A prescription for someone's hip pain may be: single leg stane on a BOSU with hip abduction, core stabilization on a physioball, soft tissue release of the psoas, Turkish get-ups, hip long axis traction, hip extensor strengthening, IT band foam rolling. My prescription for this patient may be: loaded hip extension. This is not an exaggeration. This is a representative example of what a patient might get for his complaint of hip pain with other clinicians and what I often give patients with a complaint of hip pain.
The logical question is why does this happen? The answer lies in the fact that I look at the neuromusculoskeletal system differently than other clinicians. Compared to 10 years ago, I evaluate differently and diagnose differently now. Ergo, I prescribe different treatment plans. I find that most orthopedic disorders are joints not moving well and therefore the treatment is specifically directed at getting them to move normally again.
Is there a scenario in which I would prescribe all those things in the first example? Maybe, but I can’t imagine that case. I know those things exist if I need them, though, because I used to employ them.
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
There’s a reason why if I’m treating spinal pathology, or if I’m curious about the relationship of the spine to the patient’s extremity complaint, I a) only prescribe one movement at a time and b) assess the effect of the exercise on the patient’s baselines before allowing it. Even though you may think the spine is in neutral or is not moving when an extremity exercise is being performed, there’s a strong chance that the spine is influenced. Sidelying clams, biceps curls, squats, rows, leg lifts, as examples, can easily impact the spine.
It should go without saying that a strengthening exercise for a hip muscle influences the hip joint, a rhomboid exercise influences the shoulder, and a triceps dip influences the elbow. But we must not forget about the influence on other nearby joints, namely spinal joints. And we must be deliberate when assessing cause-and-effect to determine whether an exercise is warranted. It's not difficult to take spinal baselines, implement an extremity exercise, and then re-test to see if the spinal baselines have changed. Knowing to do that, and how to do that, is where the skill lies. -- 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
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
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
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
The glutues maximus, gluteus medius, and gluteus minimus are innervated (powered) by the nerve roots L4, L5, S1, and S2, which exit the spinal cord in the low back. A muscle can only achieve optimal strength and efficiency if it’s getting an undisturbed supply of electricity. I hear loads and loads of people talk and talk about problematic weak glute muscles. I usually don’t find weakness. Instead, I find that it’s almost always inhibition - a fuse box (spine) problem. Most low back problems are at the levels L4, L5, S1. Is it any surprise then that the nerves to the glutes may be compromised? There does not have to be back pain for a nerve irritation to be present.
If we prove that your nerves are indeed working well (which we do by clinically moving your low back, and sometimes hip, repeatedly - not by looking at an image), and your glutes are still problematically weak, then we can begin all those glute exercises such as squats, lunges, donkey kicks, clamshells, crab walks, sidelying leg lifts, lateral step downs, bridges, and so on. If a professional wants to diagnose “weakness,” then he/she better have first at least ruled out inhibition. Not only does that save months of work, but it gets at the real diagnosis. When a muscle doesn't demonstrate the strength it should, I check the fuse box. -- Laura
Most of orthopedics is getting joints moving better, getting nerves conducting electricity and moving better, and getting tendons functioning at full capacity. Rare is the case that true strength needs to be built in a muscle or muscles to resolve a problem. Those scenarios include when atrophy is creating problems (secondary to a number of possible factors) and when there has been injury to a specific muscle. While I often use general “strengthening” exercises as an adjunct to the primary intervention, the intent there is to get the musculoskeletal system moving and working again, not strengthening. Of course, muscular strength, which takes significant time to build, has myriad positive effects on the body, and I wholeheartedly support strength training in general. However, when problems arise, specific distinct solutions are typically called for. -- Laura
In general, those who strength train work opposing muscles - quads/hamstrings at the knee and biceps/triceps at the elbow, for example. Notwithstanding specific athletic performance needs (a very small population), it’s generally a good idea to balance muscle groups so that innate human biomechanics are not significantly thrown off.
In the same vein, joints should be worked in opposing directions. Knee extension/flexion and elbow extension/flexion, for example. In my book, the most important manifestation of this credo is with spine flexion/extension. While people perform many activities of spine flexion (forward bending), they rarely move into spine extension (backward bending). Considering only the gym, you see squats, burpees, deadlifts, sit ups, hamstring stretching (and more!) involving spine flexion. Only on rare occasions will you see a standing back bend or “cobra” or “upward dog” stretch on the floor. I have no problem with flexion; I just want balance. Public gyms provide a glaring example that people will attend to muscle balance but rarely joint - specifically spinal joint - balance, but this applies to everyday life as well. --Laura
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