It’s not uncommon that sleeping makes problems worse. That is, symptoms become exacerbated and/or movement becomes limited. Morning stiffness to a small extent is allowable when it comes to spinal flexion, but, otherwise, after being up and about for a few minutes, you should have the same amount of mobility you went to bed with.

During sleep, we often spend considerable time in one position without moving - whether we want to or not. It is my opinion that most orthopedic problems are related to movements and postures, so it makes sense that, just like with sitting or walking, sleeping postures can easily make people worse (or better).

If the thought process is that people need muscular strength to “hold” or “stabilize” joints in the right position, then there must be profound weakness if the simple act of sleeping causes joints to destabilize. Similarly, sleeping should not be aggressive enough to strain/pull muscles.

My thought process is this: I agree healthy joints should be able to withstand prolonged positions while sleeping, but I don’t think the answer is muscle-driven stability. And I don’t think muscles get pulled in our sleep. Benign positions like sitting or lying can indeed move joints - regardless of how much muscle is nearby. And these subtle changes can commonly cause symptoms. On the whole, strength is wonderful, but I believe we need to get the joint better first by moving the joint itself.

It’s true that spinal discs enlarge when we lie down to sleep, and that may be the sole factor why someone has more pain and/or less motion upon waking (vs related to any certain position). But even if that is the causative factor, then, again, I want to primarily address the disc (part of the joint) versus address the musculature around it. It’s also true that not all orthopedic problems are joint problems. Sleeping on a painful tendon can worsen symptoms, too. But most problems do have to do with joints - and addressing them effectively is important. -- Laura

There are muscles encasing our heads and faces. I think people actually understand the concept of referred pain (or non-local pain) when it comes to headaches - they just don’t know they do. Put another way, I don’t hear much about people massaging their head (cranial) muscles, rolling them, stretching them, or otherwise treating those various muscles.

Of course muscles in general can be the producers of symptoms, but it’s rare. I write about this extensively. Everyone loves to name and treat muscles, but, while important, they’re rarely the problem when it comes to orthopedic disorders.

People seem to intuitively comprehend that head pain or headaches can come about for a lot of reasons. Stress, dehydration, allergies, hunger, concussions, and illness to name a few. There are indeed musculoskeletal causes as well - just rarely the muscles. The joints in the neck and mid-back can refer pain (or any symptom) to the head. In rarer cases, the jaw joint can create local symptoms.
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If people can understand that their head can hurt not as a result of the muscles in the area and that their chests and arms can hurt due to a heart problem, then hopefully people can start to grasp that arm pain or leg pain is not necessarily due to arm or leg muscles. -- Laura

People end up replacing and fusing their joints, not their muscles. We must focus on keeping joints healthy, not just muscles. Yes, having muscle strength helps support joints, and training muscles for endurance and strength inevitably moves joints. But focusing on joints is different than simply getting the byproducts of working out muscles. The best way to monitor joint health is monitoring range of motion. The great news is that maintaining range of motion only takes minutes a day. It’s easy to preserve full motion with self-mobilizations once you have it and once you understand the factors that decrease it. For example, you can check your shoulder mobility in one minute. Want to strip it down to the bare minimum? I’d say make sure you can reach all the way up your back and that you can elevate your arm all the way up, out to the side.

Please keep working out those muscles - they're important for musculoskeletal as well as overall health. It’s easy to see, though, that joints more often fail, not muscles. In addition to controlling lifestyle factors, we can also very easily “exercise” our joints. The most important thing is to get joints all the way to end range (especially your spine!) and make sure you can continue to do so. This is what I teach my patients how to do.  --Laura

​Depending on where a muscle originates and where it inserts, it can move the bones of your body in a specific way. It’s rare that a muscle even works in isolation. A certain muscle or muscle group may need to be a focus of rehab in the case of a problem, but there’s no hierarchy of prestige in the human body. (I’m not talking about the heart, diaphragm, etc.) Your psoas is not the key, nor is your core (a group of several muscles). No one muscle will ensure health or prevent injury.

​The relative importance of a muscle is circumstantial, based on what a particular individual’s needs are. For example, a shot putter, to improve performance, will focus on different muscles than a cyclist. Someone whose goal is to be able to get up easily from a low couch will have different needs as well. -- Laura

​Structures other than muscles can be tight. For example, nerves can get tight. Clinically we say they have lost extensibility, are compressed, or are entrapped. However, they do effectively get “tight” in many cases. Joint capsules can also get tight, as can the joints themselves. I usually use the word obstructed when referring to joints, but, to most patients, they in essence feel tight.

Tightness is also a common referred sensation. With referred symptoms, people tend to name the muscle where they feel the symptom. For instance, if the joints in the low back are referring symptoms to the front of the thigh, people usually say (and assume) they have a quadriceps problem. Understanding the concept of referred symptoms is crucial ... but it’s also very important to recognize that it’s not just pain, numbness, and tingling that can be referred. It’s also common to have referred sensations that feel tight, achy, or even hot or cold. -- Laura

Part of effective diagnosing is understanding the basics of how joints, muscles, and nerves work. People with low back pain commonly think they “pulled” a muscle. They may have. I will allow that it is possible. However, in ten years of work, not once have I diagnosed someone with a pulled or strained muscle (or tendon) in his low back. (It’s almost always a joint-driven problem - and joints can refer pain to muscles.)
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A symptomatic pulled (also known as strained or torn) muscle - anywhere in the body - will hurt when contracted. Each personal case is different, but at some angle and with some type of resistance, when that disrupted muscle is asked to contract, it will provoke pain. The second finding with pulled muscles is that they often hurt when put on tension (stretch). This may or may not create a minimal range of motion loss in the plane in which the muscle is on tension. Third, when the affected muscle is on slack (at rest) and not contracting, nothing should happen and range of motion should be full.

An extensor muscle performs extension. If it is pulled you’ll usually find painful resisted extension, pain at end range of flexion with minimal to no motion loss, and full pain-free passive extension. This applies to extensor muscles everywhere, including in the low back. Therefore, if passive low back extension (prone, using the arms or a machine) is limited or painful, I’m not likely dealing with a muscle problem. If standing extension is pain-free but limited, I’m also likely not dealing with a muscle problem.
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Again, knowing the foundations of biomechanics is essential. Just that simple piece of information can allow me to rule out a muscle. Unfortunately, many people (including clinicians) don’t apply these fundamental rules to diagnosing problems. Muscles can hurt due to referred pain, so just because pain is felt in a muscle doesn’t mean the muscle is the problem. A competent diagnostic process will provide the answer. -- Laura

​The supraspinatus is the most commonly affected rotator cuff tendon/muscle. It helps lift the arm up, out to the side. When people encounter pain or difficulty lifting their arm like this, they like to jump to the conclusion that the rotator cuff (or supraspinatus) is to blame. Sometimes it is. However, despite the fact that MRIs regularly show changes or “abnormalities” with the supraspinatus tendon or muscle, other mechanisms are at play when it comes to lifting your arm. The supraspinatus does not work in isolation (things rarely do). Problems with joints, capsules, and nerves can also make lifting your arm painful and/or weak.

When I say supraspinatus “problem” I am referring to a tendinopathy, tear, pull, or strain. How I rule in a supraspinatus problem, given no red flags. Step One: Rule out neck derangement. Step Two: Rule out mid back derangement. Step Three: Rule out shoulder derangement. Step Four: Rule out frozen shoulder. Step Five: Rule in supraspinatus problem.

Some of these steps can be completed by asking a few questions. Some require movement testing. The most important point is to recognize that other things can also create weak and/or painful shoulder abduction or a positive “empty can” or “full can” orthopedic special test. -- Laura

Hamstring pain is posterior thigh pain. Quadriceps pain is anterior thigh pain. IT band pain is lateral thigh pain. Adductor pain is groin pain.

Of course it fits that people who aren’t clinicians would label pain using structures they know. And it’s obvious most people can name big muscle groups! My issue is when clinicians inappropriately do it.

If the patient uses this language, in an effort to create rapport, I may use it with interactions with that patient as well. Mimicing language can be a nice therapeutic tool that is easy to implement. (I typically will adopt the patient’s word for describing his or her own symptoms, for example; my favorite instance being my patient who referred to his radiating leg pain as his “lightning bolt.”) I’d prefer, however, to use the correct language if possible since accurate patient education regarding his or her problem is key to a successful outcome.

I do not use these terms to refer to these parts of the body outside of that specific patient context, though. Yes, if the patient has true hamstring, quad, ITB, or adductor pathology, these words are clearly apropos. But those patients (especially among non-athletes) are rare. In most cases a patient’s posterior, anterior, or lateral thigh pain or groin pain is referred pain from the spine or hip. --Laura

​It takes many weeks for tissue to form adhesions and become tight. And when it is indeed tight, it does NOT vary day to day or week to week. I understand that the sensation patients report is one of “tightness,” but if there is variability, then the source of this tight feeling is not the tissue itself.

When I say tissue, what do I mean? I subdivide it into two main categories: contractile tissue (muscles and tendons) and non-contractile tissue. In the second group, most of the time we’re talking about joint capsular tissue, but there could also be problems with skin, fascia, etc.

Tissue can become tight for many reasons. Think of a simple cut on your skin. If you don’t move the affected tissue, over time the tissue will become tight as scar tissue lays down haphazardly, restricting normal, fluid motion. (This is a good thing - you want scar tissue to be strong! But consistent movement in the right direction will make it flexible.) Surgery is like a simple cut writ large. Many tissues are cut and repaired and, without proper re-integration of movement, often are tight months or years later. Some tissues get tight because they don’t get moved properly. That could be from life habits, patterns after a prior injury, or from 8 weeks in a cast, for instance. A frozen shoulder is another example of tight tissue - which, in the absence of an instigating trauma, usually comes on insidiously.

In these examples, it’s clear that tissue can certainly get tight - and that it can restore to normal length (with informal or formal therapy). It’s also obvious from these scenarios that this process doesn’t allow for a patient to report, “Well, some days it feels really tight, but then some days I’m fine.” Tissue does not behave like that. But joints do ... and they refer that tight feeling to nearby tissue. When I take a patient’s history, I ask very specific questions that narrow my possible diagnoses. If the patient describes variability, local tissue tightness is not the cause. --Laura