After establishing that there is no “best” universal exercise to prescribe for a lower back problem in my last article, I’ve received a lot of questions about kettlebell swings and their use in low back rehab. This article will examine the swing in detail, and why I find it highly effective in rehabilitating the lower back – but only for the right athlete, and at the right time.

When prescribed correctly, kettlebell swings can be instrumental in later stage low back rehabilitation.

Force Application for Rehabilitation

Lifting weights comes at a cost on the lumbar spine that can be understood in terms of spinal compression, when the force is produced down the spine, and shear, when the force is applied across it. One of the most important factors in later stage low back rehabilitation is building lumbar spine musculature endurance. The aim is to create lumbar spine neutral control endurance while increasing these compression and shear force loads.

The ideal kettlebell swing here creates a hip-hinge deadlift style pattern, with an unnegotiable vertical tibia decreasing the joint movement at the ankle and knee. I don’t want a squat-style-swing where the knee and ankle movement will decrease spinal sheer and compression forces. The patient will be tolerant to those at this point, so it becomes about building strength endurance.

A Step-By-Step Implementation

Knowing if the patient would benefit from a kettlebell swing prescription takes a strong understanding of their goals and sport requirements. Swings can be programmed for most people, but is not the choice of exercise to use in an acute disc injury, for example, as pain fundamentally alters movement. The kettlebell swing should be used only when pain has been abolished and the rehabilitation path is aimed at restoring athletic performance. If you have read my previous articles, you will already know that I don’t consider an athlete restored to function unless they can flex their lumbar spine painlessly, and under a load that relates to tasks their sports require.

I’ve treated a few surfers over the years. In all cases, swing work was the moment their progress leaped forwards.

The first step is confirming the patient can tolerate spinal compression without pain, then applying manual shear force to the spine to ensure that the shear forces are also painless. At this stage of rehabilitation, I’m focussing on neutral spine control and optimisation. The patient must pass these tests to move on to the swing. This is not negotiable.

When rehabilitation commences, I begin with a deadlift-based technique. This is in line with clear research evidence that hip dominant flexion patterns are safer than lumbar dominant ones. I teach the hip hinge as a preferred movement pattern. If necessary, I will have done significant work to produce an excellent hip hinge by this point with a variety of hip hinge patterning and neutral spine hip hinged deadlifting.

I start with kettlebell deadlifting before barbell deadlifting, as this brings the mass closer to the patient’s centre of gravity. This would begin in sumo stance before proceeding to conventional form. To progress to the swing, it is critical that the patient demonstrates excellent deadlift technique beforehand.

The Surfer and the Swing

Here’s an insight into clinical application. I’ll use a case study of an international surfing athlete who came to me with a multitude of lumbar spine issues dating back many years, including two major disc bulges with neural involvement. Over a period of six months, I had reached the point of implementing kettlebell swings into his rehabilitation. Although progress was slow, it had been constantly progressive and he was able to surf during this time, with limitations as high as pain levels allowed.

“The kettlebell swing is the safest exercise for low back pain, but only when the patient has progressed through all the other best exercises beforehand.”

The start of the swing work was the moment that his progress leaped forwards. Initially, I prescribed sets of 3-5 reps. I looked for perfect form, as I always do, and only increased repetitions when that was clearly demonstrated. Within two months, he was performing 3 sets of 60 reps using a 20kg kettlebell twice per week. Soon after, he was enjoying two-hour surfing sessions without pain for the first time in years. I have had a few surfers over the years, and the hip-hinge-deadlift-patterned-swings I have detailed here all led to huge improvements in their tolerance to time spent in the water.

An Athlete-Focused Prescription

I treat people with different body masses and anthropometrics, and prescribe the swing with a specific focus to the athlete’s performance demands. That is what I teach across the board: knowing when the right exercise is to be applied, and getting athletes back to the top quickly and safely, using objective markers. Keeping this in mind, the kettlebell swing is the safest exercise for low back pain, but only when the patient has progressed through all the other best exercises for low back pain and has regained excellent neutral spine control and hip hinge patterning. After this level of rehab, much more can and should follow.

To understand the swing in rehab requires an understanding of the science of low back injuries. I’ll be teaching on this with weekend courses throughout 2016 both in Australia and the US. The first one is a 2-day event in March that I’ll co-present in Melbourne with Andrew Read and Greg Dea. Click here to book your tickets.

Photo 1 courtesy of Rich Manaro.

Photo 2 courtesy of Shutterstock.

The post The Kettlebell Swing: Mindful Prescription for Low-Back Rehab appeared first on Breaking Muscle.

“What is ‘the best exercise’ for my low back problem?”

This question shows a lack of insight from injured athletes and their practitioners. There is no universal “best back exercise.” There is, however, a best system of assessment and method of choosing the best exercise for the right time.

I’ve had a mountain of enquiries from people all over the world asking the same question:

“What is ‘the best exercise’ for my low back problem?”

This question shows a lack of insight from injured athletes and their practitioners. There is no universal “best back exercise.” There is, however, a best system of assessment and method of choosing the best exercise for the right time.

Every case is different and needs to be evaluated on an individual basis. In fact, as you will see in the following case study, the exercises I recommend for back pain change every two weeks. The best exercise at one point is replaced by a better exercise when the factors are re-evaluated. To give you an idea of what goes into the planning and execution of a successful low back rehab program, I’ll present a case where successful return to maximal lifting has been achieved without any significant change in the MRI-demonstrated disc injury.

A Successful Case Study

In April 2015, this person had experienced severe low back pain after squatting, and was subsequently stuck in bed for the following week with low back and right leg pain. The MRI on the left was taken at the two-week mark post injury. The report described a 9mm retrolisthesis (posterior displacement of one vertebral body with respect to the adjacent vertebrae) and associated disc extrusion fragment 10x12x18mm. This was compressing the right S1 nerve root and, to a lesser extent, the right exiting L5 nerve root.

Compare the MRI on the left to the MRI on the right. You will see there’s little change in the disc bulge.

Compare the MRI on the left to the MRI on the right, taken six months afterwards. You will see there is little change in the bulging disc from the first image to the second one. What does this tell you? Not a lot, until you understand the rest of the patient’s story. Read on, and you will understand why you treat the person, not the MRI.

Initial Subjective and Objective Examination

The patient came to me for evaluation six weeks after the initial incident. He had just returned to training and was lifting 110kg in both the deadlift and squat with some resultant aggravation. His hope was to achieve a 220kg deadlift and squat by the year’s end.

My subjective and objective examinations are thorough. I use an in-depth subjective examination that can lead me to a hypothesis I can test further in the objective examination. I actually don’t look at MRIs or read the reports until after both the subjective and objective examinations are complete. So they never influence my evaluation of the person.

In this case, my examinations showed lumbar flexion aggravators – postures involving either static flexion (driving/sitting) or dynamic flexion (bending forward). Extension movements, such as walking, were pain free. Examination of further lumbar extension showed some limitation, and also abolition of symptoms and improved flexion/bending post-extension treatment. A moderate inflammatory component existed.

“There is no universal ‘best back exercise.’ There is, however, a best system of assessment and method of choosing the best exercise for the right time.”

To look at the MRI, it might have appeared that extension would have produced exacerbation, due to the size of the fragment and the retrolisthesis. Yet it did not. Further physical examination showed weak gluteal extension activation, but excellent hip socket range. So he was prescribed home exercise with an extension focus and told to cease squatting and deadlifting until his technique was refined. He was also prescribed glute activation in hip extension and, as he progressed, single leg bridges focusing on pelvic control.

After a Week

After a week of approximately daily 100 extension exercises (both standing and lying) and 100 daily glute activations, I reviewed him and evaluated his squat and deadlift techniques. Here I was mindful of the flexion aggravators and set out to maximise his neutral spine control. If you have read my previous article on rehabilitation for the lumbar spine, you will know how it will focus on the pars thoracis components of the erector spinae as the most effective controllers of this posture.

There was a “butt wink” at above 90 degrees in the squat evaluation. Structurally I had tested his hips and found them to be able to get him much lower without that lumbar flexion. To work on this, I utilised a two-pronged approach:

• I started him with face-the-wall squats with toes against the wall to prevent lumbar flexion and encourage the hip hinge, while using the pars thoracis group to keep neutral spine.
• I then used a counterbalance squat, whereby he held a 12kg kettlebell as far out in front of his body as he could with his heels chocked (raised). This causes abdominal bracing and total core stiffening that translates directly to a functional squat pattern.

An instant pattern changer. He was compression tolerant but shear provocative to manual testing. So this also encouraged our pursuit of neutral spine control. He was to perform the face-the-wall squats frequently each day and the counterbalance squat every training session.

After 3 Weeks

Two weeks later, his flexion tolerances improved in time, range, and frequency. He was still advised to minimize these and we began his deadlift and squat technique alteration. He had been lifting conventional style at the time of injury, but my examination showed a clear biomechanical advantage to sumo stance in both deadlift and squat for his anthropometrics. Read my article on sumo prescription to understand more about this concept. We began with a sumo kettlebell deadlift and a sumo box squat using a high bar position. The sumo kettlebell deadlift brings the bell’s mass closer to your own centre of gravity and minimises anterior shear forces. These were done daily.

After 5 Weeks

Another two weeks on, all the improvement had continued. He was now pain free and unrestricted in any movement direction. Changes to his training were still focused upon creating neutral spine control, but in more fundamental movements. I prescribed him front squats with heels chocked to maintain the neutral spine, and overhead bar box squats to continue to strengthen his erector spinae and abdominal control. He began regular bar sumo deadlifts in place of the kettlebell. All exercises previously prescribed were now decreased in frequency to accommodate the increasing variety of movements and loading.

After 7 Weeks

At the next two-week review we worked on a variety of core work. I added exercises done in kneeling with his eyes shut to enhance proprioception. These included kettlebell halo movements and some kettlebell core exercises that I have created but not named yet – hard core control work with loaded changing masses. We used a double kettlebell seated suitcase lift for glute strength progression. He continued his previous technique work.

Exercise prescription depends on an evaluation of many factors.

After 9 Weeks

At two weeks again, he was no longer provocative to shear testing manually, and we instigated kettlebell swings with 16-20kg for sets of five reps. The low numbers were prescribed to keep his technique perfect. I use a swing that is more glute- and hamstring-driven than the regular swing technique. My swing approach for rehab is all about rehab, not just getting numbers done. We also planned for him to perform squat variations every day during training, and he could now integrate low bar positioning.

Lifting 200kg at 6 Months Post-Injury

His loads were increasing throughout the entire process. I continued to review him monthly, making technique modifications where necessary. At the six-month post-injury mark, he achieved both a 200kg squat and a 200kg deadlift.

So let’s look at the list of “best exercises” for his back:

• Passive lumbar extension in prone
• Lumbar extension in standing
• Face the wall squats
• Isolated glute hip extension in prone (knee bent to minimize hamstring)
• Single leg glute and abdominal focused bridges
• Counterbalance kettlebell squats (heels chocked and heels flat)
• Kettlebell deadlifts
• Overhead bar box squats
• Kettlebell halo and associated core challenges
• Double suitcase deadlift from seated
• Front squat (heels chocked and heels flat)
• Sumo deadlift
• Back squat no wink (lumbar control and abs)
• High bar squat – avoided low bar for almost 4 months
• Low bar squat
• Squatting variations
• Kettlebell swings
• 200Kg squat and deadlift by 6-month mark post injury

The point of note here is that exercise prescription depends upon specific evaluation of many factors, and these change through time as the patient’s condition changes.

A Safe System for Unrestricted Training

This case study is an example of my unique strength training system. It is based on creating a hypothesis from the subjective patient examination and then testing it repeatedly with objective markers during the resolution process. It is important to understand spinal anatomy and human biomechanics in detail in order to be able to safely work with these disc injuries.

Look again at those MRI scans. You can see that the disc injury exists unchanged (that is another article I’ll write), yet the patient is totally asymptomatic and capable of unrestricted training. This is possible through knowing how to apply the correct hurdle requirements. The science behind this approach is in depth and spans many experts’ work, including Maitland, McKenzie, Janda, and McGill, to name just four. This does not even include the strength and neurological science works.

It has taken me more than twenty years of unrelenting work and research to produce a system that does this safely. But lucky for you, I’ll be running two-day courses on my methods during 2016. The first one being a 2-day event in March that I’ll co-present in Melbourne with Andrew Read and Greg Dea. Click here to book your tickets.

More from Andrew Lock:

• Keep (Sumo) Deadlifting: Unorthodox Rehab for Lumbar Injuries
• How to Diagnose and Treat Low Back Pain Without an MRI
• Myths About Disc Bulges: They Are Not Forever – But Training Is
• New on Breaking Muscle Today

Photo 1 courtesy of Andrew Lock.

Photo 2 courtesy of Strength Education.

The post A Safe System for Heavy Lifting After a Disc Bulge appeared first on Breaking Muscle.

“To flex or not to flex, that is the question” 

Reading between the lines, we can sense the troubling thought that concerned the Prince of Denmark, and has perplexed lifters ever since chalk met bar:

Should you allow your lumbar spine to assume a flexed posture when deadlifting, or is neutral the only allowable posture?

The problem is now solved. I have the answer, and here is the scientific evidence behind it. Let’s address the elephant in the room. Every world record deadlift I have ever seen has been performed with lumbar flexion. The lumbar spine is not in neutral. It’s a fact. At the end of this article you will understand why. I’ll show you exactly what you need to know, including evidence from physics, physiology, anatomy, biomechanics, and exercise science.

Let’s start with physics.

Physics Applied to Deadlifting

In 1687, the English physicist and mathematician Sir Isaac Newton published three clear laws governing the motion of interacting objects in his book, Philosophiae Naturalis Principia Mathematica. If you have not read my article discussing the application of Newton’s third law to deadlifting, then you will need to before proceeding. I will summarise it here for you.

Summary: For every action there is an equal and opposite reaction. When deadlifting, you should apply as pure a vertical vector to the earth to produce the concurrent maximum ground reaction force to your body. Any horizontal vector is wasted force that decreases vertical force. If you wish to run, then you apply a horizontal force to the ground and you are propelled forward. Deadlifting is purely vertical vector application.

Your tibia bone (shin) is the best indication of the force vector. So the most effective, and potentially powerful, deadlift must be assumed with a vertical tibia. Evidence to support this can be found when analysing video in both the frontal and side views of all world record deadlifts. At the moment the bar leaves the ground, perfectly vertical or nearly vertical tibia is displayed, whether in conventional or sumo.

I thank Andy Bolton for confirming this in his seminar at the World Championships in 2015. Don’t argue this fact with me, argue it with Andy Bolton, Sir Issac Newton, and every classic motion experiment since 1687. Or if you want to argue about the force required to move a body off the planet, talk to NASA or any rocket scientist.

The most effective, and potentially powerful, deadlift must be assumed with a vertical tibia.

Anatomy

Here, I’ll discuss the muscles you use to lift. I am going to concentrate on the lumbar musculature. Once again, I have written on this previously. The linked article explains which of the posterior musculature has the most effective control of your lumbar spine posture. You are expected to have read this. If you have not – click the link and do so, then resume the rest of this article after finishing it.

Summary: The posterior musculature of the spine controls the lumbar posture from extension to neutral and through to flexion. The muscles that have the greatest effect on controlling lumbar posture for deadlifting, in order of strength (by moment arm) are:

1. Pars thoracis portions of iliocostalis and longissimus
2. Pars lumborum portions of iliocostalis and longissimus
3. Multifidus

Biomechanics of the Lumbar Extensors

If you coach powerlifting and don’t have a copy of Professor Stuart McGill’s book, Low Back Disorders³, then stop now, go online, and order it. The Third Edition has just been released with support material. It is one of the most important books any coach will have on their desk. You need to understand it to understand lifting.

I have never read an explanation of what you will now read below, as it pertains to powerlifting. It is the hinge upon which lifting science turns.

First, you need to understand a moment arm. Not everyone has done math or physics, so here’s an explanation:

A moment arm is the distance between a joint axis (here, the spine axis) and the line of force acting on that joint (in this case, by the muscle). The longer the moment arm, the more load will be applied to the joint axis through leverage. So a change in a moment arm changes the force upon the joint.

Now on to the action of the lumbar muscles upon the spine. I had the good fortune of discussing my problem with the eminent Professor Stuart McGill. I spoke to him about an observation in his book. When discussing the posterior musculature, the Professor measured the moment potential of the various muscles in neutral and in sixty degrees of spinal flexion. I had a problem with the measurements, and I’ll lay it out for you.

On Table 5.3 in Chapter 5, the moment potential of the pars thoracis group, as represented by the right iliocostalis, measured 24 N.m in an upright standing position (neutral). But it measured 22 N.m in sixty degrees of lumbar flexion. Iliocostalis lumborum and multifidus did not change at all. How could the lumbar spine move through this range and the moment potential barely change?

I drew a spine for the Professor and showed him my conundrum. He then drew on my spine and showed me the answer – the thoracodorsal fascia acts as a retinaculum! A retinaculum is a connective tissue band under which tendons pass. So the thoracodorsal fascia holds the tendons of the pars thoracis, and other posterior spinal musculature, in such a position that their moment arms do not change.

Now consider this: if the muscles that hold the spine in neutral and protect the discs don’t change their effective moment arm, then what is the problem with lifting in flexion?

Compression and Shear Forces

Remember, this article explains the mechanics of deadlifting and whether you can – or should – lift with lumbar flexion. This is about the science behind the deadlift. This article is not about how spines get hurt. It’s not a discussion of the injury mechanics and biology of the lumbar tissues, especially the lumbar discs. Injury articles are for later.

The problem with lifting in flexion is that it produces a change in compression and shear forces on the spine. We can break down the forces upon the spine into compressive and shear forces that result from loading. Compressive forces act along the axis of the spine. Shear forces act across the spine, most notably at the disc.

In neutral lifting, the compressive forces are greater than in flexed spine lifting. In flexed spine lifting, the shear forces are much greater than in neutral spine lifting. We want to minimise shear, so there is a price to pay depending on the lumbar posture.

Left: Multifidus; Middle: Iliocostalis; Right: Longissimus

Physiology

So there you have it. Maximum deadlifting, in the conventional method and by experienced lifters, is achieved in lumbar flexion. But it is not for neophytes or beginners. For these people, neutral spine control must be mastered before lifting maximal weight.

There are many anatomical, physiological, and biomechanical issues to expand upon from here, but the elephant is now in the room and flexed spine lifting by elite lifters has been explained.

So back to Hamlet. “To flex, or not to flex?” It depends, my Prince. It depends.

More Back Facts From Andrew Lock:

• Rehabilitation for Lumbar Spine Recovery: The Science and the Truth
• The Rabbit Hole of Back Pain: What Your Doctor Doesn’t Want You to Know
• Embracing the Flexed Lumbar Spine in Lifting
• What’s New on Breaking Muscle AU Today

References:

1. Shakespeare, W Hamlet.” Penguin Books.

2. Kuhn, K. Basic Physics, Jossey Bass, 1996.

3. Newton, I Translated by Andrew Mott. The Mathematical Prinicples of Natural Philosophy. The University of Adelaide Library. 2015.

4.. McGill, S. Low Back Disorders. 2nd Ed. 2007.

Photo 1 courtesy of Andy Bolton.

Photo 2 by Uwe Gille (Gray Image:Gray389.png) [Public domain], via Wikimedia Commons.

The post A Unified Theory of Deadlifting appeared first on Breaking Muscle.

“You have too much lordosis due to sitting in anterior pelvic tilt.” Actually, that’s BS.

You do not sit in anterior pelvic tilt. It is a myth, it is wrong, and don’t make that mistake again.

“You have too much lordosis due to sitting in anterior pelvic tilt.” Actually, that’s BS.

Sometimes a statement gets repeated so often that people take it as truth. It occurred when people assumed the world was flat, and that the pope was infallible. Up there with such unexamined stupidity is the mantra espoused by people who should know a hell of a lot better – “You have too much lordosis due to sitting in anterior pelvic tilt that causes you to have a tight psoas muscle.”

No! No! No! Three times no, I say! What is wrong with people? Having a hard time with reality? There are three things wrong with this statement.

First, the Research

A mountain of research demonstrates that the major cause of low back injury is as a consequence of lack of lumbar lordosis. Hence, the hate mail I received upon discussing flexed spine lifting, which was probably sent by people who don’t see their conflict in decrying lordosis in sitting and then complaining about spinal flexion in lifting.

Second, You Don’t Sit in Anterior Pelvic Tilt

Just look at the spinal posture of people in relaxed sitting around you, perhaps even as you are sitting now hunched over your computer (it’s posterior pelvic tilt, Beavis). Human beings, by and large, slump and are in posterior pelvic tilt when they sit.^2,3

“[T]he concept that normal sitting posture occurs with increased lordosis is without medical and published evidence. It is in conflict with every respected paper and expert in this area.”

Then there was the beautiful study by Alexander, et al. in 2007, where upright MRI scans were performed and they showed the effect of functional positions on the movement of the nucleus pulposus. In sitting, there was significantly less lordosis than prone lying and standing, and significantly more posterior migration of the nucleus than other postures.

That’s right, medical studies, and I stopped counting after the first hundred. All of them agree that you sit in posterior pelvic tilt.

Third, Your Psoas Does Not Create Lordosis

The psoas is a hip flexor and spinal compressor, not a producer of lumbar lordosis. That’s right – the psoas, whether tight or not, does not create excessive lordosis. No, not ever. It’s wrong. Don’t say it. Zip It.⁵

Now, Put This All Together

Let’s observe the dominos as they fall. For many, this will be the first time the pieces have been put together for them.

So we agree that most low back disability is due to lumbar disc injury.⁶ This injury is as a consequence of migration of the nucleus posteriorly (due to posterior pelvic tilt and lumbar kyphosis in prolonged sitting and/or frequent/static lumbar flexion forces) and then a mechanical flexion force upon that nucleus is imposed. This flexion force, upon a posteriorly migrated nucleus, causes injury to the annular rings and/or posterior longitudinal ligament.

“A mountain of research demonstrates that the major cause of low back injury is as a consequence of lack of lumbar lordosis.”

Translated: You sit in a slump (posterior pelvic tilt) that causes the disc to have an increase in pressure upon the back area of the disc. You then bend over, the muscles do not hold the spine strongly for a moment, and this flexion force causes the disc to load more – it gets injured and a disc bulge is created.⁷

The disc bulge is at the back – not the front – of the disc.

What Do the Medical Studies Say?

When human beings sit in “normal” sitting posture (whether at work or at home), they sit with spinal flexion and posterior pelvic tilt.^{8, 9} Lumbar lordosis is an important protector against low back injury.^2,11

That’s correct – lumbar lordosis is good for you, and because people sit in kyphosis, sitting is bad for you. So the concept that normal sitting posture occurs with increased lordosis is without medical and published evidence. It is in conflict with every respected paper and expert in this area. It is only espoused by individuals who do not have sufficient education or understanding of this area.

Just look at the x-ray graphics.

This posture, assumed since the dawn of thinking man, clearly has nothing to do with anterior pelvic tilt.

Yes, they are both posterior pelvic tilt and lumbar kyphosis.

Google any image search on poor posture in sitting. You are going to see a tsunami of slumped posture. How people espouse this “you sit with increased lordosis and anterior pelvic tilt” nonsense without seeing what they, and everyone else, do around them borders on mass delusion.

Where Did This Madness Begin?

In 2004, Eric Cressey and Mike Robertson published an article called Neanderthal No More. In it, they began with the premise that you:

…hunch over a computer all day. In other words, the only trait you share with this prehistoric badass is your pathetic S-shaped posture: rounded shoulders, forward head posture, exaggerated kyphosis, anterior pelvic tilt, excessive lordosis.”

Look, I understand they were a couple of young guys trying to make names for themselves in the industry, and mistakes can be made. A few years ago, I tried to contact one of the authors and offered to rewrite the errors, but never heard back from them. The article still exists and has not been corrected, so I figure the authors still stand by this work. It’s wrong in its premise, as I have proven, and requires revision. This is not disrespecting anyone. This is science and it’s about evidence.

Also, as a side note: Neanderthals were not our ancestors. We are Homo sapiens.

In Summary

• It is a fact most people sit in posterior pelvic tilt, not anterior (open your eyes, look around).
• It is a fact posterior pelvic tilt coincides with kyphosis, not lordosis.
• It is a fact the psoas does not cause lumbar lordosis (read McGill).
• It is a fact most disc injuries are causes by flexion forces.
• Lumbar lordosis prevents disc nucleus migration and protects lumbar spines.

“Human beings, by and large, slump and are in posterior pelvic tilt when they sit.”

I have used approximately 1,100 words in this article. I have used the most important 1,100 words necessary to complete this article. If there is anything you feel has been left out, then you may be correct, but what I have left out were words less important than the 1,100 I did use. It is not that there is not more I could have added, but there is a word limit and I’m stopping here. This article is not a discussion; it is scientific fact for you to understand.

Note: This article was written under a slowly spinning mirrorball at the bar of the Sunset and Lightning Club, made easier by Clase Azul Anejo tequila, Upmann cigars, and the “Atomic Riot” demo CD.

Further Reading:

• Rehabilitation for Lumbar Spine Recovery: The Science and the Truth
• Keep (Sumo) Deadlifting: Unorthodox Rehab for Lumbar Injuries
• Myths About Disc Bulges: They Are Not Forever – But Training Is
• New on Breaking Muscle Today

References:

1. L. Punnett, et al., “Back disorders and non-neutral trunk postures of automobile assembly workers,” Scandanavian Journal of Work Environment and Health, (1991) 17: 337-346

2. R. A. McKenzie, “Prophylaxis in recurrent low back pain,” NZ Med. J. (1979) 89; 22.

3. J.P. Callahan and S. M. McGill, “Low back loading and kinematics during standing and unsupported sitting,” Ergonomics, (2001b) 44(4): 373-381.

4. L.A. Alexander, et al., “The response of the nucleus pulposus of the lumbar intervertebral discs to functionally loaded positions,” Spine (2007) 32(14): 1508-1512

5. S. M. McGill, Low Back Disorders 2^nd Ed., Human Kinetics, 2007.

6. S.D. Kuslich, et al., “The tissue origin of low back pain and sciatica: A report of pain response to tissue stimulation during operations on the lumbar spine using local anaesthesia,” Orthop Clinics of North America. (1991) 22:2;181-187

7. Fennell, et al., “Migration of the nucleus pulposus within the intervertebral disc during flexion and extension of the spine,” Spine (1996) 21: 23; 2753-2757.

8. B. Wyke, “Neurological aspects of low back pain,” In: The lumbar spine and back pain ed. M. Jayson. London, Sector Publishing (1976).

9. R.A. McKenzie, The Lumbar Spine: Mechanical Diagnosis & Therapy. Spinal Publications 1981

11. M.M. Williams, et al., “A comparison of the effects of two sitting postures on back and referred pain,” Spine (1991) 16:10; 1185-1191.

Photos courtesy of Shutterstock.

The post Dispelling the Myths About Poor Posture (And Your Poor Pelvis) appeared first on Breaking Muscle.

A Little History

The day I graduated from university, I had the privilege of working with, and under, the person considered by many to be the world’s best shoulder injury diagnostician – the eminent Lyn Watson. The fact I had played baseball for Australia as a junior and played high-level cricket before becoming a physiotherapist perhaps helped me in getting the job. I knew a bit about sporting shoulders.

After intensively working under Lyn for a year I knew a lot. I spent time observing her work, reading and being involved in her research, attending in-service education, watching surgeries by shoulder specialists, and working on rehab with some of the country’s most elite athletes. I also had my own secret weapon – weight training.

By the time I began practice on my own, I had become known as the guy to see for weight-training shoulder injuries and that has never changed. So I figure now is a good time to run through some of the relationships that cause the pain patterns in the most common of weight-related conditions – rotator cuff problems.

My Approach

A patient comes in telling me he has pain on any pressing movement, especially bench press. It usually begins with the patient pointing to the front of his shoulder when I ask where the pain is. This is the area of the biceps tendon where it passes in the intertubercular sulcus in the humerus. So when a less-experienced clinician begins by pressing on that and it hurts, he or she thinks that is the answer. The clinician announces that the person has biceps tendonitis and begins treatment for it.

“Intense pain to the front of the shoulder, in the biceps tendon area, is often produced from infraspinatus trigger points.”

I use a different approach, similar to my philosophy with low-back examinations. I look last at the place where the pain is indicated. I start with the center and work outward. I want to find out what the patient does not know. With shoulder problems, I first do a cervical spine examination of movement and a thoracic spine examination. Then, I move to shoulder movement and strength testing. When coupled with simple postural analysis and subjective history, this approach will reveal most clues.

Let’s now consider those areas evaluated as I move in to the cuff. When checking trigger points in the infraspinatus muscle, an odd occurrence manifests. I ask the patient to let me know if any of the points I press reproduce pain to the front of his shoulder. In a normal shoulder, there is no pain from these trigger points, but in rotator cuff dysfunction there usually is. Intense pain to the front of the shoulder, in the biceps tendon area, is often produced from infraspinatus trigger points.

Down the Rabbit Hole

So let’s chase this rabbit down the rabbit hole. How does this occur and what does it mean for our rehab? The answer lies in anatomy. Let us join the dots:

1. The nerve roots of C5 and C6, with a contribution from C4, join to become the superior trunk of the brachial plexus.
2. From the superior trunk arises the suprascapular nerve, composed of nerve fibers from C5 and C6.
3. The suprascapular nerve supplies both the supraspinatus and infraspinatus muscles of the rotator cuff.
4. The superior trunk is later joined by the middle trunk, which contributes fibers from the C7 nerve root, to become the lateral cord of the brachial plexus.
5. The lateral cord continues down the arm to become the musculocutaneous nerve.
6. The musculocutaneous nerve supplies both heads of the biceps muscle.

So what you get is a situation whereby the strain of the infraspinatus muscle is the cause of the biceps tendon pain. This is why shoulder-injury pain lingers for months and years when professionals who don’t understand the connection waste your time by treating “biceps tendonitis.”

There is another element that confounds this issue. Interference of the nerve signals to the bicep tendon can occur due to this situation and you can actually have changes to the bicep tendon that are consistent with biceps tendonitis and produce positive biceps tendon testing – but this is a symptom and not a cause. You still need to treat the cause to relieve the symptom.

Why the Infraspinatus?

Let’s get back to the infraspinatus. We have a strained infraspinatus and it is strained for a reason. We have to find that reason.

Let’s say we have excluded the cervical and thoracic causes and are left with a posterior rotator cuff dysfunction. When the person in question bench presses, his powerful internal rotation muscles, pectoralis major, are overpowering the external rotators and the pain from that infraspinatus is being felt at the front of the shoulder in the bicep tendon area. So much so that he cannot press without pain, whether attempting a push up or bench press.

“Sitting at work all day with protracted scapula will result in weakened rhomboids and middle trapezius.”

So why is the infraspinatus strained? Although we might have excluded direct vertebral causes, there will likely be a postural vertebral influence. Sitting at work all day with protracted scapula will result in weakened rhomboids and middle trapezius. Even though the scapula are protracted, it is a passive protraction. As such, there will often be concurrent serratus anterior weakness (which hold the scapula to the ribcage and prevent winging). The poor posture may also (and usually does) result in pectoralis minor tightness. Pectoralis minor attaches to the scapula and pulls the scapula forward.

You can see there is a situation of anterior musculature being tight and short and posterior musculature being weakened and stretched. As has been said, “You can’t shoot a canon out of a canoe.” So when you go to “fire your canon” (pressing), you’ll find your canoe has a hole punched in the bottom of it from its inability to match the firing power.

Strengthen the Base

Treatment then must focus on strengthening your base. In routine cases, this means strengthening the rhomboids and middle trapezius – but not in the way you are probably thinking. The “retract your scapula”-type exercises rarely work. There are a multitude of reasons, and I have not the space to go into them here. But a quick reason is due to length/tension relationship and optimal strength positioning.

To correctly engage the rhomboids and mid trapezius:

1. Begin in a prone position, face down on the ground.
2. Place your arms out in the “I’m-an-airplane” position and hold about 2lb/1kg in each hand.
3. Lift up your arms from the ground just a couple of inches/centimeters and touch back to the ground lightly as if the ground were made of eggshells you don’t wish to break.

In doing this sequence, the rhomboids and mid-trapezius are in their optimal activation position and you can simply do the exercise without even thinking of retraction. It will just happen.

“The plan should be to relearn the bench press movement pattern as early as possible in the treatment process.”

Once you understand this pattern, you can begin with external rotation (ER) exercises. Most ER exercises are poorly performed and useless. When you do ER, you need to ensure the lats are engaged. ER with lat activation is the imperative. When you get this right, you can then lie down for the bench press and integrate the lat cue for ER stability into the bench press. Often I superset between one set of lat activated ER and one set of bench press.

The plan should be to relearn the bench press movement pattern as early as possible in the treatment process. I currently have a few athletes who are competing in significant powerlifting competitions within a few weeks of beginning their shoulder treatment. I usually expect to have athletes beginning their pressing by the second treatment session. Seeing as I have a bench press in my practice, it makes it easy for me to work with clients pressing right in front of me.

Knowledge Is Healing

This article is intended to help you understand what may be behind your shoulder problem, and for you to perhaps recognize the red flag of a healthcare practitioner who looks no further than the area to which a patient points. As with your low back, a little knowledge may take you down the rabbit hole, but it will also take you on a better path to ultimate healing.

More Like This:

• How to Self-Diagnose Your Shoulder Pain
• How to Crawl Your Way Back to Shoulder Health
• Common Elbow Injuries and What to Do About Them
• New on Breaking Muscle Today

Photos 1 courtesy of Shutterstock.

Photo 2 by By Mattopaedia at en.wikipedia [Public domain], via Wikimedia Commons.

Photo 3 courtesy of Andrew Lock.

The post The Truth About Your Benching Pain (It’s Not Biceps Tendonitis) appeared first on Breaking Muscle.

One of the obvious questions I get from readers and athletes is why and how I use deadlifting as a lumbar rehab exercise when most health professionals avoid it. The start to that answer is pretty simple: I know how to deadlift correctly and they don’t.

If you have read my article on deadlifting, then you will understand the non-negotiable parameters of the lift. A quick scan of Facebook and YouTube proves my point, with many “coaches” posting proud videos of clients’, and their own, dangerous form with the grin of a drooling moron fixed to their faces. The Bliss of the Boneheads.

Deadlifting is safe if it’s done safely. Deadlifting correctly is a brilliant lumbar spine rehab exercise.

Case Study: A Story of Deadlifting Out of Injury

MRI films from my patient after a lumbar disc injury.

Consider the patient whose MRI films accompany this article. An experienced powerlifter who suffered a significant lumbar disc injury when deadlifting. It was January 2015 when it happened, and here is his MRI above. His symptoms included lumbar, glute, and leg pain; numbness; and loss of calf strength (he was unable to do a single leg calf raise.)

Now consider film number two. Taken twelve weeks later – one week after he competed at the Australian National Powerlifting Championships at just over 80kg bodyweight where he achieved personal records in both deadlift and squat, both over 260kg. That disc injury impact is about 90% healed here.

MRI results twelve weeks later.

This patient deadlifted from the second week of treatment and began squatting at the third week. What changed was that he was a conventional deadlifter when he got injured and I converted him to sumo for his rehab. He switched back to conventional two weeks before the Nationals and competed with that stance.

Why Sumo Deadlifts?

There has been a clear demonstration that lumbar disc injury is often associated with decreased multifidus muscle at the symptomatic level and often unilateral to the injured side. As you will know from my previous article that multifidus and transverse abdominis are not a force couple as erroneously described in the article Muscle Control-Pain Control: What Exercises Would You Prescribe? Unfortunately, this article influenced a generation of health professionals.

“It has been well established and discussed by Professor Stuart McGill that, in summary, inefficient movement patterns in lumbar injury are those that are lumbar dominant rather than hip dominant.”

Let’s consider the multifidus. Its action is best described as opposing lumbar flexion. Remember that it is usually a lumbar flexion force that produces the disc injury. So a good way to make sure it hypertrophies and becomes strong is to introduce a lumbar flexion vector that the spine can handle by producing a multifidus contraction. The force does have a flexion vector but it is kept in neutral by the opposing extension vectors of iliocostalis, longissimus, and multifidus.

Naturally, what we are talking about here are movement patterns. Lumbar spine rehab, beyond the evident biology, is about movement pattern correction and re-education. It has been well established and discussed by Professor Stuart McGill that, in summary, inefficient movement patterns in lumbar injury are those that are lumbar dominant rather than hip dominant.

So, my rationale for deadlift introduction is twofold:

1. To produce a force that will produce multifidus adaptation.
2. To produce hip flexion optimization patterns.

Remember that the most important muscles for the control of lumbar lordosis are the iliocostalis and longissimus. Movement patterns that acknowledge their contribution should be introduced. Hence, the sumo deadlift.

(Note: Remember I get approximately 1,500 words for the article. As such, it is a nuts-and-bolts affair, with only major points being covered. If you have questions, ask them in the comments below and I’ll add them to my list of potential future articles.)

Do You Know How to Sumo?

The obvious reason for choosing the sumo stance is the glute and leg dominance and reduction in lumbar torque load. Here we can load the person using the glutes and lower limbs, teach a hip-dominant pattern, and keep the “core” braced and the spine in a neutral position using the spinal musculature.

“Lumbar spine rehab, beyond the evident biology, is about movement pattern correction and re-education.”

In my assessments, I initially look at the movement patterns in flexion, extension, and bodyweight squatting. These three movements are the base assessment. There is an algorithm I use from there, depending upon the results from both the subjective history and these movement evaluations. It would take an entire article about the implications of each analysis to get an understanding of what I look for and why. That is not what this article is about. This is about using a sumo technique. It is just based from those movements that I make corrective choices.

I’m looking to optimize an individual’s hip movement. Now, here is a huge point to grasp: a person’s maximum useful hip range may, and probably will not, be what you will use. You have to gain that functional range over time. You aim for it, but you will need to start the sumo using the best range the person can achieve when loading. It will be less than their optimal passive range initially.

Note the position of the knee and the alignment of the spine.

Basic physics also have to be observed. Your tibia must be vertical when viewed from any angle. It’s not negotiable in rehab work. There are many ways to learn how to get to the best position. A simple one is to use a drill I call Becoming the Sumo.

1. Start by imagining you are in an actual sumo-wrestling ring.
2. As you stand opposite your opponent, place your hands on your knees like the wrestler pictured above. The tibia must be vertical from both the front and the sides. The upper body must aim to connect to the pelvis with a neutral or lordotic lumbar spine. Again, look at the picture.
3. Once in that position, use your glutes to pull your knees out and take your hands off your knees like the sumo pictured below. You don’t have to get your hands that high initially, you might even put your hands forward as a counterbalance, but do work toward the sumo hands high as a goal.

You now have to hold that position for thirty seconds. Every five seconds consciously reactivate your glutes to pull the knees back out. You will almost universally find the knees start to fall in within three seconds. So it becomes a 6 x 5 second glute activations in this position. Watch your vastus medialis activate here, as well (for the attentive people: yes, I have just given you an insight into some of my knee rehab work – glute and vastus medialis combination drills).

This is now the homework to be done a couple of times a day and also pre-training – as an activation drill. I’ve watched the eminent Dan Green performing repetitions where upon lowering the bar he lets his knees fall in, then he actively drives them out to initiate the next lift. What awesome technique he has created. (Hi Dan, and yes, that was my 275lb elbow that was into your glutes at the World’s in Sydney.)

The challenge is that so many people are glute weak that they have problems using gluteus medius to abduct the thigh. Remember the principle of reciprocal inhibition. Most people complain of tight hips (and usually they point to everything but the true hip area), but to release the tightness from the hip adductors/groin, you must address the weakness of the hip abductors. This will give you a starting point. Get the glutes to hold that position of the sumo.

“The optimal position will eventually be vertical tibia and low hips allowing for a very upright spine. Just like our sumo wrestlers.”

Now, to correct the common problem of the knees being too far forward in the side view. If the knees are not vertical, you have to push the hips higher to bring the knees back, assuming you do not have the hip mobility to get wider. Sure, we eventually want to be lower, but you have to prioritize. The vertical tibia is not negotiable, the hip height is. I am essentially referring to lifters who are not established with sumo lifting here. The optimal position will eventually be vertical tibia and low hips allowing for a very upright spine. Just like our sumo wrestlers.

Set Up and Variations

I favor a double overhand grip in rehab. Simply because this is rehab time, we are working on movement patterning, not setting records. Similarly, for those who really have abysmal mobility, I’m happy to set up in sumo stance to lift from a rack or box. There is a need to appreciate each case individually, and as such you may have to accommodate to anatomical and mobility problems. Use your judgement.

A favored early variation I use is a face-the-wall sumo kettlebell deadlift (FTWSKD). Similar to the face-the-wall squat corrective exercise, FTWSKD is a self-correcting movement.

1. Set up in a sumo stance with your toes either on the wall or an inch or two away.
2. The kettlebell is set up between the feet.
3. Push the knees out so that upon picking up the bell the knees are over the ankles.

The result is usually an excellent neutral spine position that optimizes the hip movement and loads the glutes brilliantly.

Shoulder Position

Next you are looking to get the shoulders above the hands. We are looking to get a vertical vector from the hands to the shoulders. Once again, we are looking for vertical position from both the front and sides views. This is unlikely to be a cue I work on in the first session. This cue comes with learning to get your bodyweight behind the bar as you take the tension from the bar when lifting. I’ve just included it here for a note for you to be aware of.

Summary

So, in summary, I use the sumo deadlift, in many variations, as a frontline rehab strength exercise for low back rehab. Konnichiwa, Grasshoppers.

Note: I’ve received a lot of international correspondence regarding the protocols I use for low back rehab and I’ve been way too busy with patients and my own training to answer so many questions. Until I finalize the last draft on my complete methods, I’ll write a few articles aimed at those questions.

Coach Lock will be conducting the Functional Strength and Rehabilitation Workshop with Greg Dea and Andrew Read, March 19-20, 2016 in Melbourne, Australia.

More Like This:

• Rehabilitation for Lumbar Spine Injury: The Science and the Truth
• The Sumo Deadlift: Is It for You?
• Proof That Functional Strength Training Cures Low Back Problems
• New on Breaking Muscle Today

Photos 1 and 2 courtesy of Andrew Lock.

Photo 4 courtesy of Shutterstock.

Photo 5 by by Ogiyoshisan (Last edited July 28, 2014), via Wikimedia Commons.

The post Keep (Sumo) Deadlifting: Unorthodox Rehab for Lumbar Injuries appeared first on Breaking Muscle.

This article is intended to assist health and fitness professionals to understand back pain and its characteristics, to then be able to train clients with a low-back injury history and to make educated and scientifically evidenced exercise choices.

Intervertebral Disc Structure

One of the most important things to understand is how pain behaves in response to exercise application. But before we go into those concepts, we first need a bit of necessary anatomy.

Note: I have to leave the in-depth anatomy aside for now, and this will be a basic introduction for illustration purposes. I’ll create some articles on lumbar spine and spinal disc anatomy in the coming months to improve the understanding of those people who don’t have an in-depth anatomical appreciation of the area. Today, though, just follow me as I take you through the most basic anatomical construct.

This illustration maps out the how the two main components of an intervertebral disc articulate with the vertebra.

Let’s get it straight – most low-back pain is caused by stress or injury to the intervertebral disc.¹ The Intervertebral disc is just as the name states. It is a disc that is placed between two vertebrae. In the lumbar spine, the disc is composed of two basic components.

1. Annulus
2. Nucleus

The annulus is a series of rings that surround the inner, more hydrated (fluid) nucleus. The annulus rings are woven into the ends of the bone (hence, why discs can never “slip”).

Now, consider the disc to behave similarly to a blown-up balloon. When you place pressure on one area of the balloon, the area furthest from the pressure will bulge out as the air moves away from the applied pressure. Your disc essentially behaves in that manner. If you bend forward and sustain that position, the nuclear fluid within the annulus will move backward away from the pressure source. As such, we can use this concept to understand the relationship between disc loading and pain behavior.

Centralization and Peripheralization

When a person has a pain that is due to injury of the intervertebral disc, then the location of that pain and that pain’s response to an exercise or posture can assist us in predicting the direction of movement we should apply to help the disc heal and prevent further injury.

So, in a disc injury that has referred pain, we consider the site of the disc pain to be central and the site of the referred pain to be peripheral. An example is the so-called “sciatic” pain, where a person may have pain in the gluteal, hamstring, or calf. This pain is considered the peripheral pain. The person may, or may not, have peripheral pain without having central or low-back pain.

“Centralization can help identify individuals with chronic low-back pain who may positively respond to exercise and training outcomes.”

There are two general directions that are most often applied to low-back injury. Lumbar flexion forces or lumbar extension forces. These are not the only two directions available, but for the purposes of this article, let’s use them for our demonstrations.

Let’s examine a situation where a person has pain in his hamstring that is due to sciatic nerve referral. But he has no low-back pain. This client is tested by making him stand and bend forward to touch his toes about ten times. Upon completion of the ten repetitions, he says his pain in the hamstring is now better, he has no back pain, and he has pain in his calf only, but it is less intense than the hamstring pain was.

WARNING: This is peripheralization. It is not the severity of the pain that is most important; it is the location. In this case, the pain has moved further from the spine. The injury has actually been increased.

Now imagine we test the same person by making him stand with his hands on his hips and bend backward ten times. This time, after completing the repetitions, he states his hamstring pain has gone, but he now has low back pain, and the low back pain is more intense than the hamstring pain was.

GREEN LIGHT – GO: This is centralization. The pain has moved from the periphery to the center. The intensity is not the variable we are following. It is location.

The origin of pain rather than its severity is the most important component in assessing a client’s movement.

<strong”>Here is your concept to understand. As a result of a movement or sustained posture, where does the pain move? Central or peripheral?

Note: I have used one example each of flexion and extension. Specifically, these were examples of standing flexion and extension. Flexion and extension can be applied in many ways and the effect of gravity and the center of mass upon the spine changes with their position. In my practice, I use a variety of positions and movements depending upon the movement and pain response. But this article is not about the variations of movement. It is only discussing pain response to imposed forces. I shall discuss exercise variations in the future.

The Importance of the Centralization Principle

Research has proven this principle is an astoundingly accurate predictor of the likelihood of a successful treatment outcome and that it reliably determines the appropriate direction of treatment exercise.² Centralization reliably differentiates discogenic pain from nondiscogenic pain, and it predicts the intact from ruptured annulus in symptomatic discs, being superior to MRI imaging in determining painful from non-painful disc injury.³

Imagine that. If you become proficient at exercise application and low-back pain, you can actually be more accurate at determining low-back injury than an MRI. I’ve executed this approach so often that I can often predict the MRI findings and exact type of injury simply through history taking and movement examination.

“Back pain, as with any physical condition, is a multifaceted and multi-influenced construct. As such, behavioral influences must always be considered.” 

The principle of centralization is an excellent diagnostic tool. Centralization and peripheralization are strongly associated with the symptoms associated with pain of discogenic origin. In a 1997 study by Donelson , centralization was strongly (91%) associated with competent annulus compared to peripheralization (54%). In a review of 87 patients with radiating symptoms, centralization occurred in 76 (87%).

The occurrence of centralization during initial mechanical evaluation is a very accurate predictor of successful outcome and it reliably determines the appropriate direction of treatment exercise. On the other side of the coin, the non-occurrence of centralization to imposed examination accurately predicts a poor treatment outcome and is an early predictor for the need of surgical treatment.²

In studies assessing chronic low-back pain, return to work, and centralizers versus non-centralizers before entry-to-work hardening programs, the outcomes showed centralizers had significant decreases in their maximum pain ratings and a higher return-to-work rate. Centralization can help identify individuals with chronic low-back pain who may positively respond to exercise and training outcomes.⁴

It is imperative to learn the source of your pain before attempting any sort of spinal loading through exercise.

The Complexity of Back Pain

Back pain, as with any physical condition, is a multifaceted and multi-influenced construct. As such, behavioral influences must always be considered. If you have the training to examine nonorganic influences, such as Waddell’s signs, it has been demonstrated that low Waddell’s scores and centralization predicts a strong return-to-work outcome. A high Waddell’s and non-centralization predicts a poor return to work outcome.⁴

 “[I]t is imperative you consider the location of the pain and its changes in response to your exercise, not simply the intensity of the pain.”

In clinical practice, I am constantly aware of behavioral influences that may impact upon my rehabilitation pathways. But it has been demonstrated that centralization is more significant than psychological factors in predicting long-term outcomes.⁵

Movement, Posture, and Pain

Now, how to differentiate between the different structures that can cause back pain, whether disc, joint, neural structure, muscle, psychological constructs, etc. That is a series of further articles to show the differentiation techniques and subjective history flags that are consistent with them. It is a lot of in-depth understanding. And perhaps we’ve covered enough already for one session.

So, for now, let’s just work on clearly understanding the relationship between movement, posture, and pain behavior as characterized by the centralization and peripheralization phenomenon. This is about pain, not structure. We are using the disc as an example, the most common example, to demonstrate a theoretical model of the cause of the phenomenon.

When you are prescribing and imposing an exercise upon a person with a history of low-back injury, it is imperative you consider the location of the pain and its changes in response to your exercise, not simply the intensity of the pain. And remember, these tools are predictors and benchmarks. Each actual case will be different and your influence as a professional can be one of the most important factors of all. Your ability to communicate your expectations, your prescriptive exercise requirements, and the client’s understanding of your approach often are the most important hinges upon which the case may turn.

Check out these related articles:

• Get the Low Down On Your Low Back
• 6 Steps to Heal Your Low Back Injury
• You Don’t Need Medication to Maintain a Healthy Low Back
• What’s New On Breaking Muscle Today

References:

1. Kuslich, S.D., et al., “The tissue origin of low back pain and sciatica,” Orth Cl N Am 22:2, (1991): 181-187.

2. Donelson, R., et al., “Centralisation Phenomenon – It’s usefulness in evaluating and treating referred pain,” Spine 15:3, (1990).

3. Donelson, R., et al., “A prospective study of centralisation of lumber and referred pain as a predictor of symptomatic discs and annular competence,” Spine 22:10, (1997): 1115-1133.

4. Karass, et al., “The relationship between nonorganic signs and centralization of symptoms in the prediction of return to work for patients with low back pain,” Physical Therapy 77:4, (1998): 354-360.

5. Weneke, et al., “A descriptive study of the centralization phenomenon – a prospective analysis,” Spine 24, (1999): 676-683.

Photos courtesy of Shutterstock.

The post How to Diagnose and Treat Low Back Pain Without an MRI appeared first on Breaking Muscle.

My approach is unique because it comes from a nearly thirty-year history of resistance training on top of a physiotherapy science background, research of the topic, and devotion to understanding the science of injury production, which conversely is about injury prevention. Professionally, my analysis is of all lifts. This article is only about deadlifting.

Internationally, most people know me for my spinal rehabilitation. But in Australia I’m especially known for my analysis of lifting technique.

My approach is unique because it comes from a nearly thirty-year history of resistance training on top of a physiotherapy science background, research of the topic, and devotion to understanding the science of injury production, which conversely is about injury prevention. Professionally, my analysis is of all lifts. This article is only about deadlifting.

Experience makes a person “see” things at an unconscious level and we often take for granted that others see things the same way. This article will show you how I “see” a deadlift when a person comes to me for rehabilitation and analysis.

I’ve broken down the art of deadlifting to an exact science and I’ll show you how recognition of basic physics and applied biomechanics can produce the perfect deadlift position for anyone. Just remember, if you use my work in the future then acknowledge the source. Like most other geniuses I have a healthy ego.

WARNING: This article is about analysis. Anyone who makes a comment about the dangers of spinal flexion in relation to this article is officially deemed a moron. This is not an article discussing loading spinal flexion. It is about biomechanical analysis. Restrict your discussion to the topic.

Base of Support and Center of Mass

Just for the semantics, in deadlifting as the person is close to the surface of the earth the terms center of mass and center of gravity may be interchanged without issue.

“Physics, biomechanics, anthropometrics, musculoskeletal mobility, strength, and weakness are all evaluated to produce a person’s ideal deadlift technique.“

Anyone who has simple martial arts and contact sports experience understands that if you move an opponent’s center of mass outside of his base of support, he will fall over. So it is with deadlifting. The aim of the combined human and loaded bar mass is to remain within the base of support (your feet).

Sounds simple? It is. So, when I work with a person, I observe his or her foot posture. For example in the conventional stance, the feet are closer together and this reduces the base of support compared to sumo stance, which increases the base of support. But in sumo, if the feet are pointing laterally out, then the anterior and posterior stability is decreased. I’m not discussing muscle recruitment here, or why we choose one stance over another, that will follow. This is to show you that foot position is an important consideration in regard to an individual’s deadlift and not to be ignored.

The bar then must travel as close to the person’s center of mass to minimise unwanted horizontal energy expenditure. We aim to keep the bar’s mass as close to the lifter’s center of gravity as possible. This is why the bar begins as close to your tibia/shin as you can get it. The bar must be close to the body.

Ground Reaction Force

We lift in accordance to Newton’s third law, often referred to as the action-reaction law. This describes the forces between two bodies. In deadlifting, one body is the combined human being and loaded bar, while the other body is the earth itself. We exert a force upon the earth with our feet and the earth exerts an equal force back to us (essentially a simultaneous event). This is the ground reaction force.

Vertical and Horizontal Force Vectors

Consider that a vector is a mathematical expression of the direction of force. Simplified for this article, we can consider that when the forces are resolved, there are two force vectors at work, either vertical or horizontal. Now the fun begins.

“When the tibia is vertical, then you have vertical force application to the ground. Any flexion at the ankle will dissipate the vertical force to include a horizontal vector, a waste of force.”

Deadlifting is an endeavor where we aim to lift the bar from its resting position in a vertical manner to upright lockout. There is no rationale to produce a horizontal force upon the earth. Any horizontal vector will be wasted energy that could have been added to the vertical vector. Perfect deadlifting is theoretically a purely vertical vector. That’s what I look for.

Combine the Concepts

Combine the concept of maximizing the vertical vector to the ground reaction force and you will produce maximum potential vertical lifting force (MPVLF). I just created that term, but it looks good and describes the concept – consider that a first.

Bring in the biomechanics now. The bone that can be used as a visual indicator of vector direction is the tibia, or shin. When the tibia is vertical, then you have vertical force application to the ground. Any flexion at the ankle will dissipate the vertical force to include a horizontal vector, a waste of force.

When I observe this in a patient, I take both front and side views to ensure the tibia position is vertical. When you photograph or video your own lifting, ensure you take both of these views at some point. Problems with vertical tibia production can be mobility, segmental strength, or movement-pattern based.

This applies to both conventional and sumo variations. The vertical tibia is the prerequisite for the most efficient force transmission in all stances. Understanding the principles behind the choices of foot position now follows. It does not mean that some champions don’t break the rule. I’m just helping you by starting with the rules. When you are good enough, you will understand variations.

The Aim: To pull the bar in a vertical vector through the shortest possible distance using the individual’s most efficient musculoskeletal tools.

Anthropometric Lengths and Stance Application

Human beings bodies vary in many ways. The bones of the skeleton are considered the levers through which forces are applied. This is part of the consideration as to what is going to be your best stance. Consider initially two segments of the body:

1. Lower body – from the pelvis to the feet
2. Upper body axial skeleton – from pelvis to shoulders

As a generalization for the purposes of this article, consider these as two separate segment lengths.

Torque minimisation is the evaluation of these two segment lengths. Clearly, we wish to move the bar the shortest distance possible from the ground to lockout and minimise torque forces upon the body by the weight. As a general rule, you will start by minimising the movement of your longest length. This is the first consideration as to whether you will be best suited to conventional or sumo stance. Minimise your longest segment.

If your torso is short, you will often tend to be conventional stance. This means you are more likely to be a person who is going to pull from your back rather that your hips. This style of pull will invariably lose the lumbar lordosis and flex the spine to use the erector spinae, especially the thoracic erector spinae, when compared to sumo.

There is nothing wrong with that, if you have good coaching. People with a lack of spinal education are rightly scared of loading flexed lumbar spines. But world records are often set that way. If you don’t know what you are doing, you can get hurt. This article is not about how to understand why spinal flexion occurs or recognition of its dangers. This article is about the analysis principles, only that.

With a lifter of very short torso length, the lifter will often appear to have “long arms.” This is more often an illusion, the person having normal arm length, but very short torso length. The truly long-armed and short-torso lifter is predisposed for short pulling distance. The conventional stance will typically load the hamstrings as the hips move over the vertical tibia to find their tension point to lift from. These rare conventional lifters may also then be able to reduce their hamstring involvement further by pointing their toes out and almost totally load their lumbar musculature.

Sumo lifters tend to minimise their longer torso lengths by using their legs and hips as the major force production, as such they will be more upright and use more glute and hamstring tension for the lift. To decrease the torso length effect, the feet are placed wider and the torso becomes more upright.

“[F]oot position is an important consideration in regard to an individual’s deadlift and not to be ignored.“

The basic physics of lifting is established. These are principles I see when I’m asked to evaluate someone’s deadlift. The more you practice, the better you will get at seeing this, too.

Foot Width

Now comes the influence of biomechanics and personal anthropometrics when we consider the mobility of the components of the individual’s joints. A person’s mobility of the hips and lumbar spine will have a huge relationship to his or her achievable position.

Note: Not the ankles, though. Never the ankles. If you want to argue about this after reading this far into my article, then go and buy a colouring book and pencils, because the whole topic must have gone so far over your head that you are beyond saving. Turn off your computer. Do not contact me.

When I identify a person who can improve his or her mobility, I prescribe an appropriate mobility for those joints to achieve. So although I may initially find a good foot position for a person in sumo, should I assess him or her as having potential to change that to his or her benefit, then I aim for that as a longer goal. Today’s optimal stance may change as the lifter becomes more able to increase mobility.

Muscular Strength

Apart from the applied physics, we must consider the real world individual’s strength and weaknesses. It is no good getting a perfect lifting posture that may emphasise glute dominance in sumo if that person has weak gluteals. Conversely, a conventional lifter with weak erector spinae will not be effective.

“Today’s optimal stance may change as the lifter becomes more able to increase mobility.“

We may have found our ideals, but now we have to apply an appropriate strengthening regimen to that person’s weak links before it can become effective. Often the correct technique may be weaker for a lifter compared to what he or she is used to until that lifter builds the new strength patterns. This will yield a long and less-injury prone career, rather than the shooting star and serious injury path.

With foot posture, you have a general rule to apply. When the toes face forward, you will be recruiting the hamstrings in the lift. The further out the toes point, the greater the gluteal recruitment. The further the toes point out, the less anterior and posterior stability you have. But if your vector production is vertical, then this is not going to be a problem. While you learn the technique, it will cause some frustration. Get over it.

Evaluation of the posterior chain musculature, personal strength patterns and weaknesses, and their contributions to the determined stance are imperative in the progression of a lifting routine and plan.

Summary

Physics, biomechanics, anthropometrics, musculoskeletal mobility, strength, and weakness are all evaluated to produce a person’s ideal deadlift technique. So next time you see a person who deadlifts and imitates a squat by placing his shins and knees over the bar, observe how loose and uncoordinated that lift appears. He probably read Starting Strength. Tightness and tension production are the goals to transmit force to the ground. Just ask Pavel.

Take your time to understand all that is written above. It gets easier the more you practice. There is so much to consider – physics, body mechanics, joint mobility, and neuromuscular strength and its coordination. If you wish to be a good coach, you need to be able to identify and understand all of these elements, and you need to practice observation. I never said it was easy. Just remember, overnight success only takes about ten years.

Check out these related articles:

• 15 Practical Strategies for Increasing Your Deadlift Max
• Mobility Video – Arching the Back for Greatness
• Why You Should Vary Your Back Squat Stance
• What’s New On Breaking Muscle UK Today

Photos 1, 2, and 5 courtesy of Becca Borawski Jenkins.

Photo 3 courtesy of Shutterstock.

Photo 4 courtesy of Shannon Khoury.

The post The Action-Reaction Law: How to Deadlift Big and Avoid Injury appeared first on Breaking Muscle.

My approach is unique because it comes from a nearly thirty-year history of resistance training on top of a physiotherapy science background, research of the topic, and devotion to understanding the science of injury production, which conversely is about injury prevention. Professionally, my analysis is of all lifts. This article is only about deadlifting.

Experience makes a person “see” things at an unconscious level and we often take for granted that others see things the same way. This article will show you how I “see” a deadlift when a person comes to me for rehabilitation and analysis.

I’ve broken down the art of deadlifting to an exact science and I’ll show you how recognition of basic physics and applied biomechanics can produce the perfect deadlift position for anyone. Just remember, if you use my work in the future then acknowledge the source. Like most other geniuses I have a healthy ego.

WARNING: This article is about analysis. Anyone who makes a comment about the dangers of spinal flexion in relation to this article is officially deemed a moron. This is not an article discussing loading spinal flexion. It is about biomechanical analysis. Restrict your discussion to the topic.

Base of Support and Center of Mass

Just for the semantics, in deadlifting as the person is close to the surface of the earth the terms center of mass and center of gravity may be interchanged without issue.

“Physics, biomechanics, anthropometrics, musculoskeletal mobility, strength, and weakness are all evaluated to produce a person’s ideal deadlift technique.“

Anyone who has simple martial arts and contact sports experience understands that if you move an opponent’s center of mass outside of his base of support, he will fall over. So it is with deadlifting. The aim of the combined human and loaded bar mass is to remain within the base of support (your feet).

Sounds simple? It is. So, when I work with a person, I observe his or her foot posture. For example in the conventional stance, the feet are closer together and this reduces the base of support compared to sumo stance, which increases the base of support. But in sumo, if the feet are pointing laterally out, then the anterior and posterior stability is decreased. I’m not discussing muscle recruitment here, or why we choose one stance over another, that will follow. This is to show you that foot position is an important consideration in regard to an individual’s deadlift and not to be ignored.

The bar then must travel as close to the person’s center of mass to minimize unwanted horizontal energy expenditure. We aim to keep the bar’s mass as close to the lifter’s center of gravity as possible. This is why the bar begins as close to your tibia/shin as you can get it. The bar must be close to the body.

Ground Reaction Force

We lift in accordance to Newton’s third law, often referred to as the action-reaction law. This describes the forces between two bodies. In deadlifting, one body is the combined human being and loaded bar, while the other body is the earth itself. We exert a force upon the earth with our feet and the earth exerts an equal force back to us (essentially a simultaneous event). This is the ground reaction force.

Vertical and Horizontal Force Vectors

Consider that a vector is a mathematical expression of the direction of force. Simplified for this article, we can consider that when the forces are resolved, there are two force vectors at work, either vertical or horizontal. Now the fun begins.

“When the tibia is vertical, then you have vertical force application to the ground. Any flexion at the ankle will dissipate the vertical force to include a horizontal vector, a waste of force.”

Deadlifting is an endeavor where we aim to lift the bar from its resting position in a vertical manner to upright lockout. There is no rationale to produce a horizontal force upon the earth. Any horizontal vector will be wasted energy that could have been added to the vertical vector. Perfect deadlifting is theoretically a purely vertical vector. That’s what I look for.

Combine the Concepts

Combine the concept of maximizing the vertical vector to the ground reaction force and you will produce maximum potential vertical lifting force (MPVLF). I just created that term, but it looks good and describes the concept – consider that a first.

Bring in the biomechanics now. The bone that can be used as a visual indicator of vector direction is the tibia, or shin. When the tibia is vertical, then you have vertical force application to the ground. Any flexion at the ankle will dissipate the vertical force to include a horizontal vector, a waste of force. 

When I observe this in a patient, I take both front and side views to ensure the tibia position is vertical. When you photograph or video your own lifting, ensure you take both of these views at some point. Problems with vertical tibia production can be mobility, segmental strength, or movement-pattern based.

This applies to both conventional and sumo variations. The vertical tibia is the prerequisite for the most efficient force transmission in all stances. Understanding the principles behind the choices of foot position now follows. It does not mean that some champions don’t break the rule. I’m just helping you by starting with the rules. When you are good enough, you will understand variations.

The Aim: To pull the bar in a vertical vector through the shortest possible distance using the individual’s most efficient musculoskeletal tools.

Anthropometric Lengths and Stance Application

Human beings bodies vary in many ways. The bones of the skeleton are considered the levers through which forces are applied. This is part of the consideration as to what is going to be your best stance. Consider initially two segments of the body:

1. Lower body – from the pelvis to the feet
2. Upper body axial skeleton – from pelvis to shoulders

As a generalization for the purposes of this article, consider these as two separate segment lengths.

Torque minimization is the evaluation of these two segment lengths. Clearly, we wish to move the bar the shortest distance possible from the ground to lockout and minimize torque forces upon the body by the weight. As a general rule, you will start by minimizing the movement of your longest length. This is the first consideration as to whether you will be best suited to conventional or sumo stance. Minimize your longest segment.

If your torso is short, you will often tend to be conventional stance. This means you are more likely to be a person who is going to pull from your back rather that your hips. This style of pull will invariably lose the lumbar lordosis and flex the spine to use the erector spinae, especially the thoracic erector spinae, when compared to sumo.

There is nothing wrong with that, if you have good coaching. People with a lack of spinal education are rightly scared of loading flexed lumbar spines. But world records are often set that way. If you don’t know what you are doing, you can get hurt. This article is not about how to understand why spinal flexion occurs or recognition of its dangers. This article is about the analysis principles, only that.

With a lifter of very short torso length, the lifter will often appear to have “long arms.” This is more often an illusion, the person having normal arm length, but very short torso length. The truly long-armed and short-torso lifter is predisposed for short pulling distance. The conventional stance will typically load the hamstrings as the hips move over the vertical tibia to find their tension point to lift from. These rare conventional lifters may also then be able to reduce their hamstring involvement further by pointing their toes out and almost totally load their lumbar musculature.

Sumo lifters tend to minimize their longer torso lengths by using their legs and hips as the major force production, as such they will be more upright and use more glute and hamstring tension for the lift. To decrease the torso length effect, the feet are placed wider and the torso becomes more upright.

“[F]oot position is an important consideration in regard to an individual’s deadlift and not to be ignored.“

The basic physics of lifting is established. These are principles I see when I’m asked to evaluate someone’s deadlift. The more you practice, the better you will get at seeing this, too.

Foot Width

Now comes the influence of biomechanics and personal anthropometrics when we consider the mobility of the components of the individual’s joints. A person’s mobility of the hips and lumbar spine will have a huge relationship to his or her achievable position.

Note: Not the ankles, though. Never the ankles. If you want to argue about this after reading this far into my article, then go and buy a coloring book and pencils, because the whole topic must have gone so far over your head that you are beyond saving. Turn off your computer. Do not contact me.

When I identify a person who can improve his or her mobility, I prescribe an appropriate mobility for those joints to achieve. So although I may initially find a good foot position for a person in sumo, should I assess him or her as having potential to change that to his or her benefit, then I aim for that as a longer goal. Today’s optimal stance may change as the lifter becomes more able to increase mobility.

Muscular Strength

Apart from the applied physics, we must consider the real world individual’s strength and weaknesses. It is no good getting a perfect lifting posture that may emphasize glute dominance in sumo if that person has weak gluteals. Conversely, a conventional lifter with weak erector spinae will not be effective.

“Today’s optimal stance may change as the lifter becomes more able to increase mobility.“

We may have found our ideals, but now we have to apply an appropriate strengthening regimen to that person’s weak links before it can become effective. Often the correct technique may be weaker for a lifter compared to what he or she is used to until that lifter builds the new strength patterns. This will yield a long and less-injury prone career, rather than the shooting star and serious injury path.

With foot posture, you have a general rule to apply. When the toes face forward, you will be recruiting the hamstrings in the lift. The further out the toes point, the greater the gluteal recruitment. The further the toes point out, the less anterior and posterior stability you have. But if your vector production is vertical, then this is not going to be a problem. While you learn the technique, it will cause some frustration. Get over it.

Evaluation of the posterior chain musculature, personal strength patterns and weaknesses, and their contributions to the determined stance are imperative in the progression of a lifting routine and plan.

Summary

Physics, biomechanics, anthropometrics, musculoskeletal mobility, strength, and weakness are all evaluated to produce a person’s ideal deadlift technique. So next time you see a person who deadlifts and imitates a squat by placing his shins and knees over the bar, observe how loose and uncoordinated that lift appears. He probably read Starting Strength. Tightness and tension production are the goals to transmit force to the ground. Just ask Pavel.

Take your time to understand all that is written above. It gets easier the more you practice. There is so much to consider – physics, body mechanics, joint mobility, and neuromuscular strength and its coordination. If you wish to be a good coach, you need to be able to identify and understand all of these elements, and you need to practice observation. I never said it was easy. Just remember, overnight success only takes about ten years.

Check out these related articles:

• 15 Practical Strategies for Increasing Your Deadlift Max
• Mobility Video – Arching the Back for Greatness
• Why You Should Vary Your Back Squat Stance
• What’s New On Breaking Muscle Today

Photos 1, 2, and 5 courtesy of Becca Borawski Jenkins.

Photo 3 courtesy of Shutterstock.

Photo 4 courtesy of Shannon Khoury.

The post Newton’s 3rd Law and How to Leverage Massive Deadlifts appeared first on Breaking Muscle.

I have the secret for you. The secret that will set you free. It is the answer to the age-old Buddhist question, “What is the sound of the one-hand clap?” I’m going to tell you the answer. Close your eyes and concentrate upon pulling your navel in towards your spine (using your TVA, of course), and listen closely, because the next sound you hear will be the sound of my large, calloused, open hand smacking loudly into the side of your thick skull, knocking some badly needed sense into it.

You have just learned the secret of the one-hand clap. Now that I have assisted you in forgetting all about your TVA, it is time pay attention to the real world.

“Let’s begin with a question, ‘What are the spinal muscles most important for maintaining the lumbar lordosis when squatting, deadlifting, and in general functional activity?’”

Dismantling the Multifidus Myth

I expect you have read my previous articles dismantling the false prophets of the TVA and Multifidus Cult. If you have not, then you will find their perusal most beneficial after reading this article. In those articles, I had promised a discussion upon the rehabilitation progressions that related to my protocols for lumbar spine injury recovery.

So, let’s begin with a question, “What are the spinal muscles most important for maintaining the lumbar lordosis when squatting, deadlifting, and in general functional activity?” No, this is not a trick question.

Please, don’t tell me you said “multifidus.” And, please, don’t tell me you are a physical therapist, chiropractor, osteopath, or any other college-graduated science professional and answered “multifidus.” If you are currently being treated for a low back condition, then perhaps you should ask this question to your treating practitioner. If they say “multifidus,” hand them a copy of this article.

Meet my friends iliocostalis and longissimus. If you deadlift often enough, then the people who walk behind you at the beach have already met them. You know them as those two big lumps of muscle on either side of your spine, sitting above the lumbar spine in the lower thoracic region.

Okay, now strap yourself in tight. I am going to do a bit of necessary anatomy here. I will attempt to produce the single clearest explanation possible, so you will be able to understand and communicate to others this absolute keystone to fundamental functional strength and rehabilitation science.

The Three Spinal Muscles That Produce Lumbar Lordosis

Let’s consider that there are three muscle groups that have a significant functional ability to influence the production of lumbar lordosis and extension.

In a pre-emptive strike, let me state clearly to the miseducated that the psoas has no significant role in lumbar lordosis. It is a hip flexor. It is mythology that it “produces lordosis.” Happy to discuss that another time, but don’t comment on it here, okay? Wait for the psoas article. And yes, latissimus dorsi also has a role in lumbar stability via the lumbodorsal fascia, but the forces are less significant than the muscles that will be the focus of this article.

Now let’s get to the three spinal muscles that actually, primarily in function, produce lumbar lordosis. Iliocostalis, longissimus, and multifidus. That’s it folks. You now know their names. Now crack your favorite energy drink and get ready for more.

The focus of this article is to educate you as to how and why Iliocostalis and longissimus are the muscles you need to understand to be able to create a program aimed at controlling and holding neutral lordosis under load. To do this I’m going to show you the best way to understand the functional anatomy, not the textbook anatomy.

“Let me state clearly to the miseducated that the psoas has no significant role in lumbar lordosis. It is a hip flexor.”

Getting Your Head Around Iliocostalis and Longissimus

If you open a regular anatomy text you will see that longissimus and iliocostalis are each defined as having two components:¹

1. Longissimus thoracis pars lumborum
2. Longissimus thoracis pars thoracis
3. Iliocostalis lumborum pars lumborum
4. Iliocostalis lumborum pars thoracis

To get the functional understanding, I arrange them into the area of attachment. So you get them defined as:

1. Longissimus thoracis pars thoracis
2. Iliocostalis lumborum pars thoracis

1. Longissimus thoracis pars lumborum
2. Iliocostalis lumborum pars lumborum

The attachment pars thoracis or pars lumborum indicates where that muscle attaches. As such, you now know that longissimus and iliocostalis have both thoracic and lumbar components. As such, those components act differently in function. So rather than differentiate the muscles anatomically from each other, you differentiate them functionally.

Left: Iliocostalis; Right: Longissimus

Physics Makes the World – and Lumbar Lordosis – Go Around

I bet no one ever told you, at that fine educational institution that certified you, that as a personal trainer you’d actually need an understanding of applied mathematics and physics to train people safely. In fact, you do.

You don’t like it? Go back to being a life coach then. It is not negotiable. Fortunately, I’m here to present a clear and simple model of the muscle forces of the lumbar spine.

Vectors for the Lumbar Spine

Bear with me, stop shaking, this won’t hurt too much. Vectors are the lines we use to demonstrate forces. When understanding a muscle’s action, the vector’s length and direction help us to understand its effect upon the joint we are examining.

Vectors have two dimensions – length and direction. Applying this vector line to the joint we can see the force applied to the joint. The direction will tell us how much compression force there is and how much shear force there is when we resolve it into its components. Compression is the force going through the joint. Shear is the force going across the joint.

Now, wipe the sweat from your brow. I’m not going to go any deeper in this article. This is simply a method to help us evaluate the contribution of the muscle to the task. So each muscle that we examine in this article will have a force that compresses the vertebral segment in a vertical direction and a force that pulls it backwards (shear) in a horizontal direction.

“Vectors are the lines we use to demonstrate forces. When understanding a muscle’s action, the vector’s length and direction help us to understand its effect upon the joint we are examining.”

Vectors for Iliocostalis and Longissimus (Pars Thoracis)

Arising all the way from the upper thoracic spine at T1 and each of the thoracic vertebra to T12, the longissimus pars thoracis attaches from each of the thoracic vertebral ribs and transverse processes. They then attach to the lumbar spine and sacrum and form the erector spinae aponeurosis, which covers the pars lumborum musculature. Meaning the effect is behind the lumbar components. The iliocostalis pars thoracis arises from the lowest 7 or 8 ribs and attaches to the ilium and sacrum via tendons as the erector aponeurosis.

Plain English: These muscles come from your thoracic spine and attach on your pelvis and sacrum behind the other lumbar muscles. They have a large compressive and minimal shear force.

Vectors for Iliocostalis and Longissimus (Pars Lumborum)

These muscles lie lateral to the multifidus muscle in the lumbar spine. The longissimus attach to the medial area on the transverse processes of the lumbar vertebrae. The Iliocostalis from the more lateral tips of the transverse processes

Each different vertebral attachment has a slightly different vector due to its individual attachment and insertion on the ilium, and in the case of iliocostalis, also the thoracolumbar fascia. Naturally, the lowest muscle components have the greatest shear/horizontal force vector and the higher have more compressive/vertical vectors.

Vectors for Multifidus

Multifidus is the largest lumbar muscle group. I’ll cut though the anatomical nomenclature and give you a scaled down overview of the multifidus. In a basic description, multifidus is attached at the spinous process of each lumbar vertebra and its surrounds. It has five parts that attach to each of the vertebra and sacrum below.

Due to their small spans between adjacent vertebrae, multifidus forces are segmental in nature. It is a bit dense to draw multifidus in its entirety without losing an understanding of the individual contributions. So the graphic here is representative of the general vector resolution. Naturally, being the closest to the joint, these muscles act with weaker force than the tendons of the pars thoracis components of the erector spinae, which are furthest from the joint.

The Most Important Muscle Group for Neutral Spine Control

So effectively, the pars thoracis group contracting uses its tendons and the erector spinae aponeurosis to produce and maintain the lumbar lordosis under load. Its distance from the vertebral column, placed furthest from the vertebral bodies enhances its effect on the lumbar lordosis like a bowstring on a hunting bow.

This is the most powerful and important muscle group we use in training for lumbar lordosis and neutral spine control. The segmental control at an individual vertebral level is contributed greater by the pars lumborum and multifidus groups. It is failure at these individual levels that causes the individual buckling of a segment that exposes the passive structures (ligaments and disc) to load and consequent injury.

The erroneous focus by rehabilitation professionals upon the multifidus muscle group to control and produce neutral spine posture is the source of many failed low back rehabilitation programs.

So, those of you who asked about the Functional Strength Rehabilitation model I created to work with low back injured athletes can begin to understand a part of my base strategy that is applied after the resolution of the acute disc symptoms. The system is broad and algorithmic in nature and involves the interaction of a lot of components. Those of you who attend any of my lumbar rehab courses will find this article worth committing to memory.

“The erroneous focus by rehabilitation professionals upon the multifidus muscle group to control and produce neutral spine posture is the source of many failed low back rehabilitation programs.”

Okay, that was a quick overview, and I’ve left out some of the more subtle muscle and fascial influences. This article is what it is. An overview and explanation of the most important contributor to lumbar lordosis and neutral spine control kept to a bit over 1,500 words.

References:

1. Macintosh JE, Bogduk N : “The morphology of the lumbar erector spinae.” Spine 1986 12: 658-668

2. Bogduk, N. Clinical Anatomy of the Lumbar Spine and Sacrum 3rd Ed. 1997.

3. McGill, S. Low Back Disorders. 2nd Ed. 2007

Photo 1 courtesy of Shutterstock.

Photo 2 modified by Uwe Gille (Gray Image:Gray389.png) [Public domain], via Wikimedia Commons.

The post Rehabilitation for Lumbar Spine Recovery: The Science and the Truth appeared first on Breaking Muscle.

Flexed lumbar spine strengthening is mandatory for an athlete to return to full ability. If you don’t teach athletes (and people in general) to bend and move, then they are certain to get injured again. Fear spinal flexion if you don’t understand it, but don’t berate it out of fear. This is a fear born of ignorance, ignorance by the medical community (which rarely understands resistance and weight training), and ignorance by educators in the health and fitness community.

I understand how this has occurred, and why we are in the situation we are as a society, and as a fitness community. It comes down to people passing themselves off as experts in areas of which they have little real understanding. They get away with it because there are few people who are qualified in this area and not many of them write or teach. So to fill this natural void you get so-called ‘fitness leaders” such as Paul Chek writing about a topic he has such little understanding of that he is just flat out wrong.

For example in his Paul Chek’s Points for More Effective Training, he wrote about the lumbar spine lordosis, “If this curvature is not maintained during lifting activities, both disk and ligament run the risk of injury. There is however a tradeoff of risks; when the low back curvature is held throughout a lift, there is an elevated risk of muscle injury, since ligament support is greatly reduced in this position.” Besides the fact he is clearly so undereducated in spinal anatomy that he cannot even spell “disc” correctly, Chek seems to think you want to rely on ligament “support” as a way to prevent muscle injury. Really?

Further he said, “With this clinical information in mind, it becomes evident that maintaining your natural spinal curvature throughout a lift is essential.” I love it when people use the word “clinical.” It makes them sound so scientific, doesn’t it? This sort of advice is okay if it comes from a trainer who knows little about lower backs and admits it, but to come from a person who holds himself up as having an understanding and authority on the subject (and then gets people to pay for it), it is abominable.

Now Paul Chek was simply the first example that came to mind to show how society and its industry are largely ignorant of total lumbar spine rehabilitation. I am here to loudly state that if you do not teach a person how to load their spine in flexed postures, then you are sure to find them getting injured when it occurs in functional life situations – and it will. Then again, if you don’t know when to flex a spine, it is a good idea to start learning about when it is safe and appropriate to do so.

This is my point. I don’t begin rehabilitation with spinal flexion, but it must be included before rehabilitation is complete. Nearly all the educators in our field are fixated upon neutral spine lifting and moving. This is unnatural. It is only one component of function. Watch any professional sport, you will see flexed, loaded lumbar spines. Watch speed skaters, wrestlers, world record deadlifts – spinal flexion is used and it is loaded. Why do people not understand this?

Look at the anatomical facts. Did you know that in the general population of eighteen to 35-year-olds the lumbar spine has approximately eighty degrees of motion between flexion and extension? That is correct. Your lumbar spine can normally move this much in function. The number is general, and there are many studies, so if you want to read more about that range then pick up Professor Stuart McGill’s book Low Back Disorders and read chapter five.

So considering this as your functional range, why do the “authorities” seem hysterical about keeping the lumbar spine in one position only at all times? Because they are scared and do not know how and when it is appropriate to teach people to flex. I met a patient once who had not bent forward for twenty years because she was told that was how she would injure her back. I don’t think she is alone.

But guess what? This lumbar movement paralysis is a relatively new phenomenon, enjoy the photos below.

Left: Harry Johnson, Mr. America 1959; Right: George Shandor

I bet there are people cringing at those photos. Why? What are you scared of? This is how normal spines can move. It is perfectly fine and good for you – if you know when and why. (Okay, George Shandor needs a bit more lumbar movement, but it is for illustration purposes only.)

Now I will state the obvious, as Eugene Sandow did many years ago. “There are no bad exercises, only good exercises poorly performed.” I’ll amend this slightly, and say, “There are no bad exercises (except anything done on a fitball by a person who does not make a living in a circus), just good exercises poorly performed or performed at the wrong time.” You can quote me, I often do.

How will you know when to begin working on exercises that involve natural lumbar spine flattening or flexing? Well, I can’t start that now at the end of this article, as it is a whole article or three in itself, but I’ll begin that discussion soon.

Let’s just finish with a few insights from the immortal John Grimek. In discussing the deadlift in all its variations he said:

When this exercise is worked regularly it serves to develop those two cable-like muscles, the erector spinea, that run along each side of the spine (from the head down to the hips) better than any other exercise except, and I repeat, the quick lifting movements. All these movements and exercises, such as the deadlift, serve to develop and strengthen the entire back. This is important since this is the region where weakness is first felt by most persons. Yet this region can be kept strong and flexible throughout life with proper training.

Yes Mr. Grimek, you were right. Strong and flexible. Strong and flexible. Not weak, stiff, and not allowed to move from lordosis.

You know Mr. John Grimek (pictured to the right) had the runs on the board not only was he was unbeaten in bodybuilding competition during his competitive years of 1939-1949 winning every top title, but he also could perform one-arm chins, one arm swing 200lbs, and do the splits. He was also the U.S. national weightlifting champion and represented the United States at the 1936 Berlin Olympics. Oh, yes, and Mr. Grimek was squatting over 400lbs when in his late sixties. Do you think he could have done all this by following Chek’s advice of “maintaining your natural spinal curvature throughout a lift is essential”?

So in the 21st Century it appears that spinal education and general strength instruction need a bit of looking backward before moving any further forward. In the future, I’ll show you how to combine modern research with old-school hard work to create that strong and flexible lower back that moves through a full range of flexion and extension. Stay strong and flexible!

Note: On the spelling of disc. Medical terminology derives from Latin, hence “disc” is the correct spelling. The word “disk” is from the Greek root, hence medically incorrect.

Photo 1 courtesy of Shutterstock.

Photo 2 by Artur Andrzej (Own work) [CC-BY-SA-3.0], via Wikimedia Commons.

The post Embracing the Flexed Lumbar Spine in Lifting appeared first on Breaking Muscle.

Take that red pill and you can never go back. In our case taking the red pill in regards to disc bulges means finding out the back pain rabbit hole goes a whole lot deeper than you ever imagined. In my series of articles you will learn what the world is really made up of. You will see some professions that treat your back pain are just snake oil salesmen in white coats. They won’t want you to understand your problem for fear they will lose money and they will lose your family and relatives that they told you to bring to them. They will put up your x-rays and tell you all that is wrong with you, but after taking the red pill you will see through them, those agents of the back pain matrix. I’m trying to free your mind. But I can only show you the door. You’re the one that has to walk through it. Education (the red pill) will set you free.

Having received a tsunami of mail regarding the athlete who I treated successfully that competed with a significant disc injury, I’ll do my best to help guide you through the disc bulge minefield. The biggest problem with low back problems, and disc problems in particular, is that most medical and paramedical professionals (let alone the local fish slapper) have never had enough education within their various undergraduate degrees to truly understand disc problems. It is a specialist’s area. Don’t let that scare you off, though. I don’t mean you cannot understand it. I mean it takes study and experience with patients to gain a depth of skill when dealing with afflicted people. Not afraid of a little hard work are we?

If you want to be a great trainer or you have a back problem and you want to understand it, here is the best place to start. I have to teach you anatomy. Understand this beast and study its habits before you engage it in battle. After the anatomy, I’ll teach you function, simple physics, and how to understand symptomatic and non-symptomatic disc problems. I’ll show you the “traffic light” system for safe exercise progression, and a whole lot more. I also figure that is going to take a lot of words, so get ready for this to be part one.

Let’s be clear. I love language. Language is specific. Words have nuances that can change whole meanings and this especially applies to scientific language. So the biggest irritant I get is when people who are not experts try to write articles on subjects that are specific and can be complex, such as disc injuries, and then totally fuck up the terminology.

In their paper Nomenclature and Classification of Lumbar Disc Pathology, doctors Fardon and Milette spent twenty pages on the clarification of the types of injuries that can occur to a disc. Dude, they never once used the term slipped. So, don’t you use it either, unless you happen use it when you say to someone who has just used the term slipped disc, “Sorry, my open hand just slipped against the side of your head rather forcefully, you idiot.”

Print out the sentence below and paste it to your favorite family photograph:

The definition of a diagnosis does not determine the symptoms.

Dammit, I think I’m going to put it on t-shirts and sell it. A specific diagnosis is a part of management consideration, but it does not dictate the treatment. Complete understanding of the nature of the symptoms and a definitive diagnosis of the problem are part of the paradigm I use to treat each individual. So, contrary to many recipe approaches, when you have a diagnosis that is specific, it does not dictate what the treatment must be. That involves a bit more understanding that will follow. For today, let’s just get our language clear and precise. I will give you a case in point later.

Here are the accepted terms you may see on a report describing the state of the disc:

• Normal – Okay, it is normal
• Congenital – Condition present at birth
• Developmental variation – Due to abnormal growth of the spine (e.g. scoliosis)
• Degenerative – A progressive impairment that can include desiccation, fibrosis, disc space narrowing, osteophytes
• Traumatic – Due to trauma

So let us look at a disc. Yes, another original drawing by me. This perspective is looking down upon a disc/vertebral section. A disc has two components you need to understand at this point. Further anatomy may be used in other articles where necessary, but today I am instructing about common disc injury terminology:

• Nucleus – in the center
• Anulus – series of rings that contain the nucleus in the middle.

What are the injuries common to a disc? Well, here we get onto more specific terminology.

• Anular tear or anular fissure – These are separations of the fibers that surround the inner part of the disc.
• Herniation – A localized displacement of disc material beyond the limits of the normal disc space. The material displaced may also be mentioned – it may be nucleus, cartilage, bone, or anular material. Herniations are subcategorized as focal, broad-based, symmetrical, or asymmetrical.
• Protrusion – A form of herniation defined by the distance it has displaced.
• Extrusion – A form of herniation greater than protrusion.
• Sequestration – Where the disc material has separated from the disc.
• Migration – Defines the movement of the disc material and its direction.
• Bulge – By definition this is not a herniation. It describes a generalized extension of the disc material beyond the normal disc definition. Bulging is often a normal situation requiring no treatment.

Here are some examples to help clarify the above terms. Figures 2-4 give you an idea of what I have defined. I have simply taken the disc shape and shown you how the various situations look on a CT or MRI scan. I could draw a few more but this should do for a start. (Commission art is upon request.)

So how many people do you know, or have met, who seem to consider a disc bulge as some sort of life sentence without parole? You may not have known it, but some disc bulges are absolutely normal and do not require any treatment. In fact, the person will have never felt pain or experienced impeded movement. Yet, tell someone they have disc bulge and watch how fast they press the panic button. At this time, just become more familiar with the terms and comfortable with their use.

You should also become far more critical of articles written by people telling you how to treat a disc bulge or low back pain. Also there are a lot of articles published about non-specific low back pain. This to me is a term used for academic laziness. Besides radiological terminology, there is also symptomatic terminology. Any article about non-specific low back pain to me indicates the researchers were not experienced in clinical spinal rehabilitation and were unsure about how to define low back problems.

So now you know the names of the most common radiological terms for disc investigations. Now, for the bad news – a lot of doctors do not use the terminology correctly themselves. You might get an MRI scan that a radiologist will term incorrectly. Sorry, not my fault. It is up to you to be interested and to ask questions if you have a scan or are training a client with scans. Ask to look at them. It does not mean you will understand them, but the more familiar you become with them the better you will grow as a professional over the years.

So grasshopper, want to try and take that pebble from my hand yet?

The Dark Side

A “doctor” I once worked with told me he ordered MRI scans for every patient. He said the more precise the investigations you ordered the more chance you would find something wrong with the patient. That was why he did it. He knew the patient didn’t understand the amount of false positive results you can get on an MRI, but he always knew he could find something. He would make disc space narrowing appear to be a terminal condition to a frightened patient. Then he would tell the patient to bring in the husband or wife so he could explain how serious it was to the spouse as well. These people exist, they prey on you being uninformed.

References:

1. Fardon and Milette SPINE 26(5) E93-E113. Nomenclature and classification of lumbar disc pathology.

Photo courtesy of Shutterstock.

Drawings courtesy of Andrew Lock.

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