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
People often remark they have a "tight" or "stiff" joint. Most times people have joints that are actually tight in only one or more directions but perfectly fine in other direcctions. The distinction matters.
Whether or not a joint is restricted in motion in one or more versus all planes of motion is extremely relevant to diagnosing. I know what people mean when they say their joint is tight, but a quality physical exam will easily reveal the specifics, including in which direction(s) motion is limited, how much is missing, and the quality of the movement and accompanying presence of symptoms. Joints have many planes of motion such as flexion, extension, side glide, external/internal rotation, abduction, adduction, and others. Missing motion, combined with a verbal history and other physical tests, helps me know whether the problem is related to a muscle/tendon, the joint itself, a nerve, an infammatory process, and so on. -- Laura
Of course I am a proponent of general movement and general exercise, but a spectrum of attention to detail does exist. If you want to be smart about your mobility and/or exercise workouts, focus more on the movements that you get less in your day-to-day life, whatever that entails.
If, for instance, you sit all day, like many people do, then biking hunched over in the seated position might not be the best way to get exercise unless you’re smart about it and also move in the opposite direction. Likewise, if you sit most of the day, your hip is usually in neutral rotation or external rotation. If you have that knowledge coupled with an interest in above-average health or desire for athletic performance, you likely want to bias hip internal rotation movements in your exercise routine. (So much hip stuff I see on the Internet focuses heavily on moving hips into external rotation compared to internal rotation, which doesn't make much sense!)
This level of knowledge and personalization is certainly rarely taken into account with general classes (yoga, Pilates, Barre, etc.) - and it’s not expected to be. But if you want to be at the end of the spectrum designating excellent health, this information should be taken into consideration. The first general goal is simply to move. But a second goal is to be purposeful about how you move and focus on balance (eg balance between joint flexion/extension, internal/external rotation, and abduction/adduction). Our joints move in lots of different directions, though our everday routine is usually comprised of only some of them. Therefore, use the time you focus on exercise intentionally to help close any gaps. -- 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
The study, “Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009-2016,” was published online Nov. 28, 2018 in the journal Metabolic Syndrome and Disroders. I propose that similarly few Americans are musculoskeletally healthy.
While there may be some debate over the absolute best criteria to use to determine metabolic health, the five used in this study are clearly important. For instance, some clinicians argue that insulin level is a more significant barometer of health than glucose level.
For musculoskeletal health, as I have written before, I propose that the criteria are: full joint mobility; full strength; full nerve extensibility; and full, pain-free function. Function means being able to do what you want to do with your body and not being limited by musculoskeletal problems. (Be aware: not being able to do something can be limited by fitness, not problems.) Yes, full, pain-free function is less objective and more individual than the other three metrics, but it is still relevant and critical.
Could you make the argument that being able to walk 1 mile in under 15 minutes should also be a criterion? Or that normal musculoskeletal health means you should be able to get up from a chair without needing your hands? Sure. Those demands, though, usually require that you meet the basic criteria. There’s certainly room for debate, and we do have valid tests that measure people’s ability to do things like this.
However, whichever metrics we use - the simple ones I propose or more involved ones - it’s clear from my experience (ten years working in orthopedics) that not many Americans would fit the criteria for being musculoskeletally healthy. -- Laura
If a muscle is actually physiologically tight (versus feeling tight), it can only restrict movement when it is put on stretch/tension. So, if your left upper trap muscle in your neck feels tight and you’re missing left side bend but have normal motion into right side bend, the left upper trap muscle is not actually tight. A muscle like this on the left is put on slack with movement to the left and put on tension with movement to the right. Therefore, something ELSE - not the muscle - is the cause of the tightness feeling. That is, something ELSE is causing both the loss of motion in left side bend as well as the feeling of tightness in the left neck.
In this scenario, it is most likely that a joint in the neck is not moving properly – and that is the issue, the cause, that needs to be addressed. Joints that are not moving well can cause loss of movement in one or more planes of movement and can cause local symptoms or referred symptoms in other areas. The term I use for this diagnosis is joint derangement. It is addressed primarily with movement in a specific direction.
Just to be clear, it is rare that a muscle is actually physically tight, especially for no apparent reason. It is common, however, for muscles to feel tight as the feeling is referred from nearby structures such as joints. We can determine if a muscle is actually tight vs feeling tight with a thorough evaluation; we don't have to guess. The most obvious example I can think of when a muscle is indeed actually tight is when there has been direct muscle injury. As it heals, the scar tissue will be tight, as is its nature. With appropriate progressive movement, the length will be regained. -- 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
There are many goals when it comes to working with orthopedic disorders, but these are the objective health parameters I aim to achieve: full range of motion, full strength, full nerve extensibility, and good mechanics. Mechanics, loosely defined as how you move, is more subjective than the others, but there are norms with quality of movement too.
Full, pain-free function, or being able to do what the patient wants to do, is the most important, but functional ability typically relies on these four domains. In the event we cannot achieve full range of motion or full strength etc. - which can happen for various reasons - our goal simply becomes to achieve the maximum possible. (Other goals with care: efficiency, risk minimization, fostering patient independence, and teaching prevention strategies.) -- Laura
How do I increase a person's ankle dorsiflexion range of motion? There is no one way to fix a sign/symptom. I can name ten possible things I would do to increase a person's dorsiflexion depending on the source of the deficit. A sign or symptom is not a diagnosis. You diagnose the problem that causes the sign/symptom and provide the appropriate treatment for that diagnosis. It’s the same as with other medical problems. There’s not one way to relieve head pain nor one way to increase low blood pressure. You figure out the reason (the diagnosis) and address that.
I know I sound like a broken record, but people want to oversimplify orthopedics when it actually takes solid diagnostic skills to achieve effective care. If a patient of mine has decreased dorsiflexion, that is just one piece of data in isolation. Combined with the other data I obtain (verbally and physically) and combined with the response to repeated dynamic testing, that piece becomes more intelligible. If you think you simply need to stretch your Achilles to gain more dorsiflexion, by all means, go ahead. It will help sometimes, but it’s not high on my list of treatments I use to gain dorsiflexion. There are many treatments I use more commonly than simple muscle/tendon stetching. So the answer to how I increase dorsiflexion is: “It depends.” -- Laura
Joint mobility is an extremely important piece of data when diagnosing and treating orthopedic disorders. Even though testing a joint’s mobility is easy, it is rarely done well. While the length of a muscle may matter, the strength very rarely does. A tight muscle (which is rare) may reduce a joint’s range of motion in a specific direction (the direction in which the tight muscle is put on stretch), but weakness is rarely a factor.
A muscle would have to be significantly inhibited and/or significantly weak for the patient not to be able to achieve full active range of motion, especially with gravity eliminated or gravity assisted procedures. (Remember: muscle inhibition usually comes from a nearby joint or spinal joints.) Muscle weakness does not impact passive range of motion, which is when the joint is moved by something external (not internal muscle strength). If a joint doesn’t move well - passively and/or actively - my investigation starts with joints themselves (local and spinal). If that proves fruitless, only then will I consider that muscles are causing reduced joint range of motion. -- Laura
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