Snow Shoveling: Smart Shoveling vs Dumb Shoveling

With low back rounded, it can cause back pain

An appropriate post with snow coming down over over the west coast!  (I know the anyone East of the Rockies has already been shoveling for a while.)  Shoveling is one of many ways that people end up hurting their backs over the holidays.  The reason for this has to do with poor mechanics and/or poor tools (shovels).  Things that are done poorly and repetitively cause a toll on our backs.  Most people when they begin to shovel snow do so without a warm up (strike number 1).  When they do start shoveling snow, they do so while bending at the back and not at the hips (strike number 2).  With the back bent, it puts tremendous stress on ligaments and discs.  Doing a number of repetitions of this will eventually "wear" on those structures (strike number 3).  If it does not cause back pain during shoveling, it may cause back pain by doing a simple task such as putting on your socks, or picking up a pen or childs toy off the ground. 

Here is a great 1 minute clip by one of the worlds leading back pain experts that explains how snow shoveling can be done while sparing your back:

Stu McGill Smart Shovel

Shovel Smart!

Why you may want to INCREASE stiffness

Isn't it a bit ironic that most of us want to improve our flexibility (by stretching), yet we always say that we want to "tighten up" our core.  From an athletic perspective, everyone from gymnasts (very flexible) to weightlifters (less flexible) are told to "stay tight" during a given movement.  So exists the conundrum of whether to increase or decrease STIFFNESS.





What does STIFFNESS mean?

Stiffness is a means to increase stability.  Thing about something rigid (such as a piece of lumber) versus something flexible (such as a rope).  If your goal was to transmit force (ie. if you choose to put a hole in the wall, which object would you choose?)  In the body, stiffness ensures minimal energy loss as forces are transmitted from joint to joint.  Optimal performance requires stability, and stability is a product of stiffness.

How do we INCREASE stiffness?

In the body, we can increase stiffness by muscle contraction.  As a muscle contracts, it produces force as well as creates compression (bringing the joints closer together).  If a joint is more congruent, it will tend to increase stability and its force transmitting capability.  Think about the spine as a force transferring structure.  The spine is clearly very flexible, and would be more like the rope in the previous example.  Its our core muscles that attach to the spine that gently compress and place tension along the spine to increase STIFFNESS so we can transmit force from lower to upper body.  It is this type of stiffness that is important from the golf/baseball swing, throwing a ball, flips in gymnastics and lifting weights.

So why not just become STIFF?

The important thing to know is when to increase stiffness and decrease stiffness in a given joint to produce the desired movement.  If a joint is too stiff, it will limit the range of motion of that joint and thus, is difficult to produce movement.  So when training for a given movement, it is important to learn the sequence of stiffening and relaxing to transmit force efficiently.  It is like using a whip.  If you mistime the sequence of the movement, you will not be able to achieve a "cracking" of the whip.  In comparison to athletic movement and performance, you can tell who has mastered the sequence of stiffness and relaxation by how fluid their movement is.  Simply look at professional athletes versus your beginner.  Most beginners look "stiff" all the time, while professionals look very fluid!

Stretching the hamstrings: Do you really know what you are doing?

I'm not a big advocate of stretching (in particular, passive stretching).  One of the reasons I'm not a fan is because most often, people don't have clue what they are stretching.  In fact, most people aren't even stretching what they are intending to stretch.

Lets take one of the most common examples, the hamstring stretch:

Question #1: What are we trying to stretch?

Of course we are trying to stretch our hamstring muscle.  We know that the muscle belly is the most extensible part of a complex that includes muscles, tendons and joints.  In fact, a muscle belly can stretch up to 10% of its resting length without damaging the muscle tissue.  With this being the case, if our hamstring muscle belly was approximately 40cm long, we would only get 4cm stretch out of the actual muscle we are trying to stretch!  This is assuming that we are actually able to ONLY stretch the muscle belly.

Question #2: What are we actually stretching?

As mentioned in the answer to question 1, we are stretching a complex of structures including tendons and joints (just to name a few).  Not only that, but while we are trying to stretch our hamstrings, we are also stretching a number of structures in our low back as we bend forward.  We may be stretching some muscles of the low back, we would also be stretching important ligaments and joint capsules that help with low back stability.  Though this may help with overall flexibility, it is detrimental to stability of the low back forcing back and core muscles to work harder to maintain stability.  As a side note, we know that people with greater low back flexibility are more prone to pain as they age.

Question #3:  What is the limiting factor?

As mentioned, we are stretching a number of structures that have varied extensible properties.  Muscles are clearly the most extensible of the bunch with joint capsules, ligaments, and tendons being less extensible.  One structure that has gone unmentioned (and frankly is often forgotten) is nerves.  Nerve tissue is very tough and not very extensible.  So when we stretch our hamstrings, as we pull our toes towards us, we end up stretching nerves (the sciatic nerve and associated branches).  In most cases, this is in fact the limiting factor during traditional stretching of hamstrings.  An analogy would be like taking an elastic (hamstring) and a rope (nerve) and stretching them as far as they can go.  Your stretch would be limited by the rope and not the elastic.  

Question #4:  Why are we stretching the hamstrings?

In most instances, I understand people are trying to stretch hamstrings to improve flexibility.  Though you may feel that you have improved your flexibility during (passive) stretching, as soon as you stand or alter your position, you nerves tell your muscles to return to their regular length.  To gain any long term flexibility, you would have to stretch numerous times a day.  Of course, my question to you would be why do you want to improve your hamstring flexibility?  Have a look at this for a better understanding of Stability, Mobility and Flexibility

I will follow up with how you can safely stretch your hamstrings should you need to improve your flexibility. 

Why do people say "No pain, No gain?"

I have heard this phrase a few times over the last few weeks and its made me a bit curious.  Where did the saying "no pain, no gain" come from?

From what I remember, this saying came from aerobics workouts in the early 1980's where the instructor would encourage participants that they need to "feel the burn" and "pain is only temporary."  The unfortunate thing is that these sayings were not the right way to go about encouraging people. Like that game of telephone we use to play as kids, where one person would start with a message, and by the time it got to the end of the line, the message was not what was originally intended, these phrases of encouragement have been long since misconstrued.

The saying "no pain, no gain" today means that people should continue on with activities that cause physical pain.  We see this in runners who feel that they should continue running even though their knee pain from poor running mechanics will continue to make the pain worse.   We see this in people with back pain who only feel a "twinge" so they continue on with their activities with the "no pain, no gain" mentality. 

So if the term "no pain, no gain" was taken literally, why don't you see people continually slamming their hand in a door, or repeatedly dropping heavy objects on their foot?  It most certainly be painful.  It is pretty clear that there is little to gain from the previous two examples.

What is pain suppose to signify?  Pain is like a warning light on your car.  It tells you that something is not right.  Most often with pain, if you cease your activity, the pain will subside (as in the runner with knee pain, or slamming your hand in a door).  However, if you later decide to resume the activity, the pain will likely return.  This is where it is helpful to see someone who can determine the cause, and treat the source of the pain. 




To go back to the origin of the motto "no pain, no gain" I believe what the aerobics instructors were trying to encourage people to do was to work through some mild discomfort to your cardiovascular and respiratory systems.  I hope they weren't encouraging people to work through back and knee pain, but it seems that this is what has become of the famous motto.

Reasons why machines should be banned from gyms

Its a wonder that some people can actually get a workout in if you go to the gym.  If you go into most gyms, you will see most of the gym floor is cluttered with large weight machines.  There seems to be a stigma that a gym has to be full of equipment and bulky machines, or it won't be considered a gym.  Most of the gyms I've been in look similar to this:

Here are some of my reasons why machines should be outlawed at gyms:

1.  We use machines everyday to make things easier (and less physical) for us.  If we are going to a gym, aren't we trying to do more physical work?  Are we not trying to get a sweat on?  If we were looking at making things easier, why are you working out in the first place?

2.  Machines are expensive.  Most cost thousands of dollars.  The hilarity of it is that they are only good for one thing.  For instance, a leg extension machine can only be used for leg extension (besides being a terrible exercise for your knees, but that is an article in itself).  There really is no other use for it.  The other thing is that it usually takes us through a fixed plane of motion (there is minimal stability required).  Very little things we do in life require us to minimize stability and move through one plane.

3.  Machines are huge.  They take up tons of space.  This reduces space to move and perform other (and in my humble opinion, better) exercises.

4. Most machines are bad for you.  I've outlined some of the machines that can cause more harm than good.  For instance, the leg press machine and weighted abdominal machine can lead to disc herniation, the oblique twist machine can stretch out ligaments in your low back, and the knee extension machine can cause patella and ligament problems.  

So if there is a gym with no machines, what can you do to workout?  You can do what they use to do in the old days and actually lift a weight and doing exercises that mimic what you do in sport or life.  Doing lifts that include lifting, carrying, pushing, pulling and dragging requires no machines and minimal equipment.  Ideally, a gym would have a squat rack (handy for many exercises besides a squat), an olympic bar, some cables (for pulling exercises), some dumbbells, and maybe a few other pieces of fancy equipment such as kettlebells, gym balls and stability boards.  With this combination of equipment, you can do a huge variety of exercises.


What about the older people or the people who are new to the gym.  Shouldn't they be using machines to introduce them and to teach them how to work out?  I would say no way!  Why would you teach them bad habits and use machines that only do one thing, when you can start fresh and teach them how to do functional exercises.  

Why you shouldn't be lifting with your legs (or your back)

I tend to hear a lot of; "Don't lift with you back, lift with your legs and use your knees."  I know these people are trying to spare their back by lifting with their legs but they are not using the right cues.  I found this picture about so-called proper lifting technique:

First, the picture of the "proper lifting technique" shows lumbar flexion (bending low back) which is not good for your back (I'll give it to you if you are saying that there is less than in the other example).  Secondly, the person's feet aren't flat so he isn't stable and there is significant stress on the knees with lifting like that. 

So if you should not lift with the legs, what should you lift with?  You should be lifting with your hips.  Your glutes are designed to do hip extension which is what you are trying to do when you are lifting something from the ground.  Olympic lifters learn how to lift extremely heavy weights by learning to stabilize their "core" and using their glutes to do most of the lifting. 

I'm an advocate of learning how to squat and deadlift using hips to accomplish standing.  So spare your knees and legs.  Let the hips do all the work. 

Are you using a disc herniation machine at the gym?

With all the machines that are in fitness facilities, there are a number that are good at helping to increase the chance you will injure one of your discs.

We know that there are two things that are not good for the health of your back (even if you are doing these exercises to improve your core.) The first is prolonged flexion.  This includes sitting for long periods and being bent in flexed postures for long periods of time.  A good analogy would be like if you took a metal rod and bent it for a long time.  You would find that the longer it bends, the more quickly it will deform and will likely break at some point.  This can also happen to your back (over a very long period of time). 

The second thing that is not good for the health of your back is repetitive flexion.  This is what is commonly seen at the gym.  In order, from bad to worst, here are some repetitive flexion exercises at the gym that will increase the chance of disc injury:

1.  Sit ups
In my opinion, there is no safe way to do sit ups (nor is there a need to.)  Sits ups are the perfect example of repetitive flexion.  Its like taking a metal rod and repetitively bending it back and forth.  Sooner or later, you will end up with a weak spot and it will break.

2. The Weighted Sit up Machine
This one is a beauty!  Not only are you doing repetitive flexion, but you are also compressing the spine while you do it.

3. The Leg Press Machine
To be honest, I've seen someone injure their disc on four separate occasions by doing extremely heavy weight.  Why did they injure their disc?  As they lower the weight, their knees come towards their chest.  As that happens, you flex your lumbar spine.  Now you have to use a tremendous amount of force to move the weight back to its starting position.  Its usually at this point that the person may feel a "pop" and a tremendous amount of pain.  

Interestingly enough, most gyms have a few variations of a sit up machine and leg presses.  Might you reconsider using them? 

How you hurt your back while picking up a sock off the ground

I can't even tell you how many times I have heard this story.  "I don't understand how I hurt my back picking up my sock off the floor this morning." 

What happened?  There are a number of things that contributed to the "incident."  It seems to occur most often in the morning.  The reason for this is that the type of cartilage that makes up the discs in our back (fibrocartilage) and the jelly like material in the middle (nucleus pulposus) like to absorb fluid overnight while we sleep.  This is the reason we are a bit taller in the mornings that we are in the evenings.  As the discs absorb fluid overnight, the become more rigid making us feel stiff in the morning.  With more rigidity in the discs, bending forward will cause the front of the disc to squish, pushing the jelly more towards the back of the disc.  This pressure can cause irritation and pain when you pick up your sock off the ground.

So has this person "blown a disc?" "slipped a disc?" "herniated a disc?"  When you go to your doctor, they will ask if you have pain going down your leg(s).  They will likely do orthopedic testing that includes ranges of motion and neurological testing.  They will also most likely do a straight leg raise (SLR) test.  A positive SLR would be indicated if it reproduces the same sciatic pain down the leg.  If this is positive, it is a good indication for a disc herniation pressing on the sciatic nerve.  The test is considered negative if no pain is felt down the leg (even if they have pain in their back). 


There is lots that can be done to treat these patients (with disc herniations and without).  The patients without herniation respond effectively to movement.  The Cat/Camel exercise is great for increasing mobility and getting rid of some of the excess fluid in the discs   One recommendation for these people is not to keep them in one position for a long period of time (ie. having them lay on their front for 30 min).  Their back may stiffen up and they may have difficulty getting going again. 

Can good posture cure back pain?

People often tell me that they think they have poor posture and that their poor posture is causing their back pain.  Is this really the case? 

My question to them is; "What is good posture?"  There really is no consensus on what is good and bad posture.  In fact, there is no clear definition as to what posture is.  The best definition of posture that I have come across is; three curves to the spine (lumbar lordosis, thoracic kyphosis, cervical lordosis).  An example of neutral spine or normal posture would be what your spine would look like if you were standing or lying (most likely with 3 curves).


One of the problems with posture is that there is no good way of measuring posture.  Plumb lines may be helpful, but I would not consider them to be reliable or valid.  Our posture is made up of a number of segments (vertebra) so how can you tell if you have made valid or reliable changes to posture?  Seeing as everyone has a bit of a different spine (some people are taller, some people have different curves to their spine etc.) everyone would have their own unique posture.

For the question of whether poor posture can be the cause of back pain, the answer is that it most certainly can.  Just think about the last time you were in a prolonged posture (probably sitting at the computer right now, or on your commute to and from work).  Were you stiff when you stood up or got out of the car?

So how can we change posture to keep ourselves out of pain.  The best answer I have is to constantly change your position.  Keep moving!  It will reduce stiffness and help keep you out of pain. 

Why the Rotator Cuff should not be called a Rotator Cuff

The rotator cuff includes four muscles that attach to the humerus: Subscapularis, supraspinatus, infraspinatus and teres minor.  These muscles have long been thought to create rotation about the humerus in the glenoid fossa (shoulder joint).  However, recent studies have shown that large muscles are the ones who do rotation.  Muscles such as the deltoid have a longer lever, thus giving it more leverage to produce large movements. 

So what do the small muscles such as the rotator cuff do?  They COMPRESS or hold the joint in place to allow for rotation to occur.  Hence, the more appropriate term for rotator cuff would be the COMPRESSOR CUFF. 

I you are biomechanically inclined, compare the lever arms of deltoid and the compressor cuff.  An analogy would be like two people opening a door.  If one person was pushing at or near the hinges, and another person were pushing at or near the door knob, the person at the door knob would be the one doing the majority of the work. 

For rehabilitation of the compressor cuff, should not be limited to traditional rotator cuff exercises.  Though it may be a good start for rehabilitaiton, progression should include functional exercises that require compression.  Rehabilitation should be progressed to include pushing, pulling, lifting and carrying exercises.

Cases of shoulder pain

So I had two similar cases present to me with similar mechanisms of injury.  In the first case, there was a fall from a ladder.  During the fall, they grabbed on to one of the rungs of the ladder to prevent falling and felt immediate pain in the shoulder.  In the second case, the person was exiting their car and slipped, but grabbed on to the top of the door to brace themselves for the fall.  The person also experienced immediate pain in the shoulder. 

Both cases showed significant decrease in range of motion as well as increased pain.  Muscle testing was also found to be painful in both cases.  No other abnormality was detected. 

Both cases were referred for further testing and after diagnostic ultrasound (and an MRI in the ladder case) they were found to have a torn rotator cuff (supraspinatus tendon).  With the fall from the ladder, it was found to be a full tear and it was recommended that it be surgically repaired.  The slip and fall was found to be a partial tear of supraspinatus.  This was handled through passive care and rehabilitative exercises. 

Goals for both cases were to increase range of motion and decrease pain (post surgically and non surgically).  Once range of motion had been achieved, rehabilitation protocols were aimed at improvement of strength and scapulohumeral movement.  Unfortunately prognosis for both cases were considered long term and took months of recovery. 


In my next post, I intend to write about why the rotator cuff is a bit of a misnomer because it does not really rotate.

How to get tennis elbow without playing tennis

What is tennis elbow? And how do you get it without playing tennis? It is a common overuse complaint that causes pain on the lateral side of the elbow.  Interestingly enough, I would say that it is more common for people that do not play tennis!  Common terms for tennis elbow are lateral epicondylitis or tendonitis (however, a more proper term for it would be a tendinopathy.)

Tennis elbow causes pain at the proximal insertion of the extensor muscle group of the forearm (for the anatomy nerds, from lateral to medial: extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris.)  These muscles have a common tendon that can become stressed if overused.  This seems to occur with people who use hammers, screw drivers, drills as well as those who keyboard too much.  Of course it can happen to those who play tennis.  Ironically, I find golfers elbow more common among tennis players than tennis elbow (figure that one out...maybe this would be good for another topic!) 

With overuse, there are a couple of types of stresses at the common extensor tendon that can cause issues.  Rapid repetitive movements (for many months, it doesn't happen overnight) such as keyboarding can cause irritation at the tendon.  Also, repetitive eccentric strain of the tendon such as hammering nails can create microtrauma causing irritation of the tendon.  These types of strain are most common where the muscle meets the tendon.  Prognosis for this is generally good.  With soft tissue treatment, modalities such as laser, shockwave and rehabilitation using eccentric strength will significantly increase recovery time.

More excessive eccentric strain such as playing tennis can cause problems where the muscle attaches to the bone (lateral epicondyle).  This is called an enthesopathy.  Prognosis for this type of injury is much worse.  Treatment usually involves resting from sport or activity for a lengthy period followed by treatment and rehabilitation. 

Though similar in presentation, it is important to distinguish between a problem where the muscle meets the tendon, or where the tendon meets the bone so you can determine the correct course of treatment. 

Ankle pain - Walking the Walk

A hockey player with ankle pain limped in to the clinic after taking a slap shot off the outside of the ankle (lateral malleolus).  He said he was able to play the rest of the game and it did not really hurt until the next morning.  When he woke up, there was moderate swelling and a bit of bruising, but he found it actually hurt more on the medial side and on the bottom of his foot. 

SIGNS
-bruising and swelling
-decreased range of motion

SYMPTOMS
-pain (weight bearing and non weight bearing)

The most likely reason for the pain on the medial and plantar (bottom) aspects of the foot are from intra-articular swelling (swelling inside the joints).  It could also be from joint dysfunction or joints being jammed.  In terms of treatment, the best bet would be to bring the swelling down ASAP.  Rest, Ice, Compression and Elevation can help.  I find that a bucket of ice cold water works more effectively than gel packs.  Compression from a tensor or tape is effective.  I have also found laser therapy to be a benefit and seems to decrease recovery time.  If joints are restricted or jammed up, mobilizations and/or adjustments can be done.  The trick is to avoid the mobs or adjustments from being painful.

The question is can they continue to walk and perform daily activities (or even play another game?)  The answer depends on how bad the ankle pain actually is.  A good way of testing this is the use of the Ottawa Ankle Rules.  This can help determine whether the person needs to go for Xrays.  If they do not need Xrays, then you should find out how comfortable it is to walk.  If they want to play a sport, you could test them with some of the movements of that sport to see if they can move without hindrance or pain.  I would test them with a one leg squat, jumping on one and two feet, and running.  If there is pain with those movements, I would recommend resting until the pain and swelling go down, but depending on the athlete and the level of sport (and importance of the game), they may ignore the recommendations

Each ankle injury will present differently.  It is important to determine the nature and severity of the injury, the type and amount of treatment that it may require, and the functional capabilities of the injured person. 

The Difference between mobility and flexibility

With a bit of understanding of the terms; flexibility, mobility and stability, we can go into the biomechanics of flexibility.

From a biomechanical perspective, flexibility of a joint is defined by the shape of the joint and how tight the joint capsule and ligaments are around the joint.  This is part of the reason why some people can touch their toes when they bend forward, and others cannot.  When you bend forward to touch your toes, the joints in your back are stretched.  This includes the joint capsules and the ligaments that surround the joint.  Knowing that when ligaments (and joint capsules) are stretched, they undergo permanent deformation and will never go back to the same length.  This does increase the flexibility of a joint, but the question is; would you want that permanent increase in flexibility?

Mobility is defined by the amount of muscular control you have over the entire range of a joint.  Talented athletes (gymnasts and dancers) have a tremendous amount of flexibility, but also have great mobility or control over the range that they do have.  Thus, many of them are able to avoid injury by controlling the amount of motion over a great range.

An injury will occur when we cannot control motion (such as through the spine) through its entire range.  Therefore, people who are too flexible will be more susceptible to injury near end ranges unless they are able to maintain control (mobility through range of motion/flexibility).  Not having the flexibility can also cause injury by not allowing one to move into a desired position (even if their mobility is good). This can lead to excess strain on joints and muscles.

The bottom line is that you want to be just flexible enough for your occupation or sport, and you want to have the control over that flexibility (mobility).