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Tools of the Trade

Here is a picture of all self massage tools I use. Each one has a particular application, they range from big – small: foam roller, medicine ball, soft ball, tennis ball, pinky ball and hard blue ball (squash?). The foam roller is the softest and has a broad contact point which is good for sensitive bodies and large muscle regions like the glutes, hamstrings and calf. The medicine ball works the same larger muscle groups but it is harder and a more pointed contact area. The soft ball is ideal for folks with a larger body mass, it’s also hard so it is good for deep, firm pressure.

Examples of self massage

 

 

 

Self massage using hands and elbows

There are situations when the best tool for self massage is our own hands (or elbows). Touching the part of our body that hurts or is injured is one of the most natural responses to the pain experience. In my experience many people have a profound sense of disconnection to their own body and the experience of body sensation and the emotional states of feeling. Self massage can be used to reconnect, repair and restore the mind/body relationship. Pain is both a physical and psycho-emotional experience. The self directed therapeutic process of self massage can foster a feeling of proactive self control.

Deep calf, medial collateral ligament and pectoral muscle w/nerve glide

Self massage, also called self-myofascial release has become a standard practice in the fitness, rehab and sports performance community for good reason. The repetitive stress of exercise and training can take a toll on muscles and connective tissues like ligaments and tendons. Painful muscle tissue (trigger points) can restrict full muscle function leading to decreases in muscle length/flexibility and strength. Poor muscle function also means poor joint control (tendon/ligament pain). It’s a slippery slope

 How does it work?

Applying pressure to muscles increases the movement of  fluids like blood/lymph, this can be beneficial if there is soft tissue trauma and edema/inflammation. Muscle soreness from exercise/training is due to micro trauma (inflammation) within muscle cells, self massage is one intervention that can aid in the recovery of exercise soreness.

Injured muscle tissue can also become stiff due to spasm, trigger points and mechanical tissue stiffness called adhesions. The formation of scar tissue is a natural component of how the body repairs damaged soft tissues. The adhesions within muscle tissue/fascia can restrict muscle length (flexibility). Self massage can alter the mechanical property of soft tissue by relaxing muscle spasms and “releasing” restricted tissue (scar/trigger points) this leads to better range of motion/flexibility.

Pressure also stimulates the nerve receptors in the skin, muscles, tendons and ligaments. Muscles spasms and the experience of pain is a nervous system phenomenon that is part of a feedback loop communication system. Massage stimulates these nerve receptors altering the signal (pain/spasm) sent to the brain/spinal cord this in turn alters the muscle tone either decreasing/increasing.

Muscle weakness is common with muscle spasms and pain even if the spasm/pain is on a low level. A muscle contracts by generating force via nervous system activation. With spams, trigger points and pain the nervous system activation of the injured muscle will be diminished. Self massage can be very effective at restoring muscle strength that has been compromised due to nervous system inhibition.

Pain and associated muscle dysfunction is a complex process that effects numerous body systems. In addition to the physical experience of pain there is emotional and cognitive experience of pain and limited mobility that can overshadow the physical process. When I teach someone self massage I am giving them self care tools that are empowering and proactive.

“Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime”

 

 

Knee pain is a common complaint for a large percentage of the US population seeking medical care especially the athletic population. There are various names for knee pain depending on symptoms, diagnosis and location. Patellofemoral syndrome and chodromalacia are common terms. Other possible causes of knee pain include arthritis, meniscus/cartilage damage and ligament sprains. This article is going to focus on the role of  body alignment and how this relates to knee pain, arthritis, injury and joint replacement.

The picture on the left is a client with an anatomical leg length difference, the right leg is longer. You can see how the belt line tilts up to the right. His original complaint was back pain, I used this picture as an educational tool to show how alignment effects joints throughout the body. If you look carefully you can see the right lower leg angles out more than the left. There is a sharper bend to the right knee as well. With a longer right leg the weight of the body shifts: the pelvis tilts down on the left which “pushes” the weight over through the right knee.

This image from an orthopedic text illustrates the same alignment (Genu Varum/bow legs) as my picture. This alignment can be hereditary if both legs bow out. If one leg bows out more than another there is a good chance this is related to knee ligament/meniscus damage, poor pelvis control or leg length difference. Regardless of cause this alignment scenario places excessive force/weight on the inside of the knee joint while at the same time it creates a gapping on the outer part of the knee – this stretches the lateral knee ligament or LCL. Over time this alignment will result in a loss of cartilage and damage to the meniscus on the inner part of the knee joint. Arthritis will develop over a period of time as joint structures progressively deteriorate. Knee replacement is the end point of this process.

With any injury or pain scenario it can be difficult to determine what caused what. Factors like the natural aging process, poor alignment, genetics, sports injuries, knee surgery etc. all contribute. In my experience I have seen the same poor knee alignment on young(er) athletes and on older clients. Addressing alignment issues at the earliest stage possible is ideal for long term joint health.

Some/many knee replacement procedures could be eliminated if the health care field did a better job screening orthopedic alignment and other “structural” body issues like leg length discrepancy. I understand there is limited research into these issues and evidence based practices may not be there yet. That said there is a shift away from knee surgery for some injuries (meniscus) because of the long term consequences like arthritis that develops as a result of the surgical procedure.

 

I work with a lot of runners with lower extremity pain and dysfunction. I insist they bring in their running shoes on the first visit so I can review what type of shoe they use and how they fit their feet/body.

All shoes are not created equal. I often find differences in fit and alignment in the same pair. To assess the shoes I place them on my desk and see if they tilt in/out. I also rock the shoe side/side and front/back. Many shoes will have a rock or twist to the sole which forces the foot/ankle into a particular position (pronation is most common).  Another test is to place a ruler across the forefoot section of the shoe, often I find a transverse curve which creates the rocking motion. The rocking motion contributes to poor ankle control/balance.

The final test is to check the athlete’s single leg balance with shoes on/off. If their balance is better barefoot then the shoe is a problem. If their balance improves with the shoe on then they’re OK. This test is often shocking to the client, they had no idea the shoes they spent so much money on were contributing to their condition/injury.

Ideally a shoe should support the natural, neutral alignment of the ankle, the sole should neither have a twist or rocker to it – it should be stable. Many people use orthotics for corrective measures. Adding orthotics to poorly constructed/aligned shoe adds to the dysfunction instead of correcting it. In this scenario you have the shoe conflicting with the orthotic and the persons body. The knee is particularly susceptible to the poor alignment stress in this scenario.

The shoes in the picture above are brand new. My client with severe knee arthritis brought them in for me to check out, she was going on a trip and wanted to make sure these shoes were going to work for her body. As you can see the shoes tilt in, the left one tilts a lot, they also rocked side/side. In the picture below with the shoes on you may notice how the left shoe/ankle tilts in more than the right. The final test was to have her walk slowly in my office. I asked her to pay attention to how her ankles, knees and hips felt. She immediately noticed tension in her knees since the shoe forced her knees to rotate inward – not a good alignment for someone with arthritis. Needless to say she never wore these shoes again.

 

Training

The internet is overflowing with content about core training and exercise. The focus of my blog posts are to provide a snapshot of my work, informing potential as well as current clients the scope of my work experience and philosophy. I like the saying “less is more”.  That said, all exercises have the potential to be “core” exercises. As a society (training/rehab/health care) we often divide the body into functional or anatomical segments – which is important for many reasons. Bringing it all back together and seeing the whole body or person is less common.

 

One of the most significant concepts I’ve learned from functional training experts is “the body knows movement and not individual muscles”. Another way of saying it is we are hardwired to perceive and process information: initiate, synchronize, maintain and adapt to a complicated series of  internal/external stimuli as a whole organism. Performing an ab crunch while lying on your back and standing on one leg provide very different stimuli. Both are core exercises.  The crunch isolates specific abdominal muscles. Standing on one leg involves the whole body: bone/muscle, eye sight, balance receptors etc. The core works in conjunction with all these other systems in order to maintain erect posture.  Balance exercises are my favorite core exercises.

Walking upright is a unique human characteristic. Walking is the “next step” in my balance exercise sequence. The transition of our torso over the base of support (foot) requires the whole body working in concert to maintain balance and propel us. That means arms, legs, feet/toes, abs, chest, neck (heart & lungs too) are all involved in walking. Without a good working core walking does not go very well.

Gait retraining is an essential part of my personal training and injury rehab work. A simple ankle sprain for a runner will cause movement and muscle function compensation throughout the whole body including the core. Proper rehab focuses on the details like the injured ankle ligaments while keeping an eye out for the big picture – how is the rest of the body/person dealing with this injury.  Proper core training can address these issues.

Sometimes the most effective core exercises are the simplest ones. I often have to bring it down to the sensing and feeling level – how the abdominal muscles tighten when an arm or leg is raised or when weight is shifted from one foot to the other. Without this basic awareness more challenging core exercises either cause harm or simply don’t work as they are intended.

 

 

 

 

 

Posture Assessment

The first step in assessing core function is to observe the client’s posture when they stand, sit and move. Ideally the spine should be supported in a neutral position by good core muscle tone during all these activities. Excessive curvature in the lumbar spine (lordosis) or the absence of a lumbar curve (flat back) are potential indicators of poor spinal control. Often these extremes of spinal positioning are adaptations due to a history of back pain or injury, poor fitness (weak core muscles) and sedentary work postures like excessive sitting.

Muscle Imbalances

The core muscles link the spine, pelvis and legs together creating a posture and movement control system. For many people, including athletes, muscle imbalances can lead to poor posture and spinal control as well as poor movement patterns. Muscle imbalances occur when certain muscles are overdeveloped or overactive while the opposing muscles remain underdeveloped or under active. These imbalances create asymmetrical movement and spinal loading patterns. Cyclists for example can overdevelop the quadricep muscles and have underdeveloped hamstrings and gluteal (opposing) muscles. Strong, well developed quadriceps are essential for cycling. The problem is once the cyclist stands up and walks the overactive quadriceps tilt the pelvis forward increasing the curvature in the lumbar spine as seen in the illustration above. Strong, healthy hamstring and gluteal muscles contribute to good pelvis/spine positioning by counter balancing the force and movement action of the quadriceps. They are also essential for good walking and running function since these muscles are responsible for moving the hip into extension.

 

Sit to Stand Assessment

Another simple assessment of spinal control is to observe common movement patterns like sit to stand. Does the person bend (flex) their spine, or use their hands to push on their thighs to assist in standing? There are many factors that contribute to these movement compensations: poor eyesight (looking down), hip/knee pain, weak hips/leg muscles , back pain and poor overall fitness are possible factors. Further testing of muscle function and joint mobility often identifies specific soft tissue or joint structures that are compromised.

Lifting heavy objects is one of the most common ways people injure their backs. The sit to stand test also identifies how a person organizes their movement around lifting or squatting movements. Ideal spinal control during this test is demonstrated by the person on the left (A) side of the illustration. Engaging the back muscles stiffens the spin by locking the vertebrae into a more rigid load bearing structure. Engaging of the back muscles also engages the abdominal muscles creating a “corset” effect – 360 degrees of muscle activation.

 

Core exercises and core training are interchangeable terms for exercises that target the abdominal area, low back and pelvis. Core training is not a new concept. Joseph Pilates, the founder of Pilates training method focused on abdominal training, postural alignment and mindful exercise in the early part of the 20th century.

In the past 15 years through advancements in anatomy research, technology and strength and conditioning research core training has taken on a bigger role in injury rehab/prevention and the sport conditioning field. Research has shown that the core is the bridge between movements and force generated in the arms/torso and the hips/legs. Athletes of all disciplines can benefit from improving the strength, coordination and control of the core so that force is safely and efficiently transferred through the whole kinetic chain without adversely effecting the spine.

Core training has also become fashionable in the fitness field – instead of abdominal crunches personal trainers use plank exercises (for example) as a means of attaining six pack abs and the “perfect”, sculpted body. There is also the misconception that a stronger (more developed) midsection leads to less back pain preventatively.

I started practicing and teaching core exercises over 10 years ago, back then they were called lumbar stabilization exercises. Research showed that patients with low back pain had delayed activation of the deep abdominal muscles –  the muscles responsible for spinal stability, position and control. Delayed activation also means poor sensory function. In other words people with back pain have an inability to sense spinal movement and are unable to control spinal positioning.

Over the years what I found in my practice treating back pain, training fitness clients and teaching exercise is that yes, it is true that people with back pain have deficiencies in sensing and activating their core muscles. So do most people regardless of the presence of back pain. Good spinal control is often the exception and not the rule for children, adults and many athletes too. Proper core training begins w/simple exercises to sense control and maintain positional control of the spine/pelvis, once this skill is improved more advanced core exercises can be introduced. The worse case scenario is the person w/poor spinal control performing aggressive core exercises.

“How long will it take for this injury to heal”? This is a common question I hear frequently from athletes with sports injuries. They don’t like slowing down or stopping their routine, injuries are inconvenient disruptions to their busy training schedule.  Answering this questions isn’t easy or straight forward.  There are many factors involved in the injury process some physical, some psychological, always a combination of both. Alleviation of pain is often the primary goal of therapy/rehab – nobody likes to be in pain.

Managing pain can actually be the easiest part of the rehab process particularly in the initial/acute phase. Rest is always good, massage helps as does heat, ice, proper nutrition/hydration etc. The RICE protocol (Rest/Ice/Compression/Elevation) is the standard go-to formula for acute sprain/strain injuries. In another post I’ll delve deeper into the management of injuries. It is when the initial pain has subsided where things get complicated.

While I do work with acute sports injuries my biggest client population have long standing symptoms that span months to years. These are the chronic/intermittent symptoms (hard to pin down diagnostically since the symptoms vary with activity/intensity/time), x-ray/MRI are often inconclusive so they are not candidates for surgery, many receive cortisone injections. They’ve typically seen other therapists with mixed therapeutic results.

The truth is the longer an injury or pain has been present the more complicated the rehab process is. Even a moderate ankle sprain, if not rehabbed appropriately, can lead to knee and hip symptoms on the same or opposite side – it’s like a domino effect since all joints in the body are linked in a dynamic movement sequence. All injuries and pain disrupt the smooth, natural movement sequence. The sports medicine field calls this disruption “movement compensation”. So whatever the initial injury, could be an ankle sprain, muscle strain etc. the athlete adapts by altering how they move in an attempt to lessen some symptom or experience like weakness, pain or poor joint control. Often they aren’t even aware of what they are doing or why.

With long standing sports injuries with movement compensation my main focus is to develop movement awareness first. Without a sense of how their body feels, moves and performs they will be unable to change the dysfunctional movement patterns into optimal movement patterns. Sometimes it requires breaking down a movement sequence like running into one slow step, feeling how muscles work (or not) and how joints balance and articulate (or not). The movement sequence of running for example begins with one small step which can be traced up through the whole body revealing poor pelvic alignment, poor arm swing/shoulder function and poor neck/head balance.

As the rehab process progresses movement awareness is reinforced by specific (corrective) exercises and alterations in the athlete’s training program. Manual therapy is utilized to target specific compromised soft tissue structures. The overall goal is always to bring the body back into a balanced state of alignment, function and control.

The first step is often the most important one.

 

“B” came to my office several years ago barely able to walk, in fact she used crutches due to severe back pain. B had a long history of back pain, now retired she wanted a more active lifestyle without pain or the constant sense of vulnerability surrounding her spine. It took some time but gradually her body got stronger, the pain subsided and she gained confidence in her ability to garden and exercise. B is an good example of how I help people transition from an injured/pain status to someone engaged in wellness/fitness.

When I work with clients over a span of years I get to know them in many ways: their likes/dislikes, their moods and behaviors. Each session I assess my client’s movement, attentiveness and energy level. I like to work with where they’re “at” as opposed to pushing them into a place they may not have the energy or desire to be at that moment.

For several months this year (2013) B was showing up for her fitness sessions tired, under the weather and unable to get herself motivated. Small aches and pains were discouraging her too, her physical world was getting small again. I had to dial back on her exercise routine, it was obvious she just couldn’t handle the stress of exercise. We talked about diet, emotions, the aging process – she felt good about where she was in her life. In her 60’s B is smart and proactive about health care and wellness, reading health related research and keeping current on health trends/studies. Something wasn’t right. We agreed she needed to see a doctor about her symptoms.

Chronic fatigue, adrenal depletion, hormonal imbalance – there are several names for a collection of symptoms that often fly under the radar diagnostically of many doctors. The research into the broad collection symptoms is scant and opinions vary. Evidence based medical practices want quantifying research and data to prove/disprove a theory, course of treatment or medicinal procedure/intervention is statistically relevant or quackery. Even though the research is lacking and while many doctors and health care practitioners dismiss the concept of chronic fatigue/hormonal imbalance there are doctors and health care practitioners other who believe the opposite.

Curious about the hormonal imbalance theory B sought out a MD with experience diagnosing and treating these conditions. After a thorough review of her health history and blood work it was determined certain hormonal levels were indeed low. The corrective treatment involved taking several nutritional supplements all available at a local health food store.

Since starting her supplement regime B’s energy level has improved. She is able to work out at a higher level of intensity for a longer period of time and her overall mood is more optimistic as well.

The aging process, stress (environmental/emotional/psychological), poor nutrition, excessive exercise all play apart in the body’s hormonal regulatory process. Here is a series of articles about the adrenal glands and hormonal imbalances I found informative.

 

 

 

As the winter months waned I kept thinking about riding my bike. I put it away when the snow started to pile up in December, it was safer to walk to work than risk falling hard on a patch of ice. Finally in March the temperature was above 40, clear skies and the roads were relatively clear of ice too. I did two, one hour rides over a weekend. It felt great to breathe deeply the cold air, riding past snow banks, frozen lakes and sugar bushes (stands of maple trees tapped for sap to make maple syrup). In the back of my mind I knew I should take it easy: stick to flatter roads, keep my pedal cadence smooth and light, no out of saddle efforts. BUT I did push it a little on a few small hills, it felt too good not to. In the evening after the second ride I noticed the familiar ache in my right knee: a diffuse, non specific joint pain and stiffness I’ve had on/off for many years.

“Too much, too soon” is a saying in the sports medicine field that pertains to athletes who suffer an overuse injury when they increase their training/exercise routine too quickly. The rapid accelleration in soft tissue tissue and joint stress without adequate recovery leads to tissue over load and breakdown.

There are three common variables in an exercise routine. 1. Frequency – how often does one train: once a week, every day etc. 2. Duration – how long is the training effort: half hour or three hours. 3. Intensity – are you lifting heavy weights, doing sprints or easy riding on flat roads. Ideally an athlete needs to balance these variables so that the desired training effect (stronger, faster, more endurance etc) occurs without over training or causing tissue damage. Considering I hadn’t ridden my bike in five months I think I over did it riding two days in a row – too much too soon.

After a day or two of rest the ache has diminished. Now I need to refocus on a progressive return to cycling by varying the frequency, duration and intensity of my rides – easy effort, short sessions w/ a few days rest in between. The lesson learned this Spring is to focus on the fundamentals of training to avoid injury: be patient, go slow, build endurance and the capacity to handle the stress of cycling.