, everyone is a hunchback, and everyone has a lazy rounded mid-back (thoracic spine). If this sounds like you, and now you’ve just sat up a little bit straighter because you read the word posture: I’m here to give you some solid info about posture, how it can be so different from person to person, and some easy ways to correct it based on your spine!
So, what are these differences? This portion of the spine tends to have the most variation from person to person in the amount of resting curve.
A “normal” thoracic spine is supposed to have a mild kyphotic (or rounded) curve. What we actually see is that about half the population has a normal or excessively kyphotic curve, and the other half is actually excessively flat. Just like being too kyphotic and rounded, being excessively flat isn’t good either (AND is addressed completely differently).
Let’s first start discussing the excessive kyphotic curve. If you have more of the stiff rounded upper back, then the traditional posture correction recommendations are for you! These include for sitting: the feet being flat, hips to the back of the chair, utilizing the back of the chair for support but maintaining an upright position, elbows supported and at your sides, and the top of the computer screen being at eye level. You can also utilize the exercises below to increase thoracic extension and rotation to improve the upright posture!
Now, here’s where things take a turn.
The other half of the population, which typically includes the majority of the younger and more athletic people, have a very flat thoracic spine. A flat thoracic spine results in a loss of normal kyphotic curvature. To connect the dots back to posture… while sitting with a naturally flat thoracic spine, when you actively sit up straighter and pull your shoulder blades back you are taking your spine further away from a normal resting curvature!
e flat thoracic spine (that is worsened by you trying to sit up even straighter) is problematic because of its role as the foundation for the shoulder blades (Scapula) and neck. Based on the photo to the left, you can see he has decent muscle bulk around the spine but the spine itself is incredibly flat.
When you lack the correct curvature of the thoracic spine, the muscles in charge of supporting the neck are given the impossible task of keeping the head in the correct position. In this case, the neck muscles end up overworked and it causes the head to start falling forward. If you think about holding a bowling ball, you could hold it a lot longer if it’s close to your body right vs arm extended, right? Now imagine, holding the 16 pounder (yes, that’s close to the average weight of the head) with your arms all the way out straight - that’s not going to last too long! Holding the ball away from you is similar to what the small muscles of the neck are asked to do as the head drops forward!
As for the shoulder blades, they need a good foundation to rest on. With a flat thoracic spine, they tend to start dropping down the back like melting ice cream. This results in too much lengthening of the muscles connecting the neck and scapula, and if you’ve read our other blog “The Myth of “Upper Trap Tightness”: Is the Upper Trap the Devil?,” then you know that over lengthened muscles are weak and will become painful! So, while bad posture at times can cause pain directly, typically it sets up other areas for failure.
If you’re like me and over 80% of the people we treat, flat back posture correction looks a little different! We still want the hips to sit all the way back in the chair, but instead of forcing the back to stay upright, you’ll want to actually push your midback to the backrest into somewhat of a slouch that is still supported. You can see in the graphic above that he is leaning into the back of his chair and actually looks comfortable! Elbow position and computer screen recommendations remain the same! As far as exercises go, if you only use those from the 1st video above you’re moving yourself further into the problem! If you have a flat back, the video below is made just for you to focus on improving flexion and rotation to restore some of the natural kyphotic curve!
Thanks for reading!
Here’s a little glimpse into my last trimester of pregnancy and my postpartum recovery journey. I’ve learned a lot during and after pregnancy with the main lesson being: the human body is amazing!
Full Disclaimer: this blog is NOT intended to be a prescription for return to Crossift postpartum. Everyone’s recovery will vary tremendously as a result of MULTIPLE different factors such as pre-pregnancy fitness levels, age, weight, pelvic floor strength, core stability, and vaginal vs cesarean deliveries to name a FEW. This is just MY experience and how I progressed back to CrossFit. I fully recommend seeking help and direction from an experienced rehab professional for detailed guidelines specific to yourself before trying any of this on your own. This will prevent speed bumps in recovery and future complications from arising!
**check out our instagram post to see what exactly this “stacked” position is**
During the 3rd trimester, I didn’t max out on any lifts, although I did PR my 3 rep front squat. And no, I didn't pee myself, wear a belt, or strain too hard to do it. It just felt good that day! Double dumbbell or heavy thrusters became more difficult for me to control my core so I usually only used one dumbbell or a lighter weight for thrusters. I actually stopped doing handstand push ups, not because it was unsafe, but because they got really hard the heavier I got. As a substitution, I did single arm overhead presses. I did end up rowing a couple times because I got tired of biking, but I just didn’t lean back at the end of the pull in order to prevent my core from coning.
In general, extracurriculars were a bit more challenging. My husband and I like to spend a lot of time outdoors with our friends so we planned a trip to the mountains around week 34. We went tubing down a shallow creek and in order to not get slammed by rocks, I’d have to lift my body up out of my tube, which was really difficult to do without coning. My friend ended up switching tubes with me (his had a net bottom and back support) which helped tremendously! Hiking was a bit more difficult because I was basically wearing a weight vest. The trail we picked ended up having a lot of actual rock climbing and uphill/uneven ground so I was REALLY fatigued. We did about 4-5miles and even those who weren’t pregnant were exhausted.
Fun fact: my fingers started tingling after writing a lot of thank you cards after our baby showers, but the doctor said that was normal and it was just swelling in my hands that mimics carpal tunnel. It would get worse being at work and performing a lot of hands on work on athletes. I would also sometimes wake up with that same numbness, but as long as I kept my wrist neutral, as opposed to bent, it would be fine. (All of this has completely subsided now that I’m not pregnant.)
As my due date approached, I felt like the doctors started trying to scare me into an induction. I really preferred to have my baby naturally, even without an epidural, so the thought of an induction didn’t sit right with me. They kept telling me the risk of stillbirth, C-sections, and complications continue to increase the longer we wait. At 39 weeks, for the health of my baby, I decided to go ahead and schedule the induction for 41 weeks. I wanted to give my body a chance to go into labor on its own.
The week of my due date, I tried everything I could to make her arrive without the induction. My OBGYN did a membrane sweep at 39 weeks + 2 days. She said it should help me go into labor in 24-48 hours. It didn't. I walked for 2 hours that night and did some deep air squats. That didn't work either. I ate Hawthorne's “The Inducer” pizza two nights in a row..still didn't work. I tried hot wings and other spicy foods. I even went and got a pedicure because I heard that was supposed to help. Eventually, Saturday night, the day before I was due, I started experiencing labor pains. I ended up having baby Harper right on time, September 19th at 5:15 in the morning, without an induction and without an epidural..ouch! She was 6 pounds, 6 ounces, and had a head full of hair!
The doctors told me not to workout for 6 weeks and with how sore I was directly after, I agreed! But as the days went by with me just sitting on the couch, I started to get all kinds of aches and pains in my low back and neck and just became uncomfortable. I soon decided that I just needed to MOVE! I started walking around the neighborhood 3 days later and then 4 days after I gave birth, I went to the gym. Yes, the gym. I skied very lightly because the idea of sitting on a bike or rower seemed uncomfortable. I did some slow air squats, slam balls, and light kettlebell deadlifts. It felt great to move again!
I continued to go to the gym daily, but for the first couple of weeks, I did my own workouts or modified the one that was programmed. I started back jogging pretty soon after delivery and it felt great! I kept weights pretty light and didn’t do any rig or core work and especially no jumping. However, I did start incorporating some simple core stability exercises like lying on my back while holding my legs 6 inches off the ground, controlled sit ups, and hanging from the rig to name a few.
Return to Rig Work (ie. toes to bar, butterfly pull ups, bar muscle ups)
My return to the rig had a couple of progressions. I started with hanging from the rig and controlled (from a breathing and coning prevention standpoint) sit ups on the ground. Once those became easier, I started to incorporate some controlled hanging knee raises. I did this for a couple of weeks until I started to add a small kip and some momentum to the knee raises. It took about a month for me to feel comfortable enough/ready to do that and then I eventually worked my way up to toes-to-bar.
Videoing all of my progressions on my phone was a HUGE help to myself! With some of these movements, it became difficult to watch and make sure everything was functioning the way it needed to, so being able to watch it back directly after helped tremendously!
At about 1.5 months postpartum, I tried some small butterfly pull ups which actually looked (from a coning perspective) and felt really good. It took about 2 months for me to feel comfortable/confident enough to try out bar muscle ups. But once I did, they ended up being successful. My kip felt awful from not doing them for months, but each time I did them, they felt better and better.
Return to Jumping
As my body continued to heal and feel more normal again, I progressed the exercises and weights. I was able to perform box jumps at about a month postpartum, but rebounding took just a little bit longer. The repetitive jumping increased the risk of leakage. Also at about a month postpartum, I tried out some light hops in place in order to test out jumping rope. My body wasn’t quite ready at that point. After that, for the next couple of weeks, I kept testing them out periodically and eventually tried out single unders as they continued to be successful (no leakage). At 2.5 months postpartum, I did double unders in a workout. The workout was a 14 min AMRAP (as many rounds/reps as possible) of 21 double unders, 12 single arm dumbbell hang clean and jerks, and 9 toes to bar. The focus of this workout for me wasn’t how fast I could go, but how successful I could be at the double unders. I started off by keeping in mind that “stacked” position I mentioned previously and broke the double unders up into 2 sets. By the end of the 14 minutes, I was able to perform all 21 reps without issue!
Fun fact: I have been and still am breastfeeding my baby while working out at a high intensity and have not had any change in milk supply. We’ve had check ups and have visited her pediatrician who says she’s growing perfectly and is getting enough to eat!
I’m now currently at 3 months postpartum and am 95% unlimited in the gym. I am back handstand walking, performing butterfly chest to bar, strict and kipping handstand push ups, and doing bar/ring muscle ups. I am still not 100% back to double unders, but I understand this will take time, especially since I had a vaginal delivery. Typically vaginal deliveries have a longer “return to jumping/running” time period while cesarean deliveries have a longer “return to core work” recovery period. I also haven’t tried GHDs yet because they seem too advanced for me at this point, but I’ve been AMAZED at how quickly I was able to return to some of these activities and how good I’ve been feeling while doing them.
While postpartum recovery is a journey in itself, so is returning to a sport or activity you love! It’s never too late to rehab the effects of pregnancy and you don't have to do it on your own! Whether you just had a baby or if your child is 10 years old, there’s likely something that can be done! If you’re looking for guidance, even if you’re one of the moms that is STILL struggling with double unders and leaking multiple years after giving birth, don’t hesitate to reach out! You don’t have to suffer or avoid movements forever!
Thanks for reading!
- Aerial B.
If you’ve ever spent any amount of time in the gym, you’ve probably heard your coach tell you not to let your knees come together while you’re squatting. This “knee-knocking” motion during the squat or deadlift is called a Valgus position. While this movement pattern can have a detrimental effect on your knees (and hips and ankles for that matter) over a long period of time, it can be advantageous in certain scenarios!
If you’ve ever spent any amount of time in the gym, you’ve probably heard your coach tell you not to let your knees come together while you are squatting. This “knee-knocking” motion during the squat or deadlift is called a Valgus position. This can have a detrimental effect on not just your knee, but your hip and your ankle as well!
So, let’s jump right into the top 5 detrimental effects valgus can have on your body!
1. Let's first kick this off with how the valgus motion affects the knee itself. During the squat, the knees pinch inwards toward each other but the hips and feet stay relatively stable. By losing the straight line between your hip, knee, and toe, you introduce a lot of rotational stress to the knee joint. Unfortunately, the knee is a hinge joint meaning that it is really made to only bend and straighten with some slight rotation. Over time, this extra rotation results in an aggravation to the sensitive structures of the knee and can begin to cause pain around the kneecap or especially the inside of the knee. If left unchecked, this can become a structural issue resulting in persistent pain, early onset arthritis, or ligament over lengthening and tears.
2. Now moving up to the hip. When the knees pinch it forces the femur, or thigh bone, to move into adduction and internal rotation. This motion of the hip increases pressure within the joint and on the structures immediately surrounding the joint. Oftentimes, this will result in a painful pinching at the front of the hip especially when squatting is repeated many times under high levels of fatigue. If this motion is allowed to continue, it will not only cause decreased hip mobility but could be potentially the cause of a hip labral tear altering the structural integrity of the hip.
. Still up at the hip, there is a secondary result of the forced adduction and internal rotation position of the hip. With the femur moving into this position, it results in over lengthening of the glutes. As a muscle is lengthened, it loses the ability to contract powerfully. Thinking about Olympic lifts, we need the quick and forceful contribution of the glutes to hit triple extension. Without as much contribution from the glutes, the quads and muscles of the low back are tasked with lifting greater loads and can result in knee pain, low back pain, or even radicular pain down the sciatic nerve.
4. The last two shift down toward the foot and ankle. Number four is regarding the ankle. While the knees pinch, the ankle no longer moves with appropriate mechanics and results in a loss of pure dorsiflexion which is the toes toward the nose direction. By not getting into pure dorsiflexion with squats, stairs, or step ups we begin to lose this motion and result in stiff ankles. So how do stiff ankles cause knee pain?? When you go to squat, your center of gravity will be shifted forward from the middle of the foot toward your toes. In doing so, it further causes the glutes to be much less active throughout the exercise but also places more demand on the quad muscle resulting in a “quad dominant” squat that can lead to pain surrounding the knee cap and patellar tendon.
5. Lastly, as the knees move into valgus the arch of the foot collapses. Similar to what happens with the glutes, loss of our arch places the muscles that support it in a lengthened position and they become unable to maintain the neutral position of the foot. So not only do we lose the stable foundation of the foot at this point, but with the arches collapsing the knee is driven FURTHER into more valgus. Extra valgus stress and an unstable base set the stage for increased pain or creation of symptoms at any joint along the leg or low back.
While there is all kinds of negativity surrounding the knee valgus position, what is rarely talked about is the BENEFIT of this position. When loading up toward your 1-3 rep max during squat or getting ready to do a max effort vertical jump, you may notice that you naturally move into and out of this position to get out of the hole. While this is still technically a valgus position, the quick movement in and out of it results in a “quick stretch” to glutes. This quick stretch is a technique the body naturally uses to increase the neuromuscular drive of that particular muscle resulting in a more forceful contraction. This is something that you will see all the time during competitions and is completely normal! Looking at the picture below, you can see his front knee is wayyyy inside the hip and ankle and he is the proud owner of 2 gold medals as well as the world record holder in Snatch, Clean and Jerk, and Total.
To wrap it up, Valgus stress at the knee can be beneficial in the well trained athlete to achieve greater max output. However, the use of this position should generally be limited. With lower percentage squat/snatch/clean work, lunges, step ups, or anything similar that pops up in a WOD we should be working to avoid the knee valgus position. For the most part, the undesirable effects of the valgus position tend to occur if we are repeatedly moving into it over long periods of time. In regards to more traditional sports athletes (such as soccer, football, or lacrosse), this position is one we need to master and even strengthen. While planting, cutting, or changing directions the knee is required to move into valgus and when uncontrolled over periods of time can lead to non-contact ACL tears. If you have had an ACL reconstruction, you were probably beat over the head by your PT and/or AT about avoiding this position, however when trying to return to sport this is absolutely something we have to train as its a normal position assumed during competition.
Thanks for reading,
GIRD has been a hot topic in the baseball world for many years, but especially the past few. What does GIRD stand for? Glenohumeral Internal Rotation Deficit. Typically, you only hear this phrase if you see an ortho or PT about any sort of elbow or shoulder pain, but
nowadays it’s not uncommon to hear it mentioned from your strength coach or athletic trainer, especially during initial assessments. The truth behind this “GIRD” phenomenon can be confusing so I wanted to take some time and really dive in deep, and also debunk a few common myths and misconceptions while we’re at it!
GIRD is actually a very common phenomenon in overhead athletes, especially throwers in sports like baseball and softball or outside hitters in volleyball. While it is common, it is seen at the most extremes in our baseball pitchers. So, what is it? It’s a shift in our range of motion at the shoulder resulting in increased range of motion into external rotation (ER) and decreased range of motion into internal rotation (IR). Believe it or not, this shift provides BENEFIT to the thrower, because the further they are able to move into external rotation, the more acceleration and velocity they are able to produce during their throw. Here’s the kicker however - this shift in the arc of motion results in altered stresses to the joint and has been linked to labral and rotator cuff tears as well as elbow ligament injuries (Tommy John Tear).
If GIRD is both beneficial and potentially harmful what does this mean? We as doctors and physical therapists must be able to differentiate between GIRD and Pathologic GIRD (pathologic meaning problematic). The loss of IR alone is not grounds for treatment as the cause of pain, if, the loss of motion into IR is re-gained in ER. So, going off the graphic below the total arc of motion in each shoulder is 180 degrees. In this instance, the loss of internal rotation would NOT be a red flag as this is considered a NORMAL adaptation to the demands of the sport.
While there is no one specific cause of GIRD, there are 3 reasons linked to this shift in total arc of motion. First, there are capsular changes. The capsule is a soft tissue surrounding the entire shoulder (largely ligamentous), and is asked to dissipate extremely high forces on the posterior, or back, side of the shoulder while throwing. As we throw, the capsule tends to take on similar stresses as the muscle resulting in significant stiffness that changes how the shoulder rotates in the socket.
Secondly, there are bony changes at the shoulder. Most athletes began throwing at a young age and this repetitive movement alters the development of the shoulder into a position called Humeral Retroversion. This changes the resting position of the ball in the socket joint and assists with gaining this increased external rotation. Remember, this increased ER is a benefit to the thrower and these changes are completely normal and harmless to development. This is the body’s response to be more efficient at a movement and is determined by the demands placed on it!
Lastly, there are muscular changes. The act of throwing requires the muscles surrounding the shoulder and shoulder blade to act in a way that slows the shoulder down after ball release. This places a ton of tensile stress on the muscles and they go through a significant recovery and repair cycle that promotes stiffness similar to the backside capsule. Based on these three pieces that result in a loss of IR, both the capsular and muscular changes are able to be altered by your physical therapist if needed.
Pathologic GIRD is now seen in the graphic below. There is a loss of internal rotation which ALSO results in a loss of the total arc of motion from 180 degrees. If there is pain present during throwing it is very important for your physical therapist to determine the appropriate course of action here. In this instance, we work to reduce the stiffness of the capsule and muscles of the rotator cuff/scapula as these are the two causes noted above that are able to be affected through treatment.
Now that we know what GIRD is and what it is not, let me hop up on my soapbox for a minute. Pathologic GIRD is actually very UNCOMMON. In three years of working regularly with all levels of throwers from the adolescent, high school, college, and professional levels I have seen ONE case of true GIRD. In my practice it has become a term that I try to avoid even using because it is always negative. To treat it, my job is to increase mobility into internal rotation. If that is not the true cause of pain and symptoms (and usually isn’t!) I am creating MORE instability and WORSE muscular control. This then results in more stress to the shoulder or elbow, more pain, decreased velocity, and decreased control of throwing.
Remember the harmful effects of GIRD? Yeah, me too. In reality, most throwers display a limited total arc of motion with less IR than the non-throwing arm. However, it is not a loss of IR that results in this change in the arc, but a loss of ER! Unfortunately, I’ve had way too many athletes receive treatment for shoulder issues that only get more painful, reduce their ability to perform, and ultimately take longer to resolve. I will leave you with one final thought: the throwing motion is developed throughout the lifespan. There is no way to predict whose shoulder will adapt into the most humeral retroversion nor is there a way to speed up that
process. If you’re having pain with throwing at the shoulder OR elbow, that is not normal and unfortunately will not just go away.
PSA for those parents trying to breed the next star pitcher: Please don’t have them lay on their back holding a weighted ball for 10 minutes to increase ER in the layback position. This will be much more harmful than beneficial. The goal is to keep throwing, keep playing, get appropriate time off, and the changes will come.
If you made it to this point, thanks for sticking with me! Throwing is one of the most primitive movements, and rotational athletes are still vastly underserved in the strength/conditioning and rehab realm which drives my passion even more! If any of this resonates with you, or your child is constantly complaining about shoulder and elbow pain, this isn’t something to wait on. Come see me and let’s fix problems well before they start limiting playing time!
Does your shoulder snap when you raise your arm overhead? Do your knees crack when you go up and down stairs? Do your hips pop when you squat? Is this normal? My body sounds like Rice Krispies...snap, crackle, pop…. Is that okay?
These sounds could be due to a number of things such as muscle tendons moving over each other or moving over bones, air building up in our joint spaces, or crepitus (grinding and clicking). In many cases, the noises that our bodies make end up being more of an annoyance than being problematic, especially if there are no other symptoms associated with these sounds. But if you do have associated pain, limited range of motion, limited strength, or have experienced some traumatic event that caused these sounds, then it may in fact be problematic...more on this to come.
Let’s start by addressing clicking and popping. For example, our shoulders, being one of the noisiest joints, are complex structures. They are known as “ball and socket” type joints with the “ball” being the head of the humerus (our upper arm bones) and the “socket” being part of the shoulder blade. “Ball and socket” type joints allow for a lot of motion, especially in the shoulder because of the size of this joint being comparable to a golf ball on a tee. Because of this, our shoulders are relatively unstable, making us rely heavily on the muscles around it to help stabilize. So oftentimes, the clicking or popping you feel, is simply all of the structures surrounding that joint (muscles, tendons, bursa) moving on one another. Similarly, popping and snapping in the ankles is another common complaint we hear. This is likely due to the tendons on the outside of your ankle slipping over bone. This could be due to a number of things, but most commonly the tendons are sitting in a more shallow groove or the band of tissue that usually holds them in place is weak, so there’s more of a chance for movement/slippage. Similar to the shoulder, the clicking may be irritating, but as long as it’s not painful, it’s almost never anything serious.
Another reason you could be experiencing pops in your joints could be due to the build up of air or gas in your joint spaces. This is known as a cavitation. Surrounding most joints is a capsule of liquid known as synovial fluid. This allows for lubrication of joint surfaces and smooth movement. For a cavitation to occur, a joint (or 2 opposing surfaces) is distracted up until a point where they separate rapidly resulting in the creation or collapse of an air cavity in the synovial fluid that produces a popping sound. This again is harmless, especially in the absence of pain. For years, it’s been thought that cracking or popping joints will give you arthritis. There’s a lot of research out there that disproves this theory such as Dr. Unger’s (who received a Nobel Prize for his research) study where he reported that he had been cracking the knuckles on his left hand at least twice daily over a 50-year period, while the right hand was never cracked and used as a control. The result? No arthritis in either hand.
Another sound I wanted to address is crepitus, or the grinding/creaking sensation our joints make. Crepitus is caused by the rubbing of cartilage on a joint surface or other soft tissues around your joints during movement. It’s common to hear this specific sound in the knee joint. Usually, your patella (knee cap) is supposed to glide smoothly over your femur (upper thigh bone) during bending and straightening of the knee. The cartilage in between these bones is what allows this smooth movement. Overtime, cartilage surfaces may start to become rough, which is a normal part of aging and is the crunching sound you hear. By itself, crepitus generally is not a cause for concern. However, over the years, once the cartilage does become rough, it’s more likely that it will wear down and could in fact lead to arthritis and accompanied pain. BUT, you can combat this simply by staying active. Having a healthy body weight and strong muscles that surround your joints can help take some of the load off of them. Also, because cartilage has a relatively low blood supply, it relies heavily on movement and activity for the influx of blood and nutrients to help keep it healthy and strong. So stay moving.
The bottom line is that these sounds usually mean nothing at all. But if you ARE in fact dealing with any of these sounds and have associated pain, swelling, redness, had some kind of traumatic event, or are suddenly less able to move a joint, then it may be time to get it checked out. When left untreated, some joint conditions can lead to increasing pain, joint damage, and eventually, disability. But if identified and treated promptly, most joint problems can be successfully managed.
Thanks for reading!
This is where we share our expert opinion on hot topics in physical therapy, injury prevention, sports performance, strength and conditioning, nutrition, and sometimes other random thoughts. Enjoy.