If I had to pick the one most important thing for preserving musculoskeletal health it would be maintaining full lumbar (low back) mobility. Of course it’s optimal to have normal mobility in every joint (including the mid back and neck joints) as well as normal strength, normal nerve length, and normal movement patterns throughout your body. But if I take into consideration prevalence of pain, amount of potential disability, and level of contribution to other disorders, then - if I had to prioritize one thing to focus on - maintaining low back mobility rises to the top.
Pain in the low back is one of the most common complaints among people, typically recurs, and often creates significant disability. Significantly, if a low back is not moving well then it can cause or contribute to any number of disorders from the low back down. A low back that is not moving well makes it hard for the lower extremities to move well (not to mention the rest of your spine) and can also cause the nerves exiting the low back to become irritated/pinched/compressed. Since these nerves control the lower extremities, if they are irritated there can be referred pain, numbness, or tingling into the lower extremities as well as weakness and poor balance. (Nerves control it all!)
So if you have full mobility of your low back (flexion, extension, left side glide, and right side glide), maintain it. Maintenance looks like different things for different people, but if you spend 10 seconds every day to at least check, you should have your full range of motion. If you don’t have your full mobility then we need to figure out what specifically you need to do in order to achieve it. (And if you don’t know if you have your full mobility, there are tests we can do to figure it out.) -- Laura
Your abdominal muscles (in the front of your trunk, not in your back) do the real work when it comes to sit-ups. Many structures are of course still involved with this exercise, though, as with any movement. When someone tells me that sit-ups hurt his back my thought is that repeated joint activity (flexion) causes his back pain. With sit-ups, the spinal joints flex, or bend forward. If repeated muscle activity was the problem causing the pain, we’d expect the pain to be in the abdomen, where the muscles actually are.
Location of pain and provoking factors are just two pieces of the puzzle when it comes to diagnosing, but they do tell me two important things. One, in this scenario the person likely has the diagnosis of joint derangement (versus a muscle or other problem). And, two, it’s unlikely the person will need spinal flexion to get better, since it is clearly provocative. (Thus it’s more likely he’ll need another spinal direction to get his joints working properly again - and therefore be able to soon tolerate all the flexion in sit-ups.) -- Laura
I wasn’t taught that lumbar spine range of motion (ROM) included left side glide and right side glide in physical therapy school. Now, however, I find it’s an indispensable part of my lumbar evaluation. In addition to lumbar flexion and extension, I evaluate side glides as a part of the simple range of motion tests. With any range of motion test for any joint in the body, both quantity and quality are assessed. And just like with any spinal or extremity joint, motion that is lacking or painful tells me a lot about the diagnosis and potential treatment options.
I often use repeated or sustained left or right side glides as part of treatment if I diagnose a lumbar derangement. Side glides are tested in free standing (feet under the shoulders, legs straight but relaxed) by pushing the pelvis to one side as far as possible. The lumbar spine therefore glides on the pelvis. This can also be tested on the wall. For treatment procedures, the wall variation is used most often, but I have also utilized side glides in free standing, in a doorway, and in sitting.
One of the several goals of orthopedic care is making sure a patient has full and pain-free motion in all planes of the joint. Maintaining full and pain-free motion is key to preventing recurrence of symptoms as well. If you're not testing this side-to-side motion of the lumbar spine, I think you're missing a lot of important information and treatment potential. -- Laura
Biking and spinning usually involve a lot of spinal flexion. That's not bad, per se. But part of having healthy joints is understanding what makes them healthy. Joint mobility is a big part of joint health.
Except for the lower neck, which is extended to look up, the mid back and low back are usually flexed forward with these activities. Sitting upright is of course an option on a bike, but when people are going for speed or effort, they tend to adopt a hunched forward posture. As I say over and over, maintaining full mobility in your joints is paramount to health. If your joints are consistently in one direction or one position - and rarely if ever get moved in the opposite direction - you are much more likely to lose range of motion. Be smart about your activities and your joint mobility and significant injuries can largely be mitigated. -- Laura
An important adage is: correlation doesn’t equal causation. One can assume one's neck or back hurts because of stress. Or one could investigate to see if stress and symptoms are simply correlated and not causal. An key step is to specifically look for a musculoskeletal cause to musculoskeletal complaints. It’s quite common that when people report stress they also report more time hunched over a computer or books or postures or activities that are different than what is typical for them. If there’s a musculoskeletal cause, then it’s almost always fixed with specific movements and postural changes. If the true cause is stress, then there are varied treatments aimed at generalized stress relief (not my domain of expertise). -- Laura
So sit-ups flex your spine? So what? We flex our spine thousands of times a day and sit flexed an awful lot as well. As long as you (1) know how to discern if an activity (such as sit-ups) is harming you and (2) know how to correct it if it is, you are good to go. The best way to know if an activity is harming you outside of symptoms is ascertaining if it decreases your motion. (If we’re talking about the low back, that means flexion, extension, left sideglide, and right sideglide.)
I incorporate sit-ups into my workouts as well as other spinal flexion exercises. I like sit-ups with my legs straight and ones with my legs bent. But, what do I also do? I spend 10 seconds every day checking if I have my normal low back motion and also perform prophylactic movements. (I’m lying on my stomach propped on my elbows right now.) If I were just starting sit-ups, I would check right after to make sure they didn’t cause me to lose motion (they never did).
Are there certain things certain people can’t do? Of course. Sit-ups could hurt your back just like brushing your teeth could or a long car ride could; they’re not extra scary. By understanding the concepts of how to keep joints healthy, we don’t have to avoid nor fear specific exercises. I’m here to teach. -- Laura
A positive FABER test does not incriminate just the hip & SI joints; it can be positive in the case of lumbar pathology as well. FABER stands for Flexion, ABduction, External Rotation. It's a test in which, in supine, the hip is placed in that position, like a figure 4. As with almost all orthopedic special tests (OSTs), I use the FABER as a baseline that informs my thinking — not as a test that tells me a diagnosis.
Just like basic range of motion, strength, or the ability to do a functional activity can be a baseline, so can a test. The FABER test, after all, judges range of motion and its effect on symptoms. As we implement an intervention, we examine if and how baselines change. I know what I expect to see change for each specific diagnosis.
So if I note that FABER is positive on the left and/or right, the questions become: Is it relevant? And: Will it change? Based on that particular baseline and all the other information I’ve gathered (verbal and physical), we apply specific movements and assess the result. I know there's a strong chance lumbar procedures, hip procedures, and/or SIJ procedures can change the FABER test. -- Laura
Yes, some patients have problems that cannot be fixed with movement. But how will you know unless you test movements and interpret the effect? In almost all orthopedic cases, diagnosing should involve repeated movement testing. Morton's neuroma is currently diagnosed by imaging and provocation testing, but, as Michael David Post and Joseph R. Maccio's paper "Mechanical diagnosis and therapy and Morton's neuroma: a case-series" demonstrates, a repeated movement exam is needed to assess if patients will benefit from repeated movements.
If you take people with no toe pain and put them in an MRI, many will have neuromas. So we know they can be present without causing pain. When patients do have pain, then, we can't assume their neuroma is the cause. We need to investigate if the spine is the cause or the toe joint is the cause. Additionally, assuming a neuroma is causing pain still doesn't mean the patient won't do well with repeated movement treatment (but you have to find the correct movement).
What percentage of patients who complain of toe pain receive a competent repeated movement exam? How many with toe complaints will have a clinician investigate their lumbar spine? And what percent will even be recommended to see a movement-based therapist if the image shows a neuroma? If these three patients hadn’t resolved their problems in just a few visits with repeated movement, what types of therapies, injections, surgeries might they have had? In this case series, three patients with medically-diagnosed diagnosed neuromas abolished their toe pain with repeated movements, with those results remaining at one year. One patient required repeated movements of the lumbar spine (low back) and two patients needed repeated movements of the affected toe.
When it comes to movement testing, I believe in end-range repeated movement testing that investigates the relevant spinal segments as well as the relevant affected joint(s). This is the core foundation of the McKenzie method. Movement testing is not the same as orthopedic special tests or palpation tests or provocation tests. It means repeatedly moving a person in the clinic and at home and evaluating the effects if has on the person’s symptoms and mechanics. Looking at a picture and seeing if something hurts when you press on it is rarely enough. -- Laura
If someone complains of foot symptoms - pain, numbness, and/or tingling - it can obviously be due to several causes. When investigating to find the source (that is, diagnosing), I collect many pieces of information. First, there’s a good verbal history during which I ask pointed questions. Second, is the physical exam. With the physical exam I look at various things; nerve tension is one of them. If you put the lumbosacral nerves on tension (there are a few ways to test this), and a patient’s symptom appears or increases in the foot, we need to investigate spinal nerve irritation as the potential source. To be clear, a negative tension test does not rule out the spine, but a positive test more strongly rules it in as a possibility. It is common that irritated nerves in the spine create pain, numbness, or tingling in the areas of the body they're responsible for, and the nerves specifically in the low back are responsible for sensation in the feet. -- Laura
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