House Call, MD

by G. John Mullen, DPT 2011

With the New Year comes the annual New Year resolution.  At the top of every New Year’s resolution list is a promise to be “healthier”.  Everyone has a different opinion regarding what it takes to be “healthier” and it can range from smoking a pack instead of a carton of cigarettes, eat two foot long subs instead of a party sub or increase your running routine from 10 to 100 miles a week.  Ok, that may be a bit of a hyperbole but when asked time and time again, the top of the New Year resolution list is related to exercise.  The most popular and simplest form of exercise is running.  Running is great cardiovascular exercise, however many injuries stem from running and often arise from doing too much too early.  One of the most common injuries is iliotibial band friction syndrome (ITBFS).  This injury can linger for long periods of time without quick and proper treatment but if assessed and treated soon, the effects can be mitigated.

Stat Fact: Health club memberships typically increase 12% in the month of January (4).

What is ITBFS?

The iliotibial band is a fibrous band that runs on the outside of your leg from your hip to your knee.  It is generally firm, but as it is irritated it may become extremely tough and sensitive.  Irritation of the iliotibial band can be due to poor biomechanics, anatomical flaws or muscle weakness.  Many of the biomechanical flaws stem from muscle weakness, but the anatomical flaws are a bit trickier.  The main anatomical flaw is flat feet, which causes your knee to internally rotate with each step, subsequently stretching your IT band.  While stretching is typically good, when done repeatedly it can break down the tissue and inflammation and tightness can occur.  The most common biomechanical flaw is too much hip adduction (bringing your thigh bones close to one another) and internal rotation (rotation of the knee inward) of the thigh bone (femur).  This motion is controlled by the gluteus maximus (the upper fibers to be exact…also the sexiest muscle in the body) and if this muscle is weak it can cause repeated stretching of the muscle leading to problems similar to those seen with anatomical flaws.  These are the main causes of ITBFS, but many other anatomical issues may cause ITBFS (leg length discrepancy, bowed legs, previous injury, improper footwear, etc.).  However, simple muscle strengthening is not the solution, especially if you already have ITBFS.

What should I do if I have ITBFS?

First, go see your physician to get a referral to a physical therapist.  Make sure your physical therapist watches you walking, running, and explains what is going on biomechanically because it is essential to understand the problem before it can be resolved.  Some modalities (ice, electrical stimulation, etc.) may be used to decrease pain and inflammation, but these things will only solve the problem temporarily. A proper running analysis, combined with a stretching and strengthening program will be most beneficial in the long run (yes, this is a purposefully placed pun).  Every physical therapist will have their own unique treatment style but, as an overview, it should include:
•    Diagnoses and evaluation of the injury
•    If ITBFS is determined, a temporary termination from running will be suggested to allow proper healing
•    The need for shoe lifts, inserts, orthotics, etc. will be assessed
•    Modalities will be used to treat inflammation and pain
•    Soft tissue mobilization to break up the tightness in the ITB (see image above utilizing a foam roller)
•    Stretching will be used to provide proper leg length
•    Strengthening will be combined with stretching and, when proper muscle activation is achieved, return to sport is indicated

Stat Fact: ITBFS has been reported to cause of 12% of all running-related injuries (5).

Prevention of ITBFS

If you do not have ITBFS but reading articles on running forums and Running World have scared you into learning about the pathology, then this is the section for you.  Remember, an ounce of prevention can go a long way.

Proper Warm-up
To stop ITBFS before it begins, a proper warm-up is necessary prior to any workout.  This warm-up should not be a light jog!  A good warm-up involves at least of 5-10 minutes of multi-directional movements of the legs and arms.  Sport specific warm-up and dynamic (moving) stretching for at least 10 minutes must also be utilized to properly warm-up and stretch your muscles (3).  Imagine trying to stretch a rubber band that’s been in the freezer.  Not a good idea, we promise.

Example Warm-up for Jogging:
•    10 minutes of jogging which includes repeated bouts of: high knees, butt kickers, skipping, side-stepping, karaoke, backwards running and high knee hip rotation
•    10 minutes of marching with legs raises in front, leg raises to side, skipping, leg swims (forward and side-to-side), lunges, side lunges, higher speed training

Proper Cool-Down

After each workout a cool-down of at least 10-15 minutes is recommended.  This warm-down should not just be walking, jogging, smoking a cigarette or drinking a coffee (or any combination of those).  A proper cool-down encompasses some jogging at a slightly lower intensity than the main workout, dynamic stretching, isometric stretching and relaxed stretching (1).

Example of Cool-down for Jogging:
•    5 minutes jogging that includes walking lunges and high knees.
•    5 minutes of isometric stretching: standing legs spread stretch to each side, standing calf stretch, seated IT band stretch (see image), IT band foam rolling or tennis ball rolling (these may be painful in the beginning), side lunge stretch (all of these stretches should be performed for at least 30 second holds)
•    5 minutes of relaxed stretching: seated legs spread stretch, forward lunge stretch, semistraddle, side quadriceps stretch, lunging IT band stretch.

Strengthening

As previously mentioned, most biomechanical ITBFS is caused by weak upper gluteus muscles.  However, simple squats won’t fix the problem because running relies on eccentric strength of the hip extensors (hamstrings, glutes).  Eccentric strength refers to muscle lengthening as opposed to concentric strength which refers to muscle shortening.  In a bicep curl, the curling of the dumbbell towards your shoulder is the concentric phase of the exercise and the lowering of the dumbbell towards your side is the eccentric phase of the exercise.  It is essential to meet with a strength and conditioning professional or physical therapist to help design a proper training program to strengthen this muscle properly and apply correct training principles.  Poor training = poor results and nobody likes walking around with a bum leg.

Example Strengthening of the Gluteus Maximus

Overview

The amount of repetitions and sets will vary depending on your primary goal and current level of conditioning.  The ultimate goal is 3 sets of 10 repetitions each.  If the exercise is too easy, add weight to increase difficulty.  Some exercises will be more difficult.  In these instances, you should reduce the number of repetitions to prevent injury and slowly work your way up to three sets of ten.

Beginner:

Bridging:

Lie on your back with your knees bent and feet shoulder width apart, push through your heels to lift your butt off the ground as high as you can (possibly into hyperextension).  Hold this position for a second and then lower your butt back to the floor.  This is one repetition.

Clams:

Lie on your side and bend your knees to 90 degrees and your hips at 60 degree with your legs one on top of the other.  Now lift your top leg open like a clam, hold for a second and then return your knee to the starting position.  Brilliant!  Complete 3 sets of 10-20 repetitions on each side.

Intermediate:

Single Leg Deadlift:

This exercise is similar to the single leg squat.  To begin, stand on one foot and bend your knee slightly (~10 degree).  Now bend at your hip bringing your chest towards the floor and touch the ground next to your foot with the opposite hand.   Hold for a second and return to the standing position.  Repeat 3 sets of 10 repetitions on each side.  To advance, you can add dumbbell weights in each hand.

Band Seated Abduction:

While seated, take a resistance band and wrap it around your thighs.  Once in this position, rotate your hips outwards by opening up your legs (similar to the clam exercise, but seated).  You should feel a burn in the lateral aspect (the outside) of your hip.

Advanced:

Kneeling Glute-Ham Fall:

Begin in the tall kneeling position (see picture) and have a partner hold onto the back of your heels to stabilize you.  Now lower yourself as slow as possible to the floor maintaining your upper body in a straight line as you lower yourself to the floor from your knees.  This can be advanced by holding a weight to your chest during the exercise (2).

Hip Thrust:

Hip thrusts are similar to the glute bridge but with weight involved in the exercise.  Begin with your shoulders higher on a couch or bench.  Place weights across your hips (preferably a barbell) starting in the seated position (See picture at right).  Press your hips towards the ceiling and hold at the top of the movement for 3 seconds then lower your hips to the starting position.  Remember to lower yourself slowly on the way down.  Perform 3 sets of 15 repetitions (2).

Time to hit the road with your new-found gluteal strength!

References:

1.    Kurz, T. Stretching Scientifically. Stadion Publishing Company, Inc 1994.

2.    Contreas, B. Dispelling Glute Myth. 2009. Available at: http://www.tmuscle.com/free_online_article/sports_body_training_performance/dispelling_the_glute_myth. Accessed January 23, 2010.

3.    National Strength and Conditioning Association. Essentials of Strength and Conditioning Conditioning. Human Kinetics. 2000.

4.    Thruston, J. Health Clubs Popular every January. 2010. Available at: http://www.post-gazette.com/pg/10014/1028048-55.stm. Accessed January 23, 2010.

5.    Cosca DD, Navazio F. Common problems in endurance athletes. Am Fam Physician. 2007 Jul 15;76

by G. John Mullen, DPT 2011

Neck pain: We’ve all had suffered through it at least once in our lives as it is one of most common areas of the body to cause pain.  However, it may be hard to diagnose the primary cause of your neck pain.  Let’s pretend you sit at a desk for 40 hours a week for work/school, and then come home and sit at a desk watching Hulu for a few more hours. Just a hunch, but I think the excessive sitting may be causing some of your neck pain.  Sitting this long is not natural for once nomadic humans.  In addition to sitting for these long hours, most people make it worse by maintaining poor posture while sitting (which is not entirely your fault…humans were not designed to sit for the long durations that our modern lifestyles require).  Despite our societal evolution, our anatomy has not adapted.  As a result, we must actively adapt our bodies to the new societal demands.  Lucky for us, we can make these changes to help improve and possibly prevent most unnecessary neck pain.

Stat Fact: It is estimated that 70% of all muscle injuries that occur without a known accident are sprains or strains.

Neck Anatomy:

The cervical spine is composed of many muscles that are contorted, stretched and shortened with poor posture.  These muscular changes can cause pain in various areas of the spine and in other body parts (shoulders, middle back, etc.).  With sustained poor posture, tiny muscles in the back of your head (suboccipital muscles) tighten or shorten.  Unfortunately, the body compensates by shortening, stretching or elongating the muscles in the front of your neck (your deep neck flexors).

Ways to tell if this is causing your pain…

If you are having neck pain and you think it’s from your poor posture, here are some telltale signs your neck pain is due to your posture:

• Persistent neck or shoulder blade aching

• Symptoms worsen with sustained poor posture

• Muscle imbalances (weak deep neck flexors and weak rhomboids)

Some simple tests you can do to test yourself:

1. Deep neck flexor test:

To perform this test lie down on your back and lift your head off the ground by tucking your chin in tight, as if you’re making a double chin (some people have to try harder to achieve this).  While holding your head 1 inch off the ground, keep your chin tucked as long as humanly possible (shaking and the urge to urinate may be present if one has extreme muscle weakness).  If you unable to hold your neck folds for approximately 30 seconds then you have weak deep neck flexors.

Stat Fact: Patients with neck symptoms (pain, for example) produced 15% less pressure than patients without neck symptoms in the deep neck flexor test.  The bottom line: people with neck pain are usually weak in their deep neck flexors.

2. Neck Rotation Test:

Another simple test to be done at home is a neck rotation test.  Rotate your neck to each side slowly and if your symptoms or pain increases as you rotate more, then your neck pain is probably caused by posture problems.

What to do next?

You have a few of the neck symptoms described above and your neck muscles aren’t as strong as Žydrūnas Savickas…don’t be discouraged there is hope for you!  First and foremost, correcting your posture is the number one cure for this ailment.  I know holding good posture is hard, but so is eating 66 hot dogs in 12 minutes and that didn’t stop Joey Chestnut did it?  A few tips for holding proper posture while at a computer or sitting down:

• Keep your feet on the floor!  You’re not a six year old kid in elementary school.  Put both feet on the floor and keep them there!

• Keep your back against the chair, especially your upper back.  If your back is not against the chair there is a high chance you are leaning forward.

• Keep your chin tucked.  You’re not finishing a 100 meter sprint against Usain Bolt.  Keep that chin tucked.

• Keep your shoulder blades close, don’t round that back!  I know many people dreamed of being a Teenage Mutant Ninja Turtle growing up, but we hope you’ve outgrown that fantasy.  No need to round out your back as an adult.

Stretches:

Next is a routine of stretches we recommend doing in the shower on a daily basis.  All of these stretches should be done twice for 30-45 seconds each.

1. Armpit Sniffer:

The arm pit sniffer is a favorite of ours for numerous reasons.  While standing, look down towards your armpit as if you were checking to see if that Old Spice has kicked in.  If done correctly, you should feel a slight pull on the neck of the opposite side.  This is stretching the levator scapulae, a muscle that is commonly tight with poor posture.   The picture shows the person pulling their head toward their armpit, but if this muscle is really tight, just looking in the direction will provide a proper stretch.

2. Corner Stretch:

This stretch is used to stretch the pectoralis muscles that are often tight due to extended periods of time sitting or at a computer.  To complete this stretch, find a doorway and put the inside of your bent arm on the surface of the wall at shoulder height.  To feel the stretch turn your body away from the arm, and you should feel the stretch in chest (amazing ponytail as seen in the photo is optional).

3. Scalene Stretch:

To complete this stretch, hold on to something for support because you will be tipping your head backwards and towards the opposite shoulder.  Tip your head slightly back and to the side, the picture shows the person pulling his head back, this should only be done if you do not feel a stretch in the front of your neck with the initial movement.

4. Upper Trapezius stretch:

This is the simplest of all the stretches.  Without rotating your neck, tip your head, as f you were trying to touch your ear to your shoulder.  If you do not feel a stretch on the  opposite side you can use overpressure with your hand to elicit the desired stretching sensation.

Strengthening:

Strengthening exercises should be performed with high repetitions to help build endurance.  We recommend 5 sets of 10 repetitions, 3 times a week for best results.  These exercises may seem simple, but if used properly they can alleviate your nagging neck pain.

1. Chin Tucks:

Similar to the deep neck flexor test done earlier, lie on your back and tuck your chin, lifting your head 1 inch off the ground.  Make sure you hold the double chins in your neck.  Hold for 30 seconds (or as long as you are able to if you cannot hold for 30 seconds) each set and complete 5 sets 3 times each week.  And, yes, this exercise falls into a category of exercises know as “Not sexy but very effective!”

2. Scapular squeezes:

Begin this exercise sitting down and, just as the name suggests, and squeeze your shoulder blades together.  By pinching your shoulder blades together, your chest will stick out slightly.  Make sure not to lift your shoulders towards your ears while holding this position!  Hold this position for 30 seconds each repetition and complete 5 repetitions per day 3 times a week.

3. Upper Cuts:

Begin with your knees bent 15 degrees and as you start the upper cut movement, punch towards your opposite shoulder (your bicep should come towards your mouth) and push through your legs.  You can make the exercise more difficult holding a weight in your hand while punching as seen in the photo.  This exercise is used to strengthen the serratus anterior.

Stat Fact: Neck musculature is estimated to contribute 80% to the stability of the cervical spine.

These are some of the exercises and stretches that can be used to help people minimize neck pain.  Next time you’re sitting at your desk, think twice about leaning forward to read the computer screen.  If your neck pain persist or worsens after doing these exercises for a few weeks, talk to your medical doctor about additional treatment options.

References:

Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001;344:363–70.

Chiu TT, Law EY, Chiu TH. Performance of the craniocervical flexion test in subjects with and without chronic neck pain. J Orthop Sports Phys Ther. 2005 Sep;35(9):567-71

Ekstrom et al, Surface Electromyographic Analysis of Exercises for the Trapezius and Serratus Anterior Muscles, J Orthop Sports Phys Ther 2003;33:247–258.

Childs J, Cleland J, Elliott J, Deydre T, Wainner R, Whitman J, et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9):A1-A34.

by G. John Mullen, DPT 2011

With Thanksgiving behind us and winter weather in full effect, snow has already begun to cap the mountains across America.  With a layer of white powder on the ground, everyone is counting the days until they can escape from work, school or writing anonymous cynical comments on message boards and hit the slopes.  Whether you snowboard, sled, cross-country ski or bare foot ski, with the rush of mountain adrenaline comes the risk for injury.  We’re here to help you train those hard-to-reach, unused muscles for the slopes so that you are prepared for anything the mountain can throw at you.

Stat Fact: Lower extremity injuries were the most common injury in the Utah slopes from 2001-2006 for both snowboarding (~27%) and skiing (~50%).

Whether you’ve looking for exercises to prevent future knee injuries, strengthen your legs for the slopes, or help make that knee pain from that 1960 football injury (quit living in the past) go away, you can utilize the exercises below to strengthen weak muscles and lengthen tight muscles. We’ll discuss some plyometrics and exercises you can use to mimic skiing or snowboarding. Even if you’re as big as Richard Sandrack (see Lil Hercules at left) your bulging biceps and six-pack abs won’t prevent lower extremity injuries…training those targeted muscles will.

STRENGTHENING:

There are hundreds of exercises that can be used to train for the slopes.  We are going to talk about the main muscle groups that will prevent injuries and go over our favorite exercises to strengthen these muscle groups.  Unless you’re like hip hop video girl Vida Guerrera, you, like most Americans, may already experience knee or hip pain (or at least feel a little weak when it comes to these joints), due to weak gluteal muscles,.  As stated, there are hundreds of exercises to strengthen these muscles…so we’ve boiled it down to some key moves to get you started:

Overview of Strengthening:

When you first begin these exercises, start with the beginner exercises in your training of  those gluteal muscles.  At the beginning start with 3 sets of 20 repetitions and after two weeks add weight and try 3 sets of 10 repetitions.  After two more weeks add more weight and go 5 sets of 5 repetitions.  After this progressive process, advance to the intermediate exercises and repeat the same amount of repetitions and sets.

Beginner:

1. Clams:

Lie on your side and bend you knees to 90 degrees and your hips at 30 degree with your legs one on top of the other.  Now just lift your top leg open like a clam, brilliant!

Stat Fact: By increasing the amount that your hips are flexed during this exercise (by bringing your knees towards your chest thus changing the angle from 30 degrees to 60 degrees) you change the gluteal muscle you are working, from gluteus medius to gluteus maximus.

2. Bridges:

Lie on your back with your heels on the ground, but your toes in the air (lifting your toes makes sure you don’t use your calves and helps you to better isolate those gluteal muscles!).  Next, lift your lower back and butt off the ground by pushing through your heels.  At this point only your upper back and feet should be on the ground.  Note: a band can be used just above your knees to keep your legs from coming together, but is not necessary.  However, keep your knees apart!

After you’ve mastered double leg bridges, you can advance to single leg bridges or double leg bridges with weights on your hips.

3. Side-lying Leg Raise:

Lie on one side with one leg on top of the other, keep both legs straight and raise your top leg towards the ceiling.  Make sure your leg doesn’t creep forward.  To do so, keep it aligned with your hip or back (you should form a straight line from your shoulder to your hip to your knee to your ankle).

Stat Fact: If done properly, with your leg in correct alignment, this exercise requires the most gluteus medius activation of the exercises without weight.

Intermediate:

Lunges:

We’re not talking about your run-of-the-mill forward lunges.  We need to use exercises that are as close to skiing as possible, thus the use of multi-directional lunges.

1. Transverse Lunge:

Start with your hands on your hips and both feet facing forward like your feet are facing 12 on a clock.  Now, with one leg take a large step towards 2 o’clock.  Make sure your back foot rises on its toes and you don’t allow your front leg’s knee to come in front of your toes!

2. Lateral Lunge:

Once again, start with your hands on your hips and both feet facing forward like your feet are facing 12 on a clock.  With one leg take a large step towards 3 o’clock.  Make sure your back foot rises on its toes and you don’t allow your front leg’s knee to come in front of your toes!

To advance the lunges, you can hold weights (or anything that will add extra weight) in your hands or if you’re at a gym you can put a bar on your back.

Advanced:

1. Single Leg Squat:

Stand on one leg and slowly lower yourself bending at your hip, knee and ankle until you can touch the floor with your middle finger without reaching your shoulder.  Remember to stick your butt out as you come down and try not to let your knee come in front of your toes.  To advance this exercise, you can hold weights in either hand.

2. Single Leg Deadlift:

This exercise is similar to the single leg squat.  To begin bend your knee slightly (~10 degrees).  Now bend at your hip and bring your chest towards the floor, reaching with your hand to touch the ground.  To advance the exercise, you can add dumbbell weights in each hand.

Stat Fact: Single leg squats and single leg deadlifts have been shown to have the highest gluteus maximus activation of any non-weighted exercise…buns of steel, here we come!

STRETCHING:

It is hard to predict what muscles will be tight on each individual, but if we were to grab 10 people off the Red Line subway in Los Angeles and test their muscle flexibility I would bet a liter of cola that 9 of those people have tight hamstrings, piriformis (a muscle in your butt… that’s all you need to know), calves and hip flexors.  What do you say we try and loosen those bad boys up.

Overview of Stretching:

As you move through the stretches outlined below, remember to stretch both legs, completing each stretch twice for 30 seconds or more.  It is hard to overstretch these tight muscles, so the more you do the better.

Hamstring Stretch:

Lie on your back, grab the back of your thigh of one leg and begin to pull that leg towards the ceiling.  If done correctly, you should feel a stretch in the back of your leg and possibly in your calf.

Stat Fact: It is estimated that 80% of persons suffering from low back pain have tight hamstrings.

Piriformis Stretch:

Once again, lie on your back but this time bend one leg over the other.  Now push your bent leg towards the ground, without lifting your back off the ground.  If done properly, you should feel a stretch in your butt.   You have now officially located your piriformis muscle.

Calf Stretch:

Being by standing facing a wall with one leg in front of the other. with the leg to be stretched extended behind you.  With your hands on the wall at the level of your head lean forward.  You should feel a stretch in your calf.  The more you lean forward, the more stretch you will feel.  Repeat these same steps on the other side as well.

Hip Flexor Stretch:

Place one knee on the ground and lunge forward with the other leg, keeping your back straight.  If done correctly, you should feel a stretch in the front of your leg around your hip on the kneeling leg.  As you push forward with your pelvis, you should feel the stretching increase in this area.

Plyometrics:

Plyometrics are activities that enable a muscle to reach maximal force in the shortest possible time.  These exercises are meant to be explosive, but need to done carefully and under proper conditions (outlined below):

• Good landing surface (grass field, suspended floor, rubber mats)

• Plenty of space

• Proper footwear (no flip flops)

• Supervision, it is highly advised to do plyometrics with a training professional (personal trainer, physical therapist)if you are new to the exercises

Since this is a high intensity exercise we will start with one basic exercise as well as some strategies for plyometric training.  First, it is important to complete a proper low intensity warm-up.  Begin with skipping, marching, or jogging. The total amount of time you spend on these activities needs to be strictly monitored.  It is recommended that beginners do a maximum of 80 contacts.  80 contacts simply means each foot should only hit the ground 80 times including the skipping and jogging warm-up.  Anyone doing plyometrics should also include the appropriate amount of rest between exercises (at least a minute per exercise).  Below are a few examples of beginner plyometric exercises that mimic skiing and snowboarding.  We highly recommend doing these beginner exercises with an exercise professional (at least when you’re first starting off…the only thing worse that hurting yourself on the slopes is hurting yourself while training for the slopes).

Forward/Lateral/Diagonal Jumps:

Just as they sound, these jumps are performed with both feet together and you jump either straight forward, to your side or diagonally.  To begin start by jumping, landing and then jumping again.  As you progress you can begin performing multiple jumps in a row.

Now that you know what strengthening, stretching and plyometric exercises to perform, make sure you always warm-up first (at least fifteen minutes of cardiovascular work to get your heart rate elevated and muscles warm).  Perform these stretches exercises every day and the strengthening/plyometrics no more than three times a week.  When you hit the slopes tell Shaun White hello for us.

References:

Distefano, L., Blackburn, J., Marshall, S., Padua, D. Gluteal Muscle Activation During Common Therapeutic Exercises. Journal of Orthopaedic and Sports Physical Therapy.  2009 Jul; 39 (7): 532-540.

Torjussen J, Bahr R. Injuries among competitive snowboarders at the national elite level. Am J Sports Med. 2005 Mar;33(3):370-7.

Wasden CC, McIntosh SE, Keith DS, McCowan C. An analysis of skiing and snowboarding injuries on Utah slopes. J Trauma. 2009 Nov;67(5):1022-6.