Envision Physiotherapy – Blog

The Deadlift; A Physiotherapist’s Perspective – by Trish Kazun

The deadlift has long been used as an integral component of a strength-training session. Many trainers and strength and conditioning coaches advocate for this exercise, praising it for its contribution to whole-body strength. Despite its benefits, however, it can also be a major contributor to lumbar spine and sacro-iliac (SI) joint pain and dysfunction.

Fig.1

Anyone who has done any work with the deadlift knows that the key factor in protecting the spine is to keep the low back straight, right? Wrong! Yes, you certainly want to avoid ROUNDING the low back, but protecting the lumbar spine is much more involved than simply keeping the low back straight.

How would you react if I said that it is the way that most people “keep the low back straight” actually contributes to lumbo-pelvic dysfunction? Here’s why:

The spine is made up of a collection of vertebrae stacked one on top of the other. In the lumbar and cervical region the spine curves forward (creating a lordosis) and in the thoracic region it curves backwards (creating a kyphosis) (see Figure 1). In the posterior part of the vertebrae lie the facet joints, which help to guide movement. Between the facet joints and the vertebral body is a foramen (hole) which allows the nerves to exit the spine (see Figure 2).

Another concern with the general cue to “keep the low back straight” is that, in doing so, the athlete is often using the muscles incorrectly. In order to try to protect the low back, people often tend to brace with the more superficial muscles that are actually meant to be creating movement (eg: erector spinae, latissimus dorsi) rather than the deep stabilizer muscles, which are engineered to stabilize. And rather than using the glutes, people often grip with their deep hip muscles (eg: piriformis). Overuse of these superficial muscles can cause muscle fatigue and strain, and SI and facet joint compression leading to joint irritation.

So what are the key muscles that should be used to protect the lumbar spine?

 To answer that question, we have to think about “the core” like the layers of an onion. The inner-most layer (called the “inner unit”) is made up of the transverse abdominus, which is the lowest layer of the abdominal muscles and wraps around the torso like a corset, the multifidus, which are tiny little muscles that connect adjacent vertebrae along the entire length of the spine, and the pelvic floor muscles. Together, these muscles act locally to provide segmental stability to the spine and SI joint, unlike the superficial muscles which connect to bones far removed from one another and act remotely.

Fig.2

To further illustrate this point, imagine a tower of blocks. If you hold the tower between your hands by putting one hand on the top and one hand on the bottom of the tower, it appears stable. BUT, if someone comes by and pushes out one of the blocks in the middle, the whole tower will crumble. However, if you glue each block to the one above and below, no one will be able to make the tower crumble.

Your “inner unit” works much like this. The transverse abdominus, multifidus, and pelvic floor are the glue that holds the tower together. The hands at each end of the tower are what we call the “global stabilizers”. These make up the “sling system”, which supplements the work of the “inner unit” to stabilize the spine and SI joint.

The posterior oblique sling is comprised of the latissimus dorsi, the gluteus maximus, and the thoracolumbar fascia (a thick layer of connective tissue that lies across the low back).

The deep longitudinal sling is made up of the erector spinae, the multifidus, the thoracolumbar fascia, and the biceps femoris.

The anterior oblique sling involves the external oblique and the contralateral internal oblique and adductor of the thigh, and the connective tissue that runs over the abdomen.

The lateral sling involves the gluteus medius and minimus, the tensor fascia lata, and the contralateral adductors of the thigh.

So how do these slings work with the “inner unit” to provide stability?

In order to ensure adequate spinal stability, the “inner unit” must contract first. If the load is too large and the inner unit alone is unable to stabilize the spine and pelvis, then the sling systems kick in to provide additional support. With these two systems working together, one can be sure that the chance of an injury to the lumbar spine and the SI joint is minimal. Too often, however, it is the muscles of the sling systems that contract first, with minimal or no contribution from the “inner unit”. This causes the sling system muscles to be overworked, and makes the back vulnerable because there is no stabilization happening at a local level.

So how does this relate back to the deadlift?

It is crucial to ensure that the “inner unit” is contracting before you even begin to move. Without the local stability that the inner unit provides, the back is vulnerable. Once the “inner unit” is active, activate the lateral sling. To do so, follow the cue that many trainers give to push your feet away from one another as if you were trying to rip the floor apart; this will help you engage the gluteus medius and minimus of the lateral sling. As you then proceed through the deadlift movement, maintain activity in the “inner unit”, and avoid the temptation to “brace” with the low back muscles and arch your lumbar spine. If you look sideways in the mirror, your back should NOT look like a letter J; in fact the curves of your spine should change very little throughout the whole movement. I use the analogy of imaging that you are a figure on a foosball table; there is a skewer through your hips and your body is rotating around this point, without changing the curves of the spine. The deep longitudinal and posterior oblique slings will kick in as you lift the load, as you squeeze your arms into your sides, activating the latissimus dorsi, and tighten the hamstrings and glutes to come to upright standing.

If you are still uncertain as to exactly how a deadlift should be performed, or if you are not sure if you are activating the right muscles in the correct pattern, follow-up with a physiotherapist or strength coach for one-on-one cueing and direction. Don’t fear the deadlift; just learn how to do it right!

Understanding MMA & Back Pain – Fighters Only Magazine

 - by Harry Toor

Mixed Martial Arts has become increasingly popular, especially here in Vancouver.  There has also been an increase in the number of people participating in various styles of martial arts throughout the city, and this has lead to more injuries seen in the clinic.  As a fan, student and physio of martial arts, I found that there is little substantiated information on the web. 

This lead me to write the article, “Understanding MMA and Back Pain” which is featured in Issue 11 of Fighter’s Only Magazine (Jan. 2010).  For the magazine version of this article, click here, and for the less concise, original version of the article, click here.

The Importance of Running Technique by Trish Kazun

As some one who didn’t run for years because “I have bad knees”, I can state firsthand that that is a lousy excuse. Once I became a physiotherapist and started learning about the biomechanics of movement, I realized that it wasn’t that I had bad knees…it was that I had bad technique. The following is a discussion of some of the common problems that give people shin splints, knee pain, Achilles tendon problems, etc (the list is endless!) when they run.

Heel strike:
The main problem that I see in my clients that come to me with running injuries is that they land heavily on their heels with every footstrike. The action of landing on your heel essentially “brakes” your forward momentum and directs force up through your leg to your knees, hips, and low back. Try jumping off of a small step and landing on your heels, with your knees locked (if you have a known knee or hip problem don’t really try it, but imagine what that would feel like). Now, try jumping off of the step and land on the balls of your foot, allowing your knees, ankles and hips to bend to absorb the force. Much more comfortable, right? That is how your lower limb should absorb the force when you run; landing on your midfoot rather than on your heel, and allowing the force to be taken up by the tendons and muscles of your leg.

Quad-pulling:
Too often I have runners complaining of tight quads and hip flexors, or knees that hurt especially after doing a hill workout. The main reason for this is that they “pull” themselves forward with their hip flexors and quads. This causes these muscles to tighten up and create imbalances. Rather than “pulling” with the front of the legs, it is more efficient to allow momentum to carry you forward. If you lean forward from the ankles, your natural tendency is to take a step forward. Try it! Now try that when you run; allow a slight forward lean, and feel how you naturally take the next step. By using momentum to carry you forward, your muscles don’t have to work as hard to move you forward; they don’t tighten up and you don’t waste energy!

Slow cadence:
Your cadence is the number of steps you take per unit of time. Athletes who run middle distances and beyond should be taking roughly 180 steps per minute (count the number of steps one foot takes in 30 sec and multiply by 4 – should be around 45). I find that most people take long slow strides and need to make them shorter and quicker to meet the 180 steps per minute. Even if you are 6’4” and you are running with someone who is 5’5”, your cadences should be very close. Regardless of whether you are running a tempo run or a long slow distance, your cadence should be the same. The difference is the stride length; faster = longer strides, same cadence.

Weak hips:
It is all too common for runners to have weak hip muscles. Weak gluteus medius leads to an inability to stabilize the pelvic girdle. Weak gluteus maximus leads to decreased push-off efficiency and causes the runner to use his or her deep hip muscles or hamstrings too much.  This can lead to low back and/or hip dysfunction, IT band problems, patellar femoral pain syndrome, and an inefficient gait pattern.

I could go on forever about running technique, getting pickier and pickier with each discussion. If you’re not sure what your technique is like, come in and see Trish Kazun for a gait analysis. We can work together to identify your weaknesses, generate a plan to improve strength in any weak areas, and correct your technique.

What is IMS? Intramuscular Stimulation

Intramuscular Stimulation or IMS Acupuncture is an anatomy based version of traditional Chinese Acupuncture.  It is developed by a Western Medicine trained physician here in Vancouver, BC, named Dr Chan Gunn and has some key differences to regular acupuncture.  First of all you need to be either a medical doctor or a physiotherapist in order to qualify for the training.  The success of IMS relies heavily on a thorough evaluation of an individual’s alignment, and movement as well as the detection of subtle signs of nerve irritation.  The nervous system is the electrical wiring of your body and when it gets compressed, stretched or generally irritated it becomes supersensitive and will result in bands of muscle knots and tension in specific areas.  This muscle tension will strongly affect your flexibility and usually your pain.  Your body will typically compensate around the tense areas and can create pain in other areas of the body due to overuse.

IMS targets these tender, taut muscles in your body and seeks to relieve the tension using acupuncture needles.  If you insert an acupuncture needle into a normal healthy muscle, you barely feel anything, but if you insert it into a trigger point, the supersensitive nervous system will cause that muscle to contract and you can feel a strong cramping sensation.  Unlike acupuncture, typically the IMS needle is only left in for a few seconds until the cramp is achieved, then the clinician will move on to another tension point.  Releasing tension points on either side of the spine and out in the periphery can be an extremely effective means of allieviating resistant, chronic pain.

How does IMS work?  Your muscles are attached to bones by tendons.  When the muscles contract the tendons are stretched.  There are stretch receptors within the tendons that are there to protect the muscle from contracting too strongly and damaging itself.  Insertion of the IMS needle into a tension point of the muscle will cause it to contract strongly which stimulates these receptors.  The receptors then reflexively send a signal to the spinal cord that send a signal back immediately saying relax, relax, relax.  So IMS can cause an immediate change in tension and pain that is stemming from nerve irritation.  This inhibition signal can continue for a few days.  It also creates a localized inflammatory reaction that helps draw blood to the area to aid in healing.

People typically end up with a “love/hate” relationship with IMS.  It works very well and quite quickly, but it can be uncomfortable along the way.  The end result is definately worth the discomfort of the process as most people will attest!  Brent Stevenson and Harry Toor both practice IMS acupuncture in Vancouver at our Envision Physiotherapy offices.  Trish Kazun is trained in traditional acupuncture, but is learning the art of IMS through her work with Brent.  For more information about IMS click this link to go to the iSTOP website.

Muscle Balancing

Muscle balancing is the concept of relative tension in your body created by your muscles.  You have hundreds of muscular tug-of-wars constantly happening throughout your body to allow you to sit, stand, walk and move.  A basic understanding of how this system works is the key to improving your pain, posture and/or sport performance.  See the video for more detail.

Types of Posture

What body type are you?  What sports have you done in the past?  What type of work do you do?  What kinds of injuries have you had?  We are what we repeatedly do!  Watch the video for more detail!

Posture & Awareness Part 2

Standing up as straight up as you can be with your shoulders back and down is not necessarily the best posture.  People will do this to a fault until they are actually leaning backwards.  Sometimes people’s attempts at correcting their posture is in fact what is causing their pain.  You can learn a lot about yourself by having a physiotherapist assess your posture.  There is an average or a mean in which the body works most efficiently, but people will tend to find their own way to stand, walk and move over time.  If you learn what body type you are, you will more effectively be able to improve your posture and prevent pain.  See the video for more detail.

Posture & Awareness

You gradually get used to holding yourself in certain postures over years of movement experiences. Your perception of where neutral is, or what good posture is may be skewed. Taking the time to have someone point out your imbalances is a necessary first step to changing things. Seeing them and feeling them are even more important. Posture and muscle imbalances can be changed, but it takes awareness and dedication. See the video for more detail.

What is Core Stability?

Throughout your body there are deep localized muscles that help to provide structural stability to your spine and peripheral joints. There are also larger global muscle slings that provide stability and movement during higher demand tasks. These two systems ideally work together to provide a strong foundation of balance, stability and free movement.

Your “Deep Inner Unit” consists of four muscle groups: the pelvic floor, the transverse abdominus (TA), the multifidus and the diaphragm. These muscles should activate as stabilizers as soon as you start moving during day to day tasks. They provide a subconscious gentle compression to your pelvis and trunk so that your larger muscle groups can function from a stable base. These muscles can become dysfunctional as a result of injury or developed muscle imbalances due to repetitive postures or sports. It is possible to compensate for a poor Deep Inner Unit by developing a lot of strength through the larger global muscle slings, but this will limit strength potential and will leave a person vulnerable to injury under low demand tasks such as bending to tie up his/her shoes.

The first step to activating your core properly is ensure your pelvis is in a neutral position, which means your glutes are relaxed and there is a gentle curvature to your low back. The muscles you are going to contract are gentle isometric muscles, which means contracting them will not produce any movement (i.e. no pelvic tilt) and you should be able to breathe and talk freely with them engaged. See the above video for more detail.

Hip Anatomy

The hip is a large ball in socket joint capable of moving the leg forward, backward, side to side and twisting. Its mobility and control is crucial to the proper function of the knees, pelvis and back. People tend to lose awareness of how to use their hips properly and end up with pain and dysfunction as a result. Watch the video for more detail.