Turkish get-up high pelvis to knee

Stepping swing, high pull, press to elbow

Week three of kettlebell fitness at the Manchester, NH YMCA

Kettlebell swing and alternating floor press

Turkish get-up (first movement) and kettlebell deadlift

 

Knee pain and Muscular Imbalance

Knee pain is one of the most common problems encountered by runners and cyclists. Initially, most people, quite reasonably, are concerned they have injured themselves, tearing the infamous ACL (anterior cruciate ligament) or MCL (medial collateral ligament). Frequently, however, knee pain (particularly in runners and cyclists) is the result of long established imbalances between certain muscle groups. With these imbalances altering the mechanics of the lower limb, abnormal stresses are placed on the tissues. If the body is then asked to work harder than it is used to, inflammation and pain can result. Often, this pain can be surprisingly severe, leading one to wonder whether something serious is going on. Nonetheless, treatment to restore normal function to the limb, followed by therapeutic exercise, can bring quick resolution.  Non-surgical knee pain revolves around three structures. Two are muscles, a portion of the quadriceps (big muscles on the front of the thigh) called the vastus medialis (highlighted in red), and a little muscle the size of a finger, called popliteus, which runs across the back of the knee. The third structure is a broad sheet of connective tissue running from the hip to the knee, called the iliotibial band, or ITB (outlined in blue below). As a result of sitting most of the time, the ITB tends to shorten, and the vastus medialis tends to shut off.  Together, this muscle imbalance alters the function of popliteus, whose job is unlocking the knee after each step.

Changes in these three structures can have a couple of effects. First, in a repetitive activity like running or cycling, the now-tight ITB can become inflamed by friction.  This is usually labeled an iliotibial band syndrome.  Second, the kneecap may begin to track towards the outside of the knee, irritating the underlying cartilage.  This is usually labeled a patellofemoral pain syndrome (PFPS).  In many cases, I have seen this manifest as a severe pain directly behind the knee that comes about a mile into a run.  Third, both problems can be present (and usually are).  What's worse is that I have frequently seen these muscular imbalances injure the dreaded medial meniscus and medial collateral ligament (the MCL) by forcing them to work harder than they were designed for. 

So if you have these problems, what can you do about it?  You may think you can stretch your way out of it; unfortunately, the muscle imbalances usually throw off the mechanics of the joints in the low back, pelvis, and leg.  This makes other muscles stretch before the ITB.  Furthermore, it is very difficult to effectively target the tight muscles with stretching, because as they shorten, the fibers become glued together, in what are know as fascial adhesions.  These days, many people try using a foam roller.  While I have found them to be quite useful for patients as part of therapy, or to prevent these problem in the first, rolling is usually too painful, and not targeted enough to break up the adhesions. 

The best treatment for this is known as Active Release Technique (ART).  ART is a soft tissue diagnosis and treatment system which breaks up the adhesions by having the patient actively lengthen the muscle, while the practitioner uses their hands to trap the muscle in a shortened position.  While some patients may experience discomfort, the process also reinforces normal movement patterns, neurologically re-educating the patient.  With the ITB syndrome, the practitioner may decide to use ultrasound before ART treatment.  Ultrasound uses high frequency sound to soften the adhesions, allowing them to release with less pain to the patient, and less effort for the practitioner.  Finally, chiropractic adjustments are applied to the pelvis, leg, or low back, allowing the joints move freely within their normal range of motion.  This last piece is often under-rated, but proper joint movement is how the brain chooses which muscles to recruit.  If joints are disfunctional, then any exercise merely piles conditioning on top of dysfunction. 

The hard fact is that the ITB needs to be rolled, and other muscles need to be stretched regularly to maintain the body for repetitive movements such as running and cycling.  If all this is done correctly, and you have learned how to avoid the problem in the future, you can expect complete resolution. 

How does Chiropractic work?

I get asked fairly often by patients whether their problem is a muscle or a joint, and have to answer, "yes."  Making sense of that answer requires understanding a little of how chiropractic adjustments work.  The best way to think of things is as a two-way street between the joints and the soft-tissues.  The muscles are recruited by the brain based on joint movement, and joints can be restricted by tight muscles. 

There are two kinds of information coming from the joints to the brain.  The first is a position sense, called mechanoreception.  It tells your brain what position the joint is in, and is an important component of balance.  The second is what eventually becomes pain, a sense called nociception.  Only about ten percent of all nociception makes it to a conscious level, but nociception affects the nervous system regardless of whether conscious or not.  This subconscious discomfort is one reason people sometimes have trouble sitting still. 

These two exotic sensations are competitive for bandwidth in the nervous system. The more pain, the less position sense, and the more susceptible to injury person is because they can't feel where their joints are as well as they should be. Vice versa, the more position sense, the less pain, and the more stable, strong, and safe the body is. 

The traditional chiropractic adjustment is described as being high-velocity, and low-amplitude.  This means we move the joint very quickly over a very short distance.  This mechanically floods the nervous system with position sense, and therefore, abruptly decreases pain, increases stability, and gives the nervous system what it needs to properly recruit muscles.  However, some muscles remain short from scar tissue and continue to imbalance joints.  Breaking up the scar tissue using Active Release Techniques, along with chiropractic adjustments, can break the cycle.  Restoring function this way allows the body to do the healing, the way it was designed to.

10 minutes of hot yoga

There are two aspects to flexibility: one, how long your body thinks the muscles are; and two, how long they actually are.  This post will deal with the latter aspect. In my last post, the 5 essentials of a long athletic career, I referenced something I call 10 minutes of hot yoga.   If you're not familiar with it, hot yoga is done in a 95-105 degrees Fahrenheit room.   It's based on the idea that you must be hot enough that you're sweating to stretch.  In fact, you must be if you wish to increase the absolute length of your muscles.    However, if you have another activity you wish to do, such as endurance sports for many of my patients, or martial arts for myself, the two hours a hot yoga class requires (1:15-1:30 in actual class time, transportation and showering after) makes them inconvenient. 

My solution to this dilemma is break up that class.  Most busy folks budget a certain amount of time for exercise.   What you do then is schedule the last ten to fifteen minutes for stretching.  If you've been working out hard, you'll already be sweating and therefore hot enough to stretch.  This allows you some of the benefits of hot yoga in a convenient format.  If you exercise 6-7 days a week, and spend the last 10-15 minutes stretching, at the end of a week you've basically gotten a hot yoga work out in for free. 

What follows is my introductory lower body stretching routine.  While upper body stretching is a good idea, most folks have much tighter legs.  Before doing these stretches it is useful to soften the muscles with the foam roller.  How to do that will be dealt with in a future post.  Each stretch should be held for 30-60 per side.  If time allows, they can be repeated a second time. The first stretch is the traditional straddle stretch.  It hits the inner thigh muscles.  Please note that my hands are behind me supporting my weight so my low back doesn't round as I lean forward. 

 The butterfly stretch also hits the inner thighs but in a different way.  Again, my hands are behind me to support the low back.  This time, the stretch is done by using your hip muscles to push the knees done; don't use your hands or elbows as you may have seen in the past.  This just forces your low back to round.

Opposite the inner thigh muscles are the hip rotators, which you just used to push the knees down in the last stretch.  Sit in Indian style, then cross the left leg  over the right knee so that the left foot is flat on the floor.  Twist back to the left and simply hug your left knee into your chest with both arms.  Lastly, sit as tall as you can. 

The next, and perhaps, most important stretch is the lunge.  Take long left step forward with the feet on two parallel lines.  Please note that my right foot is on the ball, while still pointing forward.  Tighten your stomach to keep from arching your back, stretch your head up as tall as you can, and bend the left knee a bit.  If you're doing this correctly, you should feel a stretch essentially in the front hip pocket on your right leg. Now, you can add an upper body stretch, as in the second photo by reaching the right arm behind your head and grabbing it with your left.  This will also add to the hip stretch as long as your stomach is tight.

 Stretching the hamstrings on the back of the thigh is relatively easy.  Place your feet together and arch your back.  Think of lifting your kneecaps as you tighten the muscles on the front of your thighs.  With everything pre-stretched, lean forward until you feel the back of your legs tighten. 

Stretching the quads is the last piece for the lower body.  There are a lot of ways to do this, but my favorite is standing.  In the photo, please note that I've trapped my leg up against the wall.  This is done more easily if you have something you can rest it on, such as the side of a staircase.  Straighten up, and finally, add to the stretch by pulling your knees together. 

Move into these stretches gradually and carefully, making sure to start when you're sweating already.  Doing this routine 6 days a week means that you've stretched for a full hour every week.  Over the long term, that hour can transform your body.  Take care, and feel free to post a comment if you need some help.

How to keep doing what you love, or the 5 essentials of a long athletic career

Somewhere between age twenty and age forty, most active folks realize the activities they love are harder than they used to be.  It may be more difficult to sustain the same level of effort, take longer to recover, or one may simply not be as strong or limber as one once was (say that three times fast).  At that point, they have to make a choice: either, they work harder to do what they used to; or, they give up.  Fortunately, that second choice isn't permanent.  Later, we'll return to the effects of inactivity and how to undo them.  For the moment, however, I'd like to discuss five of the best ways to keep doing what you love despite the passage of time.  They are the dynamic warm-up, 10 minutes of hot yoga (daily), the foam roller, kettlebells, and proper recovery.  In the future, I'll dedicate an entry (or series of entries) dealing with each of these.  But for the moment, let's just sketch them out a bit.

The dynamic warm-up and 10 minutes of hot yoga have to do with the two major aspects of flexibility, how long your body thinks your muscles are, and how long they actually are.  The dynamic warm-up re-sets how long your body thinks the muscles are to their actual length.  10 minutes of hot yoga done regularly will increase that actual length safely and gradually.  The foam roller is the cheap and easy solution to the tight, stiff, sore, or achy muscles that come from regular activity that don't need the attention of a health professional.  Kettlebells are a form of strength training from Russia that allow one to undo muscular imbalances and increase stability.  Weight training was supposed to increase strength, endurance, and speed, but never actually quite produced those results; kettlebells do.  Proper recovery is composed of a number of things, but chief among them are enough sleep and the right nutrition at the right time.

That's a brief outline of the 5 essentials.  Future posts will deal with each in considerably more detail.  The foam roller, in particular, will involve a whole series of posts on how to use it for each major body part.  As they say, stay tuned...

Welcome to Artful Health

Thanks for visiting the Artful Health Blog, a service of Artful Chiropractic in Manchester, NH.  This blog will offer information about health and wellness, with an emphasis on fitness and exercise.  We'll be looking at different techniques for increasing strength and stability, maintaining flexibility, and avoiding injuries. Additionally, we'll also look at the types of biomechanical problems active folks run into frequently, such as shoulder pain, knee problems, and foot issues. 

One of my particular interests is what you might call "low tech, high concept" exercise.  This refers to the use of simple technology with complex movements.  Expensive exercise machines have generally failed to provide the improvements they were designed for, whereas far simpler devices, such as kettlebells, routinely outperform them.  The key with the "low tech, high concept" exercise is working smarter before you start working harder.  You have to know more, and importantly, you can't tune out while you're exercising.  High concept exercise requires you to be in the moment.  This also makes high concept exercise better for stress relief, as you really can't be preoccupied while you do it.  

Along the same lines is the crossover between Artful Health and martial arts.  As a long-time martial arts practitioner, I see many overlaps between my clinical work and the various martial arts I practice.  Even if you're not a practitioner, learning about these can be very useful to improving your own expression of health.

Finally, I welcome your questions and comments.  Feel free to suggest a topic you'd like to hear more about.  That's all for now.

Steve Baroody, D.C.