Wednesday, 18 May 2016

The Shin Splints Troubleshooter

Shin splints suck. When they come on, it's so difficult to get away from them. It's no broken arm, but when they get bad, it's that kind of aching pain that just makes basic function agonizing, like a cavity.

"Shin splints" is considered to be a catch-all term that encompasses injuries such as muscle tears and stress fractures. However, in my practice, I stick to calling those things "muscle tears and stress fractures". As far as I'm concerned, shin splints (or medial tibial stress syndrome) involves tightness and restriction of the calf muscles muscles to the point that they pull strongly enough on the tibia (shin bone) to cause inflammation. This effect occurs when the outermost layer that covers the bone - the periosteum - is lifted up due to this tension, allowing the inflammation to develop underneath. Oftentimes, there are microtears throughout the calf muscles involves as well as pain referred through the entire medial calf. Sounds awful, huh?

Here's where I start to get more general and provide a list of the go-to-reasons why you may have MTSS and what you can do about it. Keep in mind, this training advice, not medical. If you have a real problem, seek help from a medical professional in person.

1) You're a Heel Runner

If, when you run, you strike the ground heavily with your heel, the hard impact could be a likely trigger for the inflammation beneath your periosteum if you've already been prone to it. The strike of the heel allows all the force to travel directly up your leg, causing impact-related problems all the way up to the back. Retraining of your running gait, switching to a softer running surface, or wearing a flatter running shoe that promotes more midfoot running are excellent places to start for your recovery.

2) You're a Pronator and/or Flat-Footed

If your feet have very little natural arch of if you have an exaggerated inward-roll of your feet while walking and running, this could be putting excessive strain through the medial calf muscle. Often, improper shoe support is the cause, and you may need more added to support the arch and stop the pronation. You may also need less as well. I, myself, self-corrected once I switched to minimalist shoes and no longer had an artificial arch causing my foot to roll in. Foot exercises can also help to lift the arch in your foot naturally as well, to an extent.

3) Your Butt is Asleep

If your glutes are inactive during gait (they should be the primary muscle moving you along), then the hamstrings and calves tend to take over. If you're getting your calves to take on the workload that your much stronger gluteal muscles should normally be handling, then you'll definitely see tightness and restriction through the muscles occur as a result.

4) You're Doing Calf Raises

Firstly, I hope that no one save for bodybuilding and fitness competitors are doing calf raises. Your calves were designed to run for hours, not lifting a heavy weight ten times. So that's your first problem

Secondly, most-often when someone does a calf raises, they are pronating and favouring the medial calf overall, causing it to become more stronger - and tighter - than the outer as a result. If you really have to do calf raises, try squeezing a tennis ball between your heels to help distribute the load.

5) You're Stretching Improperly

If you're stretching your calves to try to relieve your pain but are getting no results, recheck your technique. If you're doing the traditional runners stretch by lunging against a wall, pushing your toes up against the wall, or dropping your heel off a step, you may very well be moving into pronation again. Try doing the runner's lunger, but with the foot flat on an incline to keep the leg and foot properly aligned.

Furthermore, are you stretching your entire calf? When stretching, you need to do both a straight-legged stretch for the more superficial gastrocnemius muscle (which crosses the knee) and one with a slightly bent knee to get the deeper soleus which crosses the  ankle only.

6) You're Not "Born to Run"

Finally, maybe you just have anatomy against you. I don't care what some people say; we're not all naturally built to run long distances. Yes, we all did it when we were cavemen, but do you really think that our anatomy hasn't at all changed since cro magnons walked the earth? If you're naturally (or unnaturally) heavy-set and have short legs relative to your weight and height, it may just be too much for your legs to handle running a marathon without extensive and specific training. I'll never say that there's a physical feat that anyone can't accomplish, but without a doubt, it's going to be a much harder time for some than others.

Take from this what you will. Everyone's body is different though, so the reason for your pain may very well not have been mentioned. Use it as a starting point. It may take trial and error, but no one is meant to suffer without a solution.

Friday, 13 May 2016

Rotator Stuff and Other Things You Neglect

I posted before about a shoulder case study and some details about stability of the joint before, but here's some more day-to-day gym rat stuff for you all to chew on.

I work at what's known as the body-building gym of my town. Wherever you have heavy lifters, you have people with shoulder injuries, and thus there are the few of those trying to do what they can to take care of their shoulder health. There's a lot of common error when I look at lifters getting their shoulders warmed up, though, so here I am science-ing them to correction.

Firstly, let's talk about the rotator cuff. These four muscles are constantly being bogged down by injury, whether it's tendinosis, muscle tears, or impingement. The first error I run into are the people who think that simply keeping your rotators strong is the key to good shoulder health. However, most of the time when we have chronic shoulder injuries, it is not usually due to the rotator cuff being weak. In fact, even if the rotator cuff has an overuse injury itself, it is almost always as a result of weakness elsewhere around the shoulder girdle which is forcing the rotator muscles to overcompensate or causing other structures to restrict it. Most of the time, shoulder rehab programs are going to require more scapular strengthening, using muscles such as the serratus anterior in order to stabilize the shoulder blade and relieve the workload of the rotators. Here's one fairly basic warm-up exercise you can use to hit the proper muscle groups.

For something a bit more complex as you get stronger, I'll refer to one of the most well-known "shoulder guys", Eric Cressey.

Does this mean we should ignore the rotator cuff group in that case? Nope. They still need to remain strong enough for day-to-day work, especially if you're working overhead a lot. (Throwers and painters alike.) As well, if you're a traditional weightlifter who isolates your movements a lot, you still need to make up for the lack of use your rotator cuffs are getting while you do lifts such as bench or machine press. Bringing it back to Cressey, he recommends four days per week  for his baseball throwers, while the average Joe will benefit from even 1-2 times per week for three sets.

So now that we've determined that you do still get to do rotator exercises, how do we do them? Firstly, here's what not to do. The most common incorrect method I see is the standing dumbbell variation...

So wrong that it hurts. Probably her more than me though.

The problem here is that if you think about the angle of gravity with this exercise, this doesn't hit your rotators at all. With the downward pull at your shoulder from gravity, the only muscles that are actually working are your deltoids and traps. A line of pull to give resistance to the rotational movement is absent. If you're going to use dumbbells to hit the correct muscle group, you're going to have to lay down on a bench, first on your back and then on your side to hit the internal and external rotators, respectively. Standing with your arms at 90 degrees for external rotation works as well, but you'll still need to reposition to the bench for the internals.

The easier solution for your exercise is to use either a band or cable with a horizontal line of pull. I'll make one tweak to usual way of doing it, however. While performing your internal and external rotation, squeeze a towel between your elbow and body. The first reason for this is that it puts your shoulder girdle into "scapular plane", which is essentially the angle that will be the most stable and ideal for the shoulder to be moving in. Secondly, having the towel to hold on to ensures that you don't make the common cheat and allow the arm to lift away from the body, again creating compensation using your delts.

To conclude, if you want to keep your shoulders strong and stable in the gym, exercise the rotators using a band and don't neglect your scapular muscles in your upper back. Yes, we all want to get over to the bench press as quickly as possible, but proper prep before your workout will save you more time out of the rehab clinic later.

Thursday, 12 May 2016

Core Strength and Why Sit-Ups Will Hurt You

When I train clients or teach classes, people often question why I don’t employ the use of any traditional “ab” exercises - in other words, sit-ups, crunches, etc. Upon being asked why, my answer is blunt: Sit-ups are useless, if not harmful.

As a quick anatomy review, our core is a system of muscles that work together for the purpose of “anti-movement” in order to stabilize and protect the spine from damaging forces. If you don’t know, your spine is made up of numerous bony bits surrounding an extremely sensitive softer bit that acts as the closest thing you can identify as the root of all pain.

Demons and Pagan demi-gods notwithstanding.

That being considered, it's in our best interest to condition our core in the most optimal way to do the job of protecting the spine. And the best way to do that is to train using this "anti-movement" that I mentioned. What is anti-movement? It's exactly what it sounds like. It's the contraction of the muscles of your core in order to resist movements and stimuli that could result in injury. For instance:

  • Activation of the muscles in order to support the spine while in an upright position to decrease the amount of prolonged (and stressful) load going through the joints
  • Resistance against trauma that may cause the spine to move through a damaging range of motion (such as a football linebacker tackling you and risking hyperextension of your spine)

Which brings us back to the exercise. Why are we doing sit-ups to train our abs? Sure, some may argue that it's the concentric/eccentric contraction that promotes the most muscle growth to define the abdominals for aesthetic reasons, but at the same time, we're forcing our spine through loaded flexion which is the biggest predisposer to disc herniations. By way of this type of training, we end up not conditioning our core muscles at all to be able to support the spinal column, resulting in numerous back injuries.

Taking a step back to what I said above, true, sit-ups may be the better exercise for the heavily-defined 6-pack that you want for summer. However, it's important to weigh the benefits of function and aesthetics. As an example, if you look at your typical MMA fighter, a type of athlete who needs to be in the peak physical condition to out-perform the opposition, the abdominal area has a completely different appearance than, for instance, a body builder, who has the look we come to expect from television and magazines. 

As awesome as Arnold is, which of these two individuals do you think would win in a fight?

And that's how we arrive at exercises such as the plank, side-plank, and deadbug instead. By squeezing the core to resist movement rather than to initiate it, we train the core muscles for their proper, evolutionary purpose. 

Yes, I know that this philosophy would clash with that of many others, but if you're a physique athlete, then by all means, do what you need to do to get those chiselled abs. From a health, or even medical standpoint, however, sit-ups have no functional purpose and are more debilitating than beneficial - especially with the amount of time we spend in flexed, sitting positions in modern life.

So, for the sake of your back health, plank away.


Friday, 6 May 2016

Mobility - Fad or Fallout?

Mobility is a common factor cited and addressed in physical rehab by athletic therapists, physiotherapists, chiropractors, and the like. Like always, however, 'mobility' didn't become a mainstream word until personal trainers and other fitness professionals started throwing it around, and today it's the current hot-word that everyone uses to sound smart and grab attention. There are misconceptions about what mobility actually is, however, and the proper ways to address it.

So what is mobility? A lot of people use it interchangeably with "flexibility", which is understandable but incorrect. Mobility refers to the range of motion at a joint itself. For example, flexion at the shoulder joint (lifting your arm up in front) to reach over head is a range of motion. When we speak of flexibility, we are only talking about the muscles of the joint being able to lengthen and stretch. While flexibility contributes to mobility, the stiffness of a muscle is not the only factor that can affect a joint's range.

Mobility Is More Than One Factor

The joint itself has several structures that can cause limitations. Fascia covers all muscles, and while it's often considered to be part of the muscle itself, it exists as its own separate structure. There's the joint capsule, which is ligament-like bands that encompass the joint, and ligaments themselves that support the area. There are bursae, fluid-filled sacs that buffer impact and friction, which can become inflamed and limit range of motion. There's cartilage and the bone surfaces themselves, which can hinder mobility if there's damage or degeneration. (ie: meniscus tears or arthritis) Synovial fluid, which lubricates a joint, can increase or decrease based on joint health. Bone surfaces can also be incongruent and may be sitting improperly on one-another. (ie: a "stuck" rib) With all that in mind, mobility is a multi-faceted picture, and when you're trying to increase it, you're addressing all of these physical factors, not just the flexibility of the muscle.

If it was as simple as "the arm bone is connected to the hand bone", then we could just publish a "For Dummies" manual.

Now, one problem that I run into a lot is that people think that they need to aggressively mobilize every joint in their body in order to attain proper or optimal function. The fitness industry is starting to become bad with this, and even personal trainers are often over their heads when attempting to prescribe mobility exercises. This is where injury, of course, follows suit. If someone is new to exercise and can't fully flex their arms overhead, should we really be getting them into aggressive dowel-circles with the goal of having them overhead squat? Of course not! Those shoulders are unstable!

A Cyclic Relationship

Here's the word that should have accompanied "mobility" as it's partner-in-crime hot-word: Stability. Stability and mobility are directly paired, and one cannot exist without the other. In fact, in the absence or loss of one, the other will typically decrease as well. This isn't the body rubbing salt in a wound, however. In fact, when mobility decreases in response to poor-stability, this is the body creating a protective response.

Every joint in the body needs to have a certain degree of muscular stability in order to properly protect the area and prevent injury to structures. However, when stability is lacking, such as when spinal stability is lost due to inactivity and a weak core, the human body has a fantastic compensation method in order to ensure that injury and pathology can still be minimized. Hypomobility is the result. Muscular structures will increase in tension and become tighter, joint capsules become restricted, fascia will be adhesed and glued, and synovial fluid production can drop. Think of it as a loose hinge on a machine that's too stripped to repair, and so it's welded tight instead. Less movement can occur, but the structural integrity is spared.

Never compromise your integrity!

With this in mind, it should hopefully be easy to understand why aggressive mobilizing can result in injury. If the shoulder's stabilizing muscles are weak, then drastically increasing mobility is just going to cause a person to move their arms into a position that your muscles can't support, and damage will ensue.

Two types of practitioners that I often see falling into this trap are chiropractors and yogis (without trying to say that neither field has its place). Chiropractors, specifically those who are treatment-based only and favour the "crack" or other quick and aggressive techniques, definitely do the job that they're paid for by releasing a joint. However, by not taking the time to correct for the instability of the joint - the reason for why the joint became hypomobile in the first place - it sets up for the return of that client quite often once the body finishes responding to the instability by restricting the area again. On the other side of the professional field, yogis tend to do the same thing, albeit in a more conservative way. True, they do a lot of isometric bodyweight strengthening, but many individuals will not find pain-relief from the activity. When the main focus is elongating the body's muscles and maximizing range of motion and flexibility, complementary weight-training is very often a necessity in order to stabilize the body in order to compensate.

The Solution

The solution is clear. Stop being so aggressive when mobilizing clients! It doesn't matter if you're a physiotherapist, personal trainer, or witch doctor. We all need to stop removing a base of joint support without offering anything to replace it. My philosophy is as follows:

  • In educated practice, mobilization is done slowly and gradually. Ideally, it should never be the goal to try and entirely mobilize a severely restricted joint in one session. 
  • In clinical practice, joint glides and muscle energy techniques are supplemented with gentle self-mobilization homework and stabilization exercises. Even massage is best when paired with exercise.
    • Ie: For the back,  a gentle mob, a cat-camel mobilization exercise, and some core strengthening will likely show much better efficacy than a quick crack.
  • Mobilization should never hurt save for the Grade 5 (the crack) and even that's debatable. Whether the client is receiving a mobilization technique or doing a mobilization exercise, a look of excruciation on their face is a definite sign to stop.
  • Above all, if you're recommending mobilization to someone, know what you're doing! Be specific in your aims and know the limitations of your client (and you're insurance coverage). If you're throwing darts and hoping that stressing an end-range repeatedly is going to result in good health, your client is in for a nasty surprise, sooner or later.

We'll likely to continue to see mistakes concerning mobility for years to come until a new trend hits the fitness media and takes over. Until then, education is important. In failure of that, I could just start hanging out at Crossfit gyms and hand out business cards.

Tuesday, 3 May 2016

Corrective Exercises for Scapular Instability

Here's a case study for you. This is Connie:

Photographed rather than filmed, because your computer volume does not go low enough.

The frustration was getting to her.
Connie is a dedicated gym-goer with a 6-day/week workout routine. She’s a personal trainer and yoga instructor, follows her own regiment religiously, never misses a day, and embodies the image that many women would kill for.
Connie’s struggle of late has been difficulty in getting better at wide-grip pull-ups. She added assisted pull-ups to her weekly back and bicep workout, trying to see improvement.
The result: FAIL! After four months, she was still stuck maxing out at four pull-ups, assisted! This raises a flag, as we can assume she has a thorough understanding of muscular training adaptation to be able to structure her workouts and see the desired result.
This tells us there’s a glaring discrepancy somewhere in her body mechanics preventing her from achieving her goal which needs to be addressed, much like I'll almost always see when treating clients for musculoskeletal injuries.
After hearing her complaints about the lack of progress being made, I took notice of her shoulder blades. If you saw them at the time, you would have seen her scapulae winging out during any shoulder retraction, cueing us to some kind of bio-mechanical error that needed to be addressed.
No, these wings will not aid in flight.

Shoulder Mechanics

With a working knowledge of anatomy and physiology, we know that the scapular muscles (most significantly the serratus anterior, but consisting of several other muscles of the shoulder girdle) are meant to stabilize the scapulothoracic joint. These muscles should be active in maintaining the position of the scapula against the rib cage during posture and to control its movement during ranges of motion at the shoulder.
When those muscles get weak, we see this winging, causing a change in the total angle of the shoulder girdle and improper recruitment of larger muscles which are now attempting to compensate for the lack of stability.
If that sounds complicated, just know that if scapular muscles get weak, big shoulder muscles get overworked, shoulder strength and health deteriorate.
Pictured: Large, prime movers - Left
Stabilizers - Right

I see this problem arise quite often in individuals who follow traditional weight-lifting programs, whether it’s team-sport athletes, body-builders, or average-Joe’s. What’s happening is that the nature of your traditional weight-lifting routine (isolated exercises, weight-machines, supported shoulders against benches) remove the use of the small, stabilizing muscles from the equation.
High end body-builders who receive proper training subvert part of this problem by properly adding isolation of those smaller muscles into their routines, effectively strengthening the scapular stabilizers and preventing the winging of the shoulder blade that would ruin the aesthetic appearance they need.
However, these individuals are still prone to chronic shoulder injuries such as rotator cuff tendinopathies and biceps tendon impingement. Why is that? It’s because the strength of those muscles may be well-trained, but the stability is still lacking. (Note: This is a tendency, not a rule. Don’t hate.)
We see errors quite often in the clinical setting when it comes to retraining muscular stability. In much the same way traditional weight lifters will train themselves, a therapist can easily get caught up in prescribing basic isolation exercises in either excessive amount or for too much time.
True, if there is severe weakness and inactivation of a particular muscle, then of course it needs to be targeted specifically at the start of a rehab plan. But as we progress an individual to the more advance stages of returning to function, synergistic muscular training is key.
We can’t expect proper shoulder mechanics (which requires stability provided from multiple smaller muscles working together) to arise from training each muscle separately and isolated through range of motion.

Exercise Recommendations

After realizing the large discrepancy in shoulder stability, I gave Connie two very simple exercises to do.
The first one was a scapular push. This one is hard to explain in written words, so take a look at the video below. This exercise was to be done daily for two sets of 10 reps per side.
The second exercise, the T-curl is an isolation one (as I mentioned is still often important as a supplement) for serratus anterior, one of the major stabilizers. This one was prescribed for 2-3 sets of 10 reps on Connie’s “pull” day at the gym.
Keeping the upper arm parallel to the floor and the entire limb in the frontal place, the cable is curled in with the palm flipping between every rep.
Connie did these two exercises, as instructed, for 8 weeks, without modification. After four months, pre-intervention, of Connie barely being able to muster out four assisted pull-ups, she is now pushing towards ten reps, unassisted.

The results speak for themselves.

Big lats and biceps are only part of the equation; you need to take care of the small stuff as well. It’s important to not neglect the prime movers, but when attempting to retrain healthy movement, the foundational support needs to be considered first when prescribing exercise.
Exercise rehab like this is clearly vital in the clinical setting. However in Connie’s case, her condition was not yet pathological and causing pain. In the case of clinical clients, we’ll need a bit more intervention on the therapist’s side.
With individuals who have such severe scapular weakness, you’ll also typically find significant spasm and adhesion in those same muscles due to the body attempting to create stability any way it can. It’s also important to look at the antagonistic muscles to what we’re focusing on; in this example that would mean taking some time to work through the pectoralis muscles that, combined with the weak upper back, will likely contribute to a rounder shoulder and t-spine posture. Connie is going to continue her training using these interventions, possibly with some further modification, and I can confidently predict that her progress will not plateau any time soon. Luckily, we were able to target her weaknesses before they became pathological issues, but this won’t always be the case. However, whether or not your treatments in the clinic start with basic exercises or even manual treatments alone to begin with, the progression that I did with Connie is an excellent example of late-stage rehab that we can use to get our clients above and beyond their pre-injury state.