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Lower back pain is the single leading cause of disability worldwide, with about one-half of all working Americans admitting to having back pain symptoms each year. These numbers are astounding. So the question is not if you get lower back, it's more like when you get lower back pain -- what should you do about it? Most of the time we aren’t sure why what caused our lower back pain to start in the first place, much less what to do to make improvements. The following are things you SHOULDN’T do to help get you back on the right track. Lower back pain can be like an old scab -- if you continue to do things don’t allow it the opportunity to heal, it wont! Fail to acknowledge that its there Don't settle because your old, fat, out of shape, tried therapy, or someone said you had a herniated disc. Don't let it become a part of your identity. Having pain is not normal, and sometimes we struggle to recognize this. If you experience lower back pain or extreme tightness after your workouts, something's not right. It's always better to take action now before it turns into a more frustrating, more painful issue that can lead to unnecessary costly injections and procedures down the road. If you have pain, even minor pain, take action to eliminate it.  Continue doing things that aren’t helping I actually had a patient once who severely injured her back performing an overhead squat. She saw a chiropractor, was was told she will need to do prone press ups the rest of her life. Seriously? This isn’t a hit on chiropractors because I see it happening all the time in the physical therapy profession too. After 2 weeks of simple treatment specific to her injury, she was back to working out without issues. If you’ve been told something like this, or if you’ve been doing the same lower back routines day in and day out without long term relief, it might be time for a change. When it comes to the lower back, “rehab” or “conditioning” exercises should not be painful, and typically it don’t take long before patients start experiencing significant relief (if you select the right ones). If you’ve been doing the same movements or exercises for weeks or months, it's time to consider some different avenues.  Sit or rest for long periods First rule of thumb → after a lower back flare up or aggravation, that last thing you want to do is sit on the coach, binge on Netflix (unless it's Game of Thrones) and try to wait it out. If it’s really bothering us, sometimes we don’t want to move at all, however if we avoid movement, we allow the problem to fester. It may be uncomfortable to get started, but exercise has been proven to be beneficial for nearly all low back pain cases. The best action is to find a simple form of exercise that feels okay. Examples might include going for a walk, spending time on the stationary bike, or doing some light rowing. When we move around, important healing hormones are released which circulate throughout the body, and nutrient rich blood flow is directed to the healing areas. It also causing increased muscle activation, thus providing more stability to aggravated area.  Do things that are painful While this may seem like common knowledge, when our back tightens or flares up, often we continue to engage movements or positions that aggravate the area. It's almost like picking a scab. If we continue to aggravate it, it simply will be slow to recover. If a particular lift or movement (i.e. deadlift, burpee) continues to cause pain, it’s time to take a break from it. Pain is a signal that something isn’t right. Either sub the exercise out or modify it so its pain free. Just as its important to consider activities in the gym, is to consider painful activities outside of the gym. Sitting for extended periods, sleeping on your stomach, driving for long periods, lifting heavy objects with poor form, and twisting awkwardly are all common activities that tend to increase your pain. Be smart and listen to your body.  Lift with poor body mechanics Speaking of lifting, If your going through a period of lower back pain or tightness, it's important to recognize if you’re putting unnecessary stress on your back… whether from poor body mechanics when picking something up from the floor or poor technique when weight lifting. Allowing your weight to shift towards your toes when performing these activities puts increased strain on your back. Recognizing this simple concept can significantly reduce lower back pain and pressure. It's also important not to bend at your back throughout the day. If you need to pick something up, make sure to keep it close to the body and use your legs, even go down to one knee if you have continued pain.  Don’t seek help from a back pain expert (physical therapist) when you know you need it
If you’ve had an acute flare-up or experienced pain for more than a week or two, stop wasting time and see a doctor of physical therapy. Lower back pain is the most common thing we treat. Do you need a referral from an MD? No. Do you need imaging (x-ray or MRI) before treatment? No. Research studies have shown that 60%+ of people WITHOUT lower back pain have imaging studies that show bulges or degenerative changes. While it is noble to try to manage the pain yourself, the earlier you start treatment, the better your chances are of making a smooth recovery and quickly returning to normal activities, and keeping it at bay for good. If you’re a CrossFit athlete, check out my FREE ebook on the most common reasons CrossFit athletes suffer from lower back pain, and what to do about it. Just click the link below! Thanks for reading, Dr. Andrew
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This is one of the most common questions I get so I thought it would be good to expand on it today. It's the all to common story -- you’re mid wod, doing great, then all the sudden your back gets tighter… and tighter... and tighter… and so tight to the point where you’re forced to grab a weight belt or take extra long rest breaks. Your lower back muscles eventually get so tight you quit the workout in fear that you might do some long term damage. Now your on the sidelines frustrated and wondering why. Well, you’re essentially overloading the muscles of the lower back leading to the excessive “pump” feeling. This can happen from a number of causes, but here are the reasons why: You have tight hip and a stiff thoracic spine (mid/upper back) Our daily habits OUTSIDE of the gym play a tremendous role in your ability to workout safely. If we develop stiffness in the areas above and below the lumbar spine - the thoracic spine and hips - our bodies will cause the lower back to work harder to pick up the slack. And we all know happens when we overwork our lower back. If you sit all day, whether at work, while driving, or binge watching NetFlix, chances are you have tight hips, specifically the hip flexors (known as the iliopsoas). This muscle has a direct attachment to all the lumbar spine vertebrae and is one of the top contributors of lower back pain and tightness. It is absolutely essential that you spend extra attention here. Add both the world's greatest stretch (video below) and kettlebell psoas release (video below) to your warm-up routine. Also spend extra time warming up as a whole - being warm and loose increases the your bodies ability to circulate blood and fluid, which will help to mitigate the pump feel and decrease the chance it will fire up.
You use your back when you shouldn’t If you’re dealing with lower back tightness, chances are your failing to hip hinge. Meaning in instances where you should be using your hips and legs to complete tasks, you’re using your back. This can range anywhere from picking up heavy plates and loading the bar to rounding during a deadlift or dumbbell power snatch. Speaking of the dumbbell snatch - how many times have you “blown up” your back with high reps of this exercise?? You are likely not thinking about your legs enough and bending at the back with every rep. Take your time (as fast as you can of course haha), and use your legs more. Bend at the hips and try not to round at the back.  You lack weight shift control while lifting This one is HUGE. How often do you pay attention to how your weight is distributed within your feet? When performing an exercise, every time you shift towards your toes you increase pressure and demand on the lower back. This can happen with any exercise but especially when the weight (or your weight; ie running) is in front of your center of mass. This commonly occurs with front squats, cleans, overhead squats, deadlifts, dumbbell snatches, barbell thrusters, wall balls, kettlebell swings, and burpees. I bet these are some of the most common movements that tighten up your back, right? Pay attention to how your weight is distributed in your feet! Ideally your weight should be evenly distributed between your heel, the ball of your foot, and just behind the pinky toe OR shifted more towards the heel only depending on the movement (ex: deadlift). Being conscious of this tip alone will make a huge difference.  You lack core strength and control
Essentially you’re allowing too much spinal motion during your CrossFit movements -- both extension backwards and flexion forwards. A great example of when this occurs is when pushing weight overhead. If your shoulders are tight, you’ll likely extend at the lower back to get the weight fully overhead. Not good. Another example is the power clean -- when the load starts to get heavy, an athlete will often extend forcefully at the lower back, and even worse, catch the load in the extended (over arched) position. Here's where athletes go wrong. They are often told by Dr. Google or another healthcare practitioner to strengthen the lower back with movements like supermans, reverse hypers, or bird dogs. What you should be doing is training stability of the anterior core. And i’m not talking the 6 pack exercises like crunches, russian MB twists, or sit ups. I’m referring to “anti-motion” exercises like the plank, pallof press, or ball slam. These exercises will give you the stability you need to prevent the overworking tightness on the posterior side. Add them into your routine. It sucks when your lower back starts to tighten because it can often ruin a workout. Paying attention to these key 4 concepts will make a huge difference when implemented regularly. What doesn’t work includes inversion tables, hot packs, e-stim, gravity boots, hamstring stretching, foam rolling, or other passive modalities. If you want a long term fix, take action. Lower back pain is the number 1 area we treat at The Charlotte Athlete and we would be glad to help. If you’re in the Charlotte area and are interested in working with a unique professional that can help you improve your lower back health long term, we need to talk. Being proactive and staying on top of your health will help you avoid serious health problems down the road. Submit a contact request by clicking the button below and we’ll get you set up with one of our Doctors for a free 15-minute phone consult. Thanks for reading, Dr. Andrew Have you ever seen someone squat in the gym with their knees about to touch? What about that time you were running behind someone and watched their knees give in whenever their foot hit the ground? A voice deep inside of you says that doesn’t look right. Their knee is basically caving in. Then, you are at the gym one day and record yourself squatting or watch yourself squat in the mirror, and then suddenly you realize YOUR knees cave in too! Is this normal??  The short answer is no – as this movement pattern has been highly correlated with an increase in both traumatic (ex: ACL tear) and non-traumatic (ex: patellar tendinosis) injuries. However, this movement pattern is so common, some might consider it normal. Let’s first talk about what’s going on here. Firstly, this movement pattern is known as dynamic knee valgus, also referred to as valgus collapse or knee caving. The knee joint functions generally as a hinge joint; however, it also rotates subtly both in internal and external rotation as we flex and extend out leg. This mild rotation cannot be overlooked. If we develop excessive amounts of rotation in either direction, shear forces increase, and pain can result.  Knee valgus occurs when we combo this excessive rotation with hip adduction and often opposite side pelvis/hip drop. Now, many athletes will display this movement pattern without pain – this relates directly to their tissue tolerance. These athletes haven’t created enough shear yet to reach the pain threshold, and often they can get away with it, sometimes for a long period of time. However, if left untreated, it can lead to patella-femoral pain syndrome, IT band syndrome, patellar tendinosis, hamstring tendinopathy, meniscal tears, ligamentous injuries and a host of other issues up and down the chain. So what causes excessive rotation at the knee? For starters, women are more likely than men to display this movement pattern during activity, much of which is related to their anatomy (wider hips and “Q” angle – see below). It’s also commonly seen in sports or activities that require ‘toeing out’ such as with ballet dancers, soccer, basketball, and ice skaters. Some people may have structural factors such as natural bone structure in their hips, knees, and ankles which may predispose them to have more knee valgus than others. However, the knee valgus we refer to the most is dynamic knee valgus which occurs during movement, and often due to a variety of modifiable risk factors. It’s often correlated with squatting, jumping, running, lunging, but can be present anytime we bend our knee while weight bearing.  Here are the top reasons dynamic valgus can occur:
Knee valgus could initiate from a combination of these factors, but once it “sets-in,” it becomes a brain/nerve problem (muscle memory) and not just a strength or flexibility problem. Therefore, you’ll always have to re-groove squat patterns even after restoring impairments or imbalances.  If your dealing with this movement pattern, you need to put in effort to correct it. Understand that just because you may not have pain at the moment, it doesn’t mean that its normal. Making efforts to keep your knees in relative alignment with your hips and ankles when your workout can go a long way. First see if you can correct the movement pattern by simply paying more attention to your technique. If it still feels very difficult, it may be related to your mobility (hips and/or ankles) or your strength balance (glute max and glute med primarily). Check out our YouTube channel for great hip and ankle mobility exercises. For strengthening; exercises like deadlifts, lunges, step ups, side steps, or KB swings – all of which target the glutes – are great options. If you’re dealing with knee pain and want the fast track back to 100%, we can get you there. E-mail andrew@thecharlotteathlete.com or click the button below to get started! Thanks for reading, Jesse Xiong Edited by Dr. Andrew The diaphragm! The diaphragm plays a major role in trunk stabilization and posture by creating and modulating the correct amount of IAP to minimize excessive spinal motion during movement in sports. As the intensity of any activity increases, the tendency is for less diaphragmatic activity and increased thoracic breathing, or "chest breathing.” Chest breathing is produced by the accessory muscles of respiration, which includes the upper traps and many of the neck muscles. It becomes problematic during breathing when these dominate over the lower muscles such as the diaphragm. Over-activity of these accessory muscles have been also linked to many postural and motor control issues, especially in the neck and shoulders, and reduces the ability to produce sufficient IAP for proper stability during activity.  Okay, so what exactly is diaphragmatic breathing? Let's first talk about what it’s not. Diaphragmatic breathing is NOT the same as belly breathing. When someone takes a deep breath and you see only their belly rise, many people think this is the proper cue because it appears they are using the diaphragm correctly – but it’s actually incorrect. The key to proper diaphragmatic breathing is what we call 360 breathing – where you get 360 degrees of abdominal expansion. We don’t just want a forward distention of the belly as in belly breathing, we want a 3 dimensional expansion – forward, backward, and side-to-side. We want to see this without too much upward movement of the chest. 360 breathing is key for IAP development, and that’s true core stability. The better you can perfect 360 breathing, the more effective those big breathes prior to a 1RM squat will be, and the more efficient your CrossFit workouts will become.  When it comes to our CrossFit and weightlifting workouts, we need to be able to do 2 things well. We need to achieve what the experts call: (1) synchronization with movement and (2) coordination during recovery. Synchronization with movement is basically the ability to have the diaphragm create the necessary IAP to provide core stability for that specific movement demand. For example – when you are doing a heavy lift, let’s just say a deadlift. Prior to the lift, you inhale. As you initiate the lift, which is typically the heaviest part, you hold that breath which creates your IAP to stabilize. Some people maintain this hold throughout the lift, and some people slowly exhale throughout the lift. Doesn’t matter. The most important aspect was the synchronization of the most IAP with the most difficult part of the lift, which was the initiation. Ideally, we want really good synchronization of breathing during any kind of performance. A great example is the barbell thruster. You all know how important it is to exhale in rhythm at the top of the lift. The key is to take that same concept and apply it to all our movements. In regards to coordination during recovery, this refers to recovery both during our CrossFit workouts, and afterwards. The goal is to maximize the total amount of air we breathe both in and out as much as possible, which will allow the most oxygen intake and carbon dioxide output. This occurs if the diaphragm is allowed to move through the zone completely….which means minimizing chest breathing.
SO during our workouts we need focus on controlled 360 diaphragmatic breathing, not just when were tired, but from the get-go. Remember – the diaphragm is a muscle, so it responds to stimulus and it can be trained. The more you practice, the better it will function and the better you will feel! Thanks for reading, Dr. Andrew Other than bracing for a heavy lift, most CrossFit athletes don’t pay much attention to the way they're breathing—inside or outside the gym. How many times a day do you think we breathe? Typically over 20,000 times! Breathing is a foundational movement that plays a critical role in not only oxygen in and carbon dioxide out, but..
 Shallow breathing, which is using the chest and not the diaphragm, is a very common dysfunctional breathing pattern that doesn't allow you to get as much oxygen as you otherwise would — it mimics the type of breathing common during stressful situations. You see this all the time in athletes. They will perform a tough workout, and they will partially hinge over, hands on their knees, and drop their head down and try to catch their breath. And you will see their shoulders are up by their ears. I’m guilty of this at times as well – over the past few months as I’ve revisited these concepts I’ve been able to adjust my ability to recover through proper breathing, and it’s made a HUGE difference. There's nothing worse than being dead out of breathe during these workouts without muscle fatigue. Okay so what exactly is going on here? Well, dysfunctional breathing can have many negative consequences on respiratory chemistry which can have a huge effect on a wide range of system functions….. respiratory chemistry meaning the balance of chemicals in your lungs and breathing systems: 1). Chest breathing causes an increased amount of CO2 in your body, which increases the acidity of your blood. The more acidic your blood becomes, the more inefficient your muscles will be, and overall performance will suffer. 2.) Elevated CO2 levels also put your body in what's called a “fight or flight” state -- which is a stress response that occurs in your body during a threatening situation. This can increase HR, increase anxiety, increase stress, impair reflexes, and impair focus. 3.) Speaking of focus – How many of you have pile-drived through a workout and midway through suddenly can’t remember what round you’re on or what your rep count is? Breathing affects this as well. Being focused on the task at hand is just as important as performing the task. Focusing on breathing correctly (think quality vs quantity) will create:
 Now, we talked a bit about performance, but what about injury? Dysfunctional breathing patterns have been shown to play a significant role in posture, technique, and movement control associated with back, neck, hip, and shoulder pain. Here are some examples: The spine is one of the most frequently injured body regions in CrossFit. There are a few things happening here with excessive chest breathers (these are related to non-acute injuries):
It’s important to recognize that dysfunctional breathing has been recognized for many years as a potential source of a wide variety of unexplained symptoms. If you're one of those people that’s had continued issues in any of these areas, you’ve received treatment, but things still linger or come back, I highly recommend you consider your breathing patterns and implement some of the concepts I'm about to talk about.  What’s also important is to recognize that your breathing patterns play a crucial role in core stability. Core stability must come from the inside out, not the outside in -- such as weight belts for example. A healthy spine is dependent on strong core stability and the dynamic coordination of many muscles especially the deep abdominal muscles. Are you familiar with what IAP is? – it’s that big breathe you take prior to big lifts, and it’s the smaller controlled breathes you take to do burpees for example so you don’t flop like a worm. Simply put, it’s the pressure your body generates from within to keep you safe during workouts.  Intra-abdominal pressure (IAP) is an important parameter that influences spinal mechanics and stiffness….. And its generated by the muscles of respiration aka breathing. What muscle is main key driver of breathing? Check out Part 2 to find out, AND learn how to breath correctly to boost performance!  So you’ve been crushing it at the gym over the past few months. Your body is getting stronger and your conditioning is improving. You can do a ton more now compared to when you first started working out. You’re finally starting to feel like an athlete! Until one day you begin to notice some nagging pain after your finish up a workout. At first it's not bad and you ignore it, but then it starts to progress and interfere with your lifts. All the sudden you’re modifying all your workouts and you’re experiencing pain through non-gym activities as well. Now a couple of weeks have gone by and your shoulder continues to get worse. You’re frustrated! You’re also not alone. By some estimates, as many as 67% of people experience shoulder discomfort at some point over the course of their lives. It's also the most commonly injured body region in CrossFit athletes. And by all accounts, I agree. 3 out of the last 4 new patients that have come to see me were for shoulder issues. Below I listed some things to consider if you’ve been dealing with nagging shoulder pain -- check them out, and make adjustments as needed.  Do you have an appropriate balance of shoulder mobility and stability? First things first, let’s clarify what these terms mean. “Mobility” refers to the ability for you to access a particular range of motion, whereas “stability” refers to the ability to be strong and sturdy throughout the range of motion, including end range (ex: when the arm is fully overhead). CrossFit, for example, is a unique sport in that not only demands extreme end-range mobility, but also adequate stability at those end ranges to handle heavy loads. If you lack the appropriate mobility to get your shoulder into the positions required to perform the exercise -- don’t force it! While i’m certainly an advocate of working into an exercise with a limitation (ex: front rack position), you don’t want to force it, repetitively, under load, during a high intensity workout. That’s just a recipe for an injury.  Do you have balanced programming? Whether you design your workouts yourself, or follow a gyms programming (such as CrossFit or weight lifting), its very easy to develop strength imbalances between opposing muscle groups. The two most common shoulder imbalances that arise are pushing vs pulling strength and “large muscle” vs “smaller muscle” strength, so let’s talk about each. Pushing exercises include those that push weight away from you -- the push-up, bench press, shoulder press, push press, etc. Pulling exercises are just the opposite; those that pull weight towards you -- pull-ups, rowing, power cleans, deadlifts, etc. If you’re programming has a tendency to overwork one particular direction, imbalances can develop over time and pain can arise. Another important imbalance involves over-dominance of the larger muscle groups -- particularly the lats, pec major, and teres major. A healthy shoulder is one where the ball (upper arm bone called the humerus) stays centered in the socket (shoulder blade, aka the scapula) during movement. When these larger muscles over-dominate over the smaller ones (specifically the rotator cuff and scapular muscles), the ball moves and glides excessively, failing to stay centered in the socket, and often leading to impingement and pain. While the “beach” muscles are fun to train, attention needs to also be directed towards stabilization and accessory exercises of the little guys.  Do you sleep on your shoulder? Our bodies heal and recovery while we sleep. If you’re dealing with nagging shoulder pain, the last thing you want to do is sleep on it. Studies have shown that sleeping on your shoulder literally cuts off the blood supply to the rotator cuff tendons, which commonly are the irritated structures that cause shoulder pain. Make it a point to not sleep on your shoulder at night, or on your stomach with your arm overhead for that matter (just as bad, if not worse). Try sleeping with your injured shoulder towards the ceiling and a pillow between your arm and your body. You should wake up everyday feeling refreshed and pain free. If this isn’t the case, adjust accordingly!  Do you also have neck pain or pain that radiates down the arm?
Most shoulder pain results from an injury or condition in the shoulder itself. However, pain in the shoulder region can also stem from elsewhere in the body, especially the neck. If your shoulder pain is also accompanied by neck pain or stiffness, it may be the neck that’s the primary issue, particularly if your pain is located in the upper trap, near the shoulder blade, or radiates down the arm. Each area of the body requires different treatments. To help you better pinpoint what the source of the problem is check out these lists below: When the shoulder is the suspect:
When the neck is the likely culprit:
So what should you do if you’re dealing with a shoulder injury? The best answer is to get yourself checked out before starting some significant training. The shoulder is one of the most common areas of the body we treat. If you’re in the Charlotte area and you’ve been dealing with a shoulder injury, give us a call. We can help get you back to do what you love faster than any other medical group in the area. Part 4 - Shoulder Pain(Including Rotator Cuff Tears and Shoulder Impingement) The shoulder complex is a tricky body region to picture the moving parts and understand how they are all interrelated. I find myself teaching basic shoulder anatomy and kinesiology to almost all of my shoulder patients because most people don’t understand what the shoulder actually looks like and how it is attached to the rest of the body. I’ll kick-off this post with the same education I give my patients. First off, take a look at the pictures below. It is important to appreciate that the “ball-and-socket” joint doesn’t have much of a socket. And it is also important to appreciate how the shoulder blade has only one small boney connection to the rest of the body (the AC joint), and otherwise the entire scapula is just gliding over the ribs at the whim of the periscapular muscles that attach to it. Finally, we can see the thorax in which the shoulder blade sits on top of. This has a natural kyphosis, or forward bend, to it.
So take that third picture. Imagine that the thorax doesn’t have the ability to straighten out. You can see how this may limit the ability of the shoulder complex to perform in an overhead position. The thorax is the foundation for shoulder movement. If this are isn’t operating properly, then we can’t expect a fully functioning shoulder. Now let’s address the second pic. This shoulder blade isn’t your typical joint. The shoulder blade can move into MANY motions; upward rotation, downward rotation, elevation, depression, abduction, adduction, external rotation, internal rotation, anterior tilt, posterior tilt, retraction, protraction, winging, and any combination of the above. With a typical presentation of shoulder impingement, the main motion that is limited is upward rotation. And lastly, look back at the first pic. You can see the socket is actually part of the scapula. So you can imagine, in reaching overhead, the ball will roll up, and the socket should move too. If the ball moves too much with relation to the socket, you can get some nasty pinching type pains in the shoulder. Looking at this picture below, you can see that it is the rotator cuff tendons that suffer from this as they are located in this region. If this goes untreated, this may result in a tearing of these tissues. Sometimes, people can have a tear in these tissues, and walk around without any pain or symptoms! In fact, having a rotator cuff tear that goes unnoticed is extremely common. However, the treatment should be directed towards treating the aforementioned underlying issues instead of focusing solely on the tear.  So how may conventional powerlifting training help? Now that you have a better understanding of the injurious cascade of untreated shoulder pain. Let’s answer the question, “How can Powerlifting training be therapeutic?” The quick answer is, powerlifting training, with correct form, will address each of the typical impairments that you see in the textbook shoulder impingement patient.
How do I get started? Sold already, but don’t know where to start? No worries! I have posted directories below that will point you in the right direction so you can find skilled practitioners in your area. The Charlotte Athlete - If you’re local to the Charlotte Area, The Charlotte Athlete is a group of healthcare providers and highly accredited sports doctors that specialize in various sports setting including Powerlifting, Bodybuilding, Strongman, Olympic Weightlifting, Crossfit, and recreational athletes and youth athletes. There is also free, quality, information on how to improve your lifts and ways to work around common aches and pains. APTA Specialist Directory - This is the directory for the American Board of Physical Therapy Specialties (ABPTS). There are options to search within each specialty. An orthopedic specialist would be able to help best with nagging aches and pains and help get you back to sport specific training. A sport specialist may help you overcome, manage, or avoid injury within your sport. Some Sport Specialists have a subspecialty with a specific sport, or set of sports. The Clinical Athlete - This is a directory of healthcare providers that happen to be athletes themselves. Again, you can search by location and filter for specific providers. Peruse each providers website to see who is the best fit for you. RSCC Registry - This is a directory of Strength and Conditioning Specialists that are registered with the National Strength and Conditioning Association (NSCA). This directory allows you to filter by location and search based on years of experience. Peruse this directory to find a Strength and Conditioning Specialist in your area. Author: Dr. Michael Masi Masi Fitness, LLC IG: @Masi_Fitness Part 3 - Knee Pain(Including: Patella Femoral Pain Syndrome, Patellar Tendinopathy, Arthritis)The knee is arguably the largest joint in the human body. It is comprised of four bones, the patella, femur, tibia, and fibula. The three most common knee pain diagnoses I treat are Osteoarthritis, Patella Femoral Pain Syndrome, and Patellar Tendinopathy.  Osteoarthritis (OA) is part of a natural degenerative cascade that effects everyone. This is not to be confused with rheumatic arthritis which is an auto-immune related, chronic inflammatory disorder. Imaging reveals OA in both symptomatic and asymptomatic patients in various body regions, sometimes beginning as early as the third decade of life. Prevalence is highest amongst those over 65 years of age. Before becoming painful and restrictive, arthritic joints are often joints that get utilized most in the body. This is sometimes portrayed as a protective mechanism against uneven wear and tear on the body, perhaps due to an inability or unwillingness to allow neighboring joints to contribute to motion. Patellar Tendonitis is a pathology characterized by inflammation of the patellar tendon. Unlike arthritis, this is an acute condition that is reversible. It is brought on by improper loading of the tendons secondary to either poor mechanics of movement or improper loading rate/frequency. Patella-femoral pain syndrome (PFPS) is knee pain around the patella that otherwise cannot be attributed to anything else. It is a diagnosis that literally translates to “pain around the knee cap.” Unlike the aforementioned knee pathologies, with PFPS there does not have to be a compromise in structural integrity of the joint or its surrounding tissues. Oftentimes, symptoms are resolved with improving the quality of movement that the patient or client is performing. To be succinct, all of these diagnoses involve poor movement, stressing various tissues, and manifesting as knee pain. The knee joint is fundamentally a hinge joint, meaning, similar to opening your front door, it moves in one plane. With the exception of some rotary motion, the knee primarily flexes and extends (i.e. bends and straightens). For a hinge joint to get faulty motion, there is usually a force being enacted on the joint in directions outside of its intended range; think of hanging from your front door as its opening. But how and why are these sub-optimal forces placed on the knee? Well, most of the painful knee movements involved closed chain activity, meaning that the foot is affixed to a surface as the knee is moving (i.e. going up/down a flight of stairs, squatting, or stooping). Considering the foot is fixed, the main joint that determines where that knee will be in space, is the hip. The hip moves the leg side to side and will ultimately determine which forces are imposed at the knee. A commonly seen problem, is that when the hip is weak, the knee may move inwards during a lunge, squat, or a step.  So how may Conventional Powerlifting training help? Almost all main powerlifting movements involve utilizing the hip musculature. Even in a bench press, the client is trained do drive through the legs, utilizing the hips to improve stability of the body during the exercise. In order to generate more force, the hip must be trained to stabilize the knees in a neutral position, as the knees come outside of the position, the body sacrifices its structural integrity, which will result in poor performance. Proper alignment during movement and exercise will also yield increased joint space which is imperative when a space occupying lesion, such as osteoarthritis, is present in the joint. So, moving with proper mechanics will increase pain free range of motion within these movements. Many of the lower extremity movements we perform throughout the day involve a squat or hinge, which are key components of the back squat and deadlift exercise respectively. Mal-alignment of the joint may also result in PFPS considering the forces enacted around the patella may be stronger on one side than the other. Considering the patella is a free-floating bone, this may create issues on how that patella tracks during movement. One of the principles of a sound squat and deadlift includes aligning the knees with the toes in order to generate more force. When done correctly, this promotes proper strength and stability around the joint, and optimal movement around the functional patterns being trained. This also enables the hips to contribute more to the movement, which involves muscles that have larger force generating capabilities than those that surround the knee joint. Literature currently suggests that hip strengthening should be a key component of PFPS rehabilitation likely for the aforementioned reasons. As stated before, tendons respond to improper loading. Sometimes the form can be perfect, but the body is asked to do to much over too short of a time without the proper conditioning. This is usually seen when the total volume of work is increased beyond the body’s ability to recover. During rehabilitation, volume is scaled back considerably and exercise intensity increases as per the patient’s tolerance. This very closely emulates the programming of powerlifters! How do I get started?
Sold already, but don’t know where to start? No worries! I have posted directories below that will point you in the right direction so you can find skilled practitioners in your area. The Charlotte Athlete - If you’re local to the Charlotte Area, The Charlotte Athlete is a group of healthcare providers and highly accredited sports doctors that specialize in various sports setting including Powerlifting, Bodybuilding, Strongman, Olympic Weightlifting, Crossfit, and recreational athletes and youth athletes. There is also free, quality, information on how to improve your lifts and ways to work around common aches and pains. APTA Specialist Directory - This is the directory for the American Board of Physical Therapy Specialties (ABPTS). There are options to search within each specialty. An orthopedic specialist would be able to help best with nagging aches and pains and help get you back to sport specific training. A sport specialist may help you overcome, manage, or avoid injury within your sport. Some Sport Specialists have a subspecialty with a specific sport, or set of sports. The Clinical Athlete - This is a directory of healthcare providers that happen to be athletes themselves. Again, you can search by location and filter for specific providers. Peruse each providers website to see who is the best fit for you. RSCC Registry - This is a directory of Strength and Conditioning Specialists that are registered with the National Strength and Conditioning Association (NSCA). This directory allows you to filter by location and search based on years of experience. Peruse this directory to find a Strength and Conditioning Specialist in your area. Author: Dr. Michael Masi Masi Fitness, LLC IG: @Masi_Fitness Part 2 - General Low Back PainLow back pain (LBP) is the number 1 most common orthopedic issue treated by physical therapists and seen by sports medicine physicians. This is an extremely common problem, as the lifetime prevalence of LBP is upwards of 70%! This suggests that up to 70% of the population have, at some point in their life, experienced LBP. Furthermore, most people who experience activity-limiting LBP go on to have recurrent episodes. Estimates of recurrence at 1 year vary, but studies suggest these numbers may be as high as 80%. LBP causes more global disability than any other condition. This is the leading cause of activity limitation and work absence throughout much of the world, imposing a high economic burden on individuals, families, communities, industry, and governments. Let that sink in for a bit. LBP is a pandemic, experienced at some point by the majority of the population, which limits people from performing their activities at work and their activities of daily living. These activities primarily include, lifting, carrying, squatting, pressing, pulling, reaching, and prolonged positioning. So, it makes sense, when training for health and injury prevention, to use these movements in your training and to perform them well. It would not be a stretch to suggest that repeatedly performing these movements incorrectly, or not being conditioned appropriately to handle the stressors of these movements, can generate the symptoms of LBP. Let’s take a brief look into the anatomy of the lower back as it relates to the regions above and below. The lumbar spine is made up of 5 boney segments, otherwise known as vertebrae. These vertebrae are separated by gelatinous discs that absorb shock and allow considerable flexibility. If you look at the cross section of this area below, you will see the spine is not in the middle of the body. It resides along the back side. Leaving considerable surface area to be supported by the residing musculature.  The body region immediately above the lower back is the thorax. The thorax consists of the 12 thoracic vertebrae with their coinciding discs, and a rib on either side that wraps around the body connecting to the sternum or the surrounding cartilage. Some of these ribs do not connect, but still provide support and protection for the organs housed within. Though mobile, the thoracic spine provides considerable stability due to the its circumferential distribution.  The body region directly below the lower back is called the pelvis. The lumbar spine sits directly atop the sacrum, which is 5 boney vertebrae fused together to create a triangular structure. Connecting to the sacrum are the remaining pelvic bones that, much like the thorax, create a ring and attach together in the front of the body. Each articulation is supported by a network of ligaments that prohibits any substantial movement. These bones are also referred to as the hip bones because the femur articulates with them as well.  Considering the anatomy, one can’t help but appreciate the juxtaposition of the lumbar spine as it relates to the adjacent body regions. The lumbar spine is an inherently mobile, and relatively unstable, area of the body. The thorax and pelvis have some of the largest muscles of the body (Latissimus Dorsi and Gluteus Maximus respectively) as well as some of the strongest inert tissues (Sacroiliac Ligament, and the Y-ligament). It makes sense that low back pain is a very common problem, and the number 1 most treated orthopedic condition.
So how may conventional powerlifting training help? Well, first consider the seven most trained movements within the sport (i.e. squat, bench, deadlift, overhead press, pull-up, carry, and bent over row). These emulate functional tasks that we perform daily, tasks that my patients complain they cannot do well without pain (i.e. picking up objects, carrying child or briefcase, standing or sitting to various surfaces, lifting and reaching into cabinets overhead, pushing open doors, etc.). Next, consider that strength is the primary objective for powerlifters. That means that it would be in the competitors’ best interest to use muscles that have a greater ability to produce force. The glutes, being incredibly stronger than any muscle spanning the lumbar spine, create motion at the inherently stable hip joint. In this sport it is encouraged to exhaust the range of motion utilized from these joints and to mitigate motion from the lower back in an effort to produce the most force and move through heavier resistances. This requires incredible strength and control of core musculature and the ability to disassociate the hip from the lumbar spine during movement; two attributes that most physical therapists will be assessing and improving on most of their LBP patients. Lastly, lets look at the identified modifiable risk factors for low back pain; occupational posture, depressive moods, and obesity. That means these attributes are the risk factors somewhat without our control to modify in an effort to alleviate or avoid LBP. Exercise in general is effective at modifying mood by releasing endorphins, increasing serotonin, and normalizing sleep. Exercise is also effective at combating obesity, though powerlifting specific training may have the capacity to burn more calories per time spent training. This is in comparison to other styles of training that do not address multiple muscle groups and body regions simultaneously with little, if any, external support. Furthermore, body weight is an important factor considered when determining the best lifter in a powerlifting competition which may require athletes to manage their weight to remain competitive. How do I get started? Sold already, but don’t know where to start? No worries! I have posted directories below that will point you in the right direction so you can find skilled practitioners in your area. The Charlotte Athlete - If you’re local to the Charlotte Area, The Charlotte Athlete is a group of healthcare providers and highly accredited sports doctors that specialize in various sports setting including Powerlifting, Bodybuilding, Strongman, Olympic Weightlifting, Crossfit, and recreational athletes and youth athletes. There is also free, quality, information on how to improve your lifts and ways to work around common aches and pains. APTA Specialist Directory - This is the directory for the American Board of Physical Therapy Specialties (ABPTS). There are options to search within each specialty. An orthopedic specialist would be able to help best with nagging aches and pains and help get you back to sport specific training. A sport specialist may help you overcome, manage, or avoid injury within your sport. Some Sport Specialists have a subspecialty with a specific sport, or set of sports. The Clinical Athlete - This is a directory of healthcare providers that happen to be athletes themselves. Again, you can search by location and filter for specific providers. Peruse each providers website to see who is the best fit for you. RSCC Registry - This is a directory of Strength and Conditioning Specialists that are registered with the National Strength and Conditioning Association (NSCA). This directory allows you to filter by location and search based on years of experience. Peruse this directory to find a Strength and Conditioning Specialist in your area. Author: Dr. Michael Masi Masi Fitness, LLC IG: @Masi_Fitness  Sprain your ankle, tweak your back, sharp knee pain at the bottom of your squat? For many, the next step is to slap an ice pack or a bag of frozen peas on it. It's even likely that your doctor recommends that you “RICE” (Rest, Ice, Compression, Elevation) the injury, which has been the go-to post-injury treatment for almost 40 years. But does ice really help the healing process? What if RICE is wrong? Nearly everyone who ices today believes they're doing it to prevent inflammation, reduce swelling, and control pain. But here’s the problem - icing doesn’t prevent inflammation or swelling, it may even delay it. Though icing has been considered a mainstream treatment by everyone from physicians to athletic trainers, a closer look reveals the practice to be more of a habit than based on scientific evidence. Even the physician who coined the term RICE (Dr. Gabe Mirkin in his 1978 sports medicine book) has officially retracted his stance on rest and ice. In fact, a 2012 review in the British Journal of Sports Medicine stated, “Ice is commonly used after acute muscle strains but there are no clinical studies of its effectiveness.” We know far more now about the role of inflammatory cells and healing then we did in 1978, and we’re discovering that applying ice can not only delay healing, but may even increase the overall recovery time. Let's take a closer look why. How inflammation works The human body is one of the most resilient machines in existence. Over thousands of years, we have become extremely efficient at healing following an injury and really good at recovering. When you damage a tissue through trauma or injury, your body produces inflammation, and for a good reason. Inflammation is the body’s natural response to protect itself from harm. It does this through your immunity, the same biological mechanisms that you use to kill germs. If you have an infection or disease, your immune system dispatches potent chemicals, cells, and repair proteins into the infected area to kill the germs. Similarly, when you suffer tissue damage or an injury, your immune system sends the same army of inflammatory cells and potent chemicals to sweep away cellular debris and deliver healing nutrients. Those chemicals and cells set off a cascade of reactions that we refer to as inflammation. More importantly, this is also what initiates the HEALING process. What about swelling? Swelling occurs as a waste byproduct of the inflammatory cascade that accumulates around the injury. Swelling is a sign that the repair processes are at work, but you want the body to naturally remove it as quickly as possible. Swelling reduces naturally via the lymphatic system, one-way vessels that remove waste products from our body. However, the lymphatic system is passive, meaning it relies on the natural contraction and compression of muscles to pump out fluid. When ice is applied to a body region for a prolonged period, nearby muscles suffer a decrease in their ability to contract and waste doesn’t get removed. Further, ice inhibits lymphatic pump opening. Applying ice to an inflamed area essentially hits the pause button on and may actually delay the healing process.  But ice makes it feel better
No doubt, ice can reduce pain and make you feel better. One thing ice has been shown to do effectively is reduce pain. Studies have shown that even people with chronic pain feel better after using ice or cold therapy. However, if the goal is to help the lymphatic system evacuate trapped waste from the damaged area or to help deliver fresh blood and nourishment to the region, ice should be used sparingly. Remember, ice only dulls the pain, so it also may create a false sense of security, which may tempt you to work out again before your body is ready. Bottom Line Ice is a cheap, effective, drugless method for taking the edge off the pain of fresh injuries. Safe application of ice to your skin can relieve symptoms from sprains, strains, bruises, and tendinitis. But the fact of the matter is, icing appears to have no effect on recovery at all, good or bad. What few studies we have on this just show - no difference. My Recommendation - The Active Recovery Alternative So what is the alternative to icing and resting? The answer is active recovery. The loading (mechanical stress on tissues caused by muscle activation and contraction) of tissues associated with active recovery has been shown to accelerate healing of bone, fibrous tissue, and skeletal muscle. Tissue loading will bring in nourishment and supplies, remove waste products, improve production and release of healing hormones, and remodel the injured tissue. If you suffer an acute injury, stop exercising immediately. If the pain is severe - you are unable to move or bear any weight through it - you should seek out medical attention. If swelling is present, I recommend intermittent icing (no more than 10-12 minutes) off and on for the first 24-48 hours. After this initial phase, icing has not been shown to do any good. Since the lymphatic system relies on muscle activation to remove waste, light exercise and pain-free movement can jumpstart the healing process. Recent research has shown that active recovery is effective for reducing inflammation and cellular stress post- exercise and post- injury. The simple act of getting your heart rate up will increase circulation and assist in flushing out swelling and inflammation. While icing may be helpful to decrease pain in the acute phase, increasing your amount of movement and exercise in a progressive, controlled, pain-free manner, is paramount to a fast recovery, and will assist in getting you back to your sport as fast as possible. Hope you enjoyed the read! -Dr. Andrew |
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.
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