Tag: pain

Don’t Forget Your Back

Most of us spend a large portion of the day hunched forward.  Think about when you are working on the computer, cooking, driving or even relaxing.  Your typical posture during these activities is head and neck forward, shoulders rounded forward, back curved and hips flexed.    When you remain in this position for an extended period of time, the muscles in the front of the body tend to shorten or contract, while the muscles in the back of the body tend to weaken.    This can be a set up for back, neck and shoulder problems and in addition, tends to make you look shorter, heavier and less confident.

Stretching before and after exercise as well as during the day is often overlooked in the rush to “get your workout in”.   Stretching however, has numerous benefits.   According to a study published in the Annals of Physical Medicine and Rehabilitation Medicine in September 2016, by I Fekhfekh, et al, dynamic muscle stretching of the knee musculature actually resulted in an increase strength gain in those muscles.  Interestingly, this study also found a decrease in the postural stability of the knee after stretching.    In English, it appears that stretching helps your to build strength, but may decrease the stability of the muscles you stretch at least temporarily.

In general, stretching helps to improve flexibility, joint range of motion, and usually is helpful for injury prevention.    Stretching helps by increasing blood flow to the muscles stretched.  This increased blood flow carries important nutrients to your muscles to allow for muscle growth and repair.  In addition, the increased blood flow helps to wash away muscle “waste” which leads to decreased soreness and inflammation of the muscle.

If allowed to remain in a contracted position for a prolonged period of time, our muscles will shorten.  For example if you spend a large portion of your day sitting in a chair or driving, the muscles in the front of the hips, your hip flexors will shorten.  These muscles have a direct effect on both your posture and your back health.

 

So what should you do?

It is important to stretch the muscles in the front of the body at least daily.

Exercises that focus on the hip flexors:

-Kneeling hip flexor stretch  – in the position of a lunge, allow your back knee to touch the floor and drive the hip of your front leg forward.  This will stretch the hip flexor of the knee on the floor

–Pigeon stretch – extend your right leg straight back and bring the heel of your left leg underneath your right hip.  Then drive your hips forward towards the ground.  Stretch and repeat on the other side.

– Yoga poses such as: low lunge, crescent lunge, upward facing dog, and revolving side angle pose

 

Stretches that focus on the chest muscles and prevent rounded shoulders:

– Door Frame stretch- stand in a doorway or at the corner of a room with your arms up like you were going to stop traffic.  Line your arms up from the elbow to the hand with the doorframe or in the corners of the wall.   Step towards the door and you should feel a stretch in your chest (pectoralis “pec” muscles) and hold for 20-30 seconds.

– Wall slides – stand with your back to the wall and keep your shoulders against the wall.  Walk forward 1-2 steps and slide your arms up and down the wall and squeeze your shoulder blades together.  You should feel a stretch in your upper chest muscles.

–Shoulder squeeze stretch –  clasp your hands together behind your back and slowly try to lift your hands.  Squeeze your shoulder blades together to stretch out the chest wall.

– Yoga poses include : bridge pose, camel pose, cobra pose and cow face pose

 

Stretches for your neck:

– Chin Tucks (Neck Retraction) – keep your shoulders back and your head in a neutral position (eyes facing forwards, chin level) slowly move your head backwards until you feel a slight stretch in the back of your neck.  Hold for 10-20 seconds and repeat.  If needed you can apply a gentle pressure on your chin with your fingertips to press your chin backwards and deepen the stretch.

Incorporating these exercises into your daily routine will help to prevent shortening of the muscles in the front of the body which leads to poor posture and often pain of the neck and back.  As always, if you are having pain which persists you should be evaluated by a certified health care professional to ensure that these exercises are safe for you.

This week we primarily discussed stretching exercises to prevent muscle contraction, and next week we will discuss the importance of strengthening the back muscles to further combat the issues of a hunched posture.

Exercise Through The Pain Versus Get It Checked?

As an individual either new or returning to exercise it is very common to sustain injuries.  Most often injuries occur in the joints such as knees, hips, feet, low back, neck and shoulders.   Although there are numerous reasons for injuries, the most frequent injuries are a result of poor body alignment, overuse injuries, increasing exercise duration or intensity too quickly, unequal strength that develops in opposing muscle groups, and improper shoe wear.

The warm up before exercising is very important because it allow for an increase in blood flow to the muscles.  Red blood cells carry oxygen, a requirement for muscle function.  As you become more “fit” your muscles get better at extracting oxygen from the blood.   In addition to carrying oxygen, the increased blood flow to the muscles helps to “wash away” hormones and neurotransmitters that can build up in the muscles and cause irritation and pain.

Pain is an adaptive mechanism that the body uses to prevent injury.  For example, if you put your hand near a fire you will sense instant pain and reflexively pull your hand away to prevent a burn and limit further damage.   In this case the sensation of pain in beneficial.

The pain pathways are very complex and the body has a remarkable way of increasing and decreasing pain sensation.  When you bang your leg and develop a bruise, the bruise and the surrounding areas become exquisitely sensitive.   Due to the release of certain substances, the body is able to up-regulate the sensation of pain.  Over time, as the bruise heals and the swelling decreases, the sensitivity in that area returns to baseline. However, sometimes the pain system can go awry.

In some cases, there is an acute injury that causes increased pain sensitivity, but instead of the pain receptor sensitivity returning to normal over time, they remain ultra-sensitive.  Even though there is no longer a reason for the sensation of pain to be generated, the body gets “confused” and can interpret sensations of light touch, heat, cold, or pressure as pain.   In this instance, the pain is no longer adaptive nor beneficial.   This malfunction is often seen in individual with chronic pain.

In my mind, there are two types of pain, “safe pain” and “dangerous pain”.   Safe pain to me, is pain that does not indicate worsening damage, cancer pain, or harmful injuries.  Safe pain is pain that often gets better during exercise and mobility.   In contrast, dangerous pain is pain that indicates a significant issue that needs prompt attention.   Some examples of dangerous pain include but are not limited to:

A fall or high-speed injury resulting in immediate severe pain and the inability to bear weight.  This pain can indicate conditions such as fractures, ligament injuries, or instability.

Chest pain or heaviness which occurs during exercise should never be ignored.  Typically, cardiac pain is described as chest tightening or pressure which often radiates down the right arm or into the jaw.  However, in individuals with diabetes, chest pain can be atypical and present like indigestion.  Chest pain is a medical emergency and should be evaluated immediately.

Neck or low back pain with associated numbness, tingling, or weakness should also be evaluated promptly.  In addition, any neck or back pain associated with bowel and bladder symptoms such as difficulty controlling urine, loss of sensation or funny sensation around the buttocks, and/or constipation and loss of bowel control needs to be addressed by a doctor.

The general rule of thumb is that pain which worsens incrementally with activity, persists despite rest, or is associated with numbness, tingling, radiating pain down arms or legs should be evaluated by a trained medical professional.   Pain that improves after a few minutes of exercise and is not associated with the above mention symptoms will often improve in its own.  Again, it is most important to listen to your body.  If you feel that “something isn’t right” or your symptoms are not improving you should  go with your gut and have your symptoms evaluated.

Rotator Cuff Tendonitis

The shoulder joint, or glenohumeral joint, is like a ball in a socket.  The shoulder joint is the interface between the humerus (arm bone), the scapula (shoulder blade) and the clavicle (collar bone).  Because the bony part of the socket of the shoulder is not deep enough to fully contain the top of the arm bone, there is a cartilage ring surrounding the bony joint to further contain and stabilize the arm.  The shoulder capsule is made up of fibrous tissue, helps to hold the arm bone in place inside the joint.   This capsule is fairly lax and allows for a good deal of movement in this joint which is both beneficial and detrimental.

The rotator cuff is a group of four muscles the help to move the arm in the shoulder socket but also serve to further stabilize the arm bone to allow for proper joint alignment and motion.  The 4 muscles in the rotator cuff joint are the supraspinatus, the infraspinatus, the teres minor and the subscapularis.  Each of these muscles have tendons, which serve to connect the muscles to the bone.  The most commonly injured muscle/tendon is usually the supraspinatus.  This is because the supraspinatus runs between two bony surfaces.  Depending on the anatomy of your shoulder, you might be at more risk for injury, especially if there is not much space between theses bony surfaces.  Over time, constant repetitive shoulder motion and friction causes micro-tears and fraying of these tendons.  High velocity injuries such as falls, car accidents or other trauma can cause also partial tears or rupture of these tendons and muscles as well.

Typically, rotator cuff tendonitis pain is brought on by specific movements of the shoulder joint.  Pain is usually located in the front or side of the arm and can radiate down to the elbow.  If the pain radiates further then the elbow, it is more likely your pain is due to a pinched nerve in the neck, rather than from your shoulder.

Rotator Cuff related pain includes (but is not limited to):

  • pain with overhead movements
  • pain with movements behind the back
  • pain with specific motions, but not all shoulder and arm movements
  • difficulty sleeping on the affected shoulder (this pain is also related to other shoulder pathology as well)
  • pain when raising or lowering the arm

Pain from the rotator cuff can be due to three different but often related issues. If the space between the bones is limited, when you raise your arm overhead, the rotator cuff can get pinched.  This is called impingement, which can be painful on its own.  Repetitive impingement can cause frays and tears of the tendons.    When the rotator cuff tendons get frayed this causes inflammation which leads to further development of pain.  Finally, the third reason for pain is shoulder bursitis.  The shoulder bursa is a fluid filled sac which allows for smooth motion between the tendons.  This sac or bursa can become inflamed and cause a significant amount of pain and point tenderness over the shoulder.

One of the reason for shoulder pain in improper body alignment.  In order for the rotator cuff to work optimally, the scapula or shoulder blade needs to move properly against the back of the chest wall.  Often times, during an exercise routine, you focus more on strengthening certain muscles but not others.  This can lead to muscle imbalance and improper alignment.   In addition, it is important to select the proper weights which are neither too heavy, no too light.  Your muscles should start to fatigue after 8-10 reps of heavy weight lifting but your form should not alter.  If you find that your form deteriorating, then you need to choose slightly lighter weights.

In my personal experience treating rotator cuff tendonitis, it seems that the body has a remarkable ability to heal itself if given the time to do so.  Unless you have specific anatomy which predisposes you to tears and impingement syndrome, usually the shoulder will recover within 6-12 months without much intervention.

That being said, there are interventions which may help with symptom management and prevention of recurrence.   Surgery might be required if you have a full thickness tear, a partial thickness tear and are a high level athlete, or anatomical issues which will not correct on their own.

Generally speaking, rotator cuff tendonitis is treated with rest, ice, and anti-inflammatory measures (either medications or dietary changes).  Sometimes, a cortisone injection into the shoulder is helpful if conservative treatments fail.  In addition, treatments such as PRP (platelet rich plasma) are used to help with regeneration of tissue.   After the initial rest phase, which should be short, as you don’t want to create a frozen shoulder, progressive shoulder motion exercises are recommended.  Once you regain shoulder motion, the next step is strengthening the muscles which fix the scapula (shoulder blade) to the chest wall.

Exercises such as:

  • Punches
  • Shoulder shrugs
  • Rows

are recommended next because proper strength and alignment of these muscles will help to fix the scapula motion with respect to the chest wall.  After you have re-established proper motion and increased the strength of these muscles (such as the rhomboids, latissimus dorsi, trapezius, serratus anterior, pectoralis muscles, etc), then you can progress to specific exercises of the rotator cuff muscle.

The reason you are often referred for physical therapy is that therapists are trained in the proper progression of these exercises and can instruct/monitor you for proper form and technique.  In addition, modalities such as taping, heat, ice, ultrasound, phonophoresis (using ultrasound to help medications penetrate into the shoulder joint, and iontophoresis (using electric current to help medications penetratethe shoulder joint may be effective, though the research studies are equivocal for some of these treatments.    Finally using a shoulder brace may help however, it is important to remove it often to prevent a frozen shoulder.

If you have shoulder issues, make sure to get examined by a medical professional so that you can begin the appropriate treatments and start on the road to recovery.

Exercising With Arthritis

 

We have all different levels of fitness. Some individuals have been exercising for years, while other individuals have never exercised a day in their lives.  We are all at different levels in terms of our cardiovascular fitness, our muscle strength and flexibility and our overall health.   It is quite important to remain active in spite of arthritis.  In fact, movement in people with arthritis is crucial to health and well-being.

Despite what we once thought, it is my experience that it is possible to modify the severity of certain types of arthritis.   In my mind, arthritis, chronic pain and other autoimmune diseases are the result of multiple factors.  All these factors such as genetics, environmental exposures, nutritional deficiencies, dietary influences, and gut health to name a few factors, all line up as if you were to “win” in the slots.  When this potent combination occurs in your body, havoc ensues.   The result is inflammation and chronic disease.   While you can’t change your genes per se, it is now thought that you can change or modify your gene expression.  In addition, you can certainly modify some of the other risk factors just mentioned to offset the severity of your debility.

In most cases, moderate exercise is essential to health and well being.  Proper, varied forms of exercise raises heart rate, raises endorphins, improves muscle strength, improves balance, improves flexibility and increases blood flow throughout the body including the muscles and joints.  In the case of arthritis, there is inflammation in the joint capsule and the bones themselves which leads to severe pain and often deterioration.     The nerve endings in the joint become super sensitive and pain can be unbearable.

Believe it or not, your choice of diet can directly impact your ability to exercise. When you consume an Anti-Inflammatory Diet, often you will notice you will able able to exercise with less pain is because this diet eliminates many known triggers for arthritis.

 

Some examples of arthritis triggers include:

  • Fried and processed foods
  • Thought to be due to compounds called AGE – (advanced glycation end products) These products are the result of heating, grilling, and frying foods.  The body utilizes pro-inflammatory molecules called cytokines in an effort to break them down and the result is excess inflammation in general as well as in the vascular system (blood vessels).
  • Sugary foods
  • Dairy
  • Alcohol
  • Foods/Oils with Omega-6 fatty acids – such as vegetable oil (safflower), corn oil, fried foods, certain nuts and seeds, mayonnaise

 

Some examples of beneficial foods include:

  • Foods containing high levels of Omega-3 Fatty acids – (ex. salmon, herring)
  • Avocados
  • Flax seed
  • Cherries and other berries (contain anthocyanins that are thought to be anti-inflammatory)
  • Leafy vegetables, broccoli – contain vitamin D
  • Green tea – has EGCG (epigallocatechin-3-gallate) a powerful antioxidant
  • Vitamin C containing foods (ex. papaya, brussel spouts, broccoli, citrus fruits)
  • Garlic, onions and leeks

 

It is very important to listen to your body.  Pay attention to the foods you are eating and the way you feel.  Often times, foods that are considered healthy may cause issues for you.  If you suffer from arthritis, try rotating your foods (i.e. do not eat the same food everyday).   If there are certain foods you think might bother you, wait 3 days in between eating them.  Then pay attention to the way you feel when you re-introduce those foods.  If you notice you have more difficulty with pain or decreased ability to exercise try eliminating the offending foods for a week or two.

Typically, it will take several weeks of following the diet closely before you see results with regard to decreased pain from inflammation.

When exercising with arthritis, it is important to modify your exercises as per trainer recommendations.  If exercises hurt, if possible, discuss with your trainers to find another way to exercise that muscle group.  In the beginning, there may be some exercises you simply cannot do.  What is important is that you are attempting to exercise.  With each passing week you will find that you can do a little more than the previous week.  Progress may be slow, with ups and downs.  As always, if despite closely following the diet, you are still having issues, it might be time to seek the advice of a health care professional.

Plantar Fasciitis

Plantar fasciitis is a common cause of foot and heel pain. Typically this pain is located on the bottom of the foot just in front of the heel pad on the inner or middle side of the foot. The plantar fascia is a thick tendon that connects the heel bones to the toes. This tendon serves as a shock absorber for the foot and helps in supporting the arch of the foot. Overuse or excessive stress on this tendon can cause small tears that lead to inflammation and significant pain.

 

 

Some common risk factors for plantar fasciitis include:

  • Obesity
  • Poor foot mechanics
  • Improper shoe wear
  • Long distance running
  • Jumping exercises
  • Prolonged standing

Exercise regimens that consists of a fair amount of jumping or plyometric exercises are very good for cardiac conditioning and development of muscle power. Generally speaking the heart muscle gets conditioned faster then skeletal muscle. Therefore, your skeletal muscles will fatigue more quickly and your form will break down before you get exhausted due to deconditioning from the heart.

There are muscles on both sides of the foot and leg that help to support the foot and ankle. The peroneus longus and peroneus brevis insert on the outermost or 5th metatarsal (mid bones of the foot) and the tibialis anterior inserts on the inner or 1st metatarsal bone. When these muscles are strong and conditioned, they help with stabilizing lateral (side-to-side) foot motion and control the rate of movement in the foot during jumping exercises. If however, these muscles fatigue quickly or are not yet strong, the foot and ankle has more mobility and collapse in the arch, which in turn can put more strain on the plantar fascia.

This is one of the reasons that plantar fasciitis typically develops in an exerciser after several weeks or months of exercise. It generally occurs when the aerobic or cardiac conditioning out paces the skeletal muscle conditioning. In other words, your heart endurance allows you to jump or run for longer periods of time, but your leg muscles are not conditioned enough to control your ankle motion. If in addition to decreased muscle strength, you are carrying around extra weight, are wearing improper shoes, have poor foot mechanics or are increasing the amount of time or the intensity of your jumping, you are a set up for plantar fasciitis.

So what should you do?

It is important to know what type of foot you have and have the proper shoe wear before embarking on exercise and lifestyle changes. There are several very good running stores and even some online stores which will question you about your feet and recommend proper shoe wear. Podiatrist or Sports Medicine/Rehabilitation Medicine physicians are also useful for providing recommendations and treatment plans. It is important to note that not one type of sneaker is good for everyone. Sometimes due to foot or even hip and knee mechanics you will need an orthotic insert to place in your shoe.

In general, a helpful guideline for shoe wear and orthotic use is to fix what is too flexible (i.e put in arch support in a very flat foot or over-pronating foot) and to accommodate foot deformities that are fixed (i.e. relief or padding around bony deformities such as bunions). A common mistake is to over correct too much (using too rigid or too high an arch support). This can lead to other issues higher up the kinetic chain such as knee, hip or back issues.

Plantar Fasciitis is typically worst in the morning just after getting out of bed. Pain is usually severe with initial weight bearing and then subsides throughout the day with walking and weight-bearing. Pain can also be severe after prolonged sitting or immobility. It is often helpful to wear nighttime splints to keep the foot/Achilles tendon stretched out overnight. This will decrease the initial severe morning pain because the fascia will have more mobility and will not be able to scar down overnight.

Aside from using proper shoe wear and night time splints, occasional use of anti-inflammatory medications such as Motrin will be helpful. Adding anti-inflammatory foods such as turmeric, (curcumin), boswellia, and Omega-3 fatty acids in addition to decreasing intake of Omega-6 fatty acids may also be helpful. Icing can be helpful as well. Sometimes, despite the above interventions, you will might need a cortisone injection into the plantar fascia to decrease inflammation and pain.

During the acute inflammatory phase of plantar fasciitis, it is important to limit the activities such as high impact jumping and running that can aggravate the condition. Modify your exercise to limit jumping until pain resolves during activity and upon wakening. As pain decreases is it imperative to resume jumping/high-impact exercises slowly over a period of weeks to even months to prevent recurrence. As with all my recommendations, if you have persistent heel pain that is refractory it is important to seek the advice of a medical professional to make sure other modifications or treatments are indicated.