The following is a picture that shows the four things I look for first when I'm looking at someone with mid back, shoulder or neck pain. I've found that if any one of the four are uneven, most adjustments to the spine of the mid back and neck won't last very long.
The orange line is the medial border. This should be vertical. The green line is the horizontal border. This should be even. The blue line is the distance between the spine and the medial border. This should be equal. The grey arrow indicates that the shoulder blade should be sitting square on the thoracic rib cage. Often you will find one tipped forward.
Only after all four indicators are level will an adjustment, in my opinion, hold its value so to speak.
I find the green line affected most by the latissimus dorsi. The orange line by the rotator cuff muscles, the serratus anterior and levator scapulae. The blue line by the rhomboid group. The grey line by the pec minor. Of course these are all generalizations. But it's a great starting point to quickly gain a thought process in treatment.
The quadratus femoris is one of the six hip muscles that provide external rotation. It is the most inferior of all of them. The QF is a rectangular shaped muscle that attaches to the anterior ischium (sit bone) and the posterior greater trochanter. The sciatic nerve often lies on top of this muscle.
The function of the hip rotators is to provide stability to the hip joint. If they present as continually tight in an athlete or patient, this is a sign that the hip joint isn't being centered and the hip rotators are always "on."
The QF is also a lateral rotator in flexion and extension.
Because of its attachment points there is a fascial connection to the biceps femoris, sacrotuberous ligament and adductor magnus.
I have found that it can significantly limit hip abduction. After the QF is treated, hip centration improves and better function out of the glute medius and minimus is achieved. It can also significantly improve active straight leg raise.
The sub occipital muscles consist of the Superior Oblique, Inferior Oblique, Rectus Capitis Posterior Major and Rectus Capitis Posterior Minor. All of these muscles can contribute to headaches when tight or short. A very common headache comes from an entrapment of the greater occipital nerve in the Inferior Oblique.
Now an often overlooked contributor to headache is the Rectus Capitis Posterior Minor (RCPMinor). It has connections to the posterior arch of C1 and travels up to the nuchal line on the occiput. Often overlooked and I believe very important is that it also has connections into the spinal dura.
These connections seem to somehow help monitor the cerebral spinal fluid. We do know that all the sub occipital muscle have loads of muscle spindles in them to provide proprioception to the Central Nervous System.
If the RCPMinor becomes tight the atlantooccipital joint is not as stable. Proprioception will be hindered and perhaps most importantly, cerebral spinal fluid will be altered.
On a personal side note, every person/athlete I have ever treated post concussion have had extremely tight RCPMinor and Major.
If you receive treatment or seek treatment for cervicogenic pain or tension headaches, make sure to ask about the RCPMinor.
I'm a pretty big advocate of using a foam roller to help free up tissue, even if some people claim it's for a very small amount of time. My views on this. If one uses the new range of motion within this time frame, one gets stronger and gradually increases the tissue quality in that new ROM.
Is there a difference in the method one chooses? I believe there is.
There are things called mechanoreceptors in your muscles, ligaments, joint capsules and fascia. They respond to different pressures, frequencies and oscillations. A few of these mechanoreceptors are called ruffini, pacini and interstitial receptors.
Ruffini (type 2) respond to deep sustained pressure. This would be where the foam roller would be of most value. It has the ability to inhibit the sympathetic nervous system. When a muscle is tight or short, this is a good idea. In the therapy world, myofacial release and massage would be of high value. Our central nervous system receives the most input from the myofascial tissues. (more then eyes, ears, skin)
Pacini receptors respond to vibration and rapidly changing pressure, many think a high velocity low amplitude adjustment (HVLA) common in chiropractic, stimulate this form. This would also be where the vibration would be of value. The biggest benefit to this is an increase in proprioception and kinesthesia. One becomes more aware of posture and where one's body is in space.
Another home therapy tool is a popular product called The Stick. This does the least amount in terms of therapy in my opinion. It mostly just stimulates afferent impulses from the skin. Similar to using a vegetable brush. This would be something you could use to rapidly run across muscles before a lift or immediate activity.
The interstitial receptors are the newest receptors discovered. They are further classified into Type 3 and Type 4. These in fact make up the majority of your muscle receptors at about 80%. In the past they were thought to perform pain reception as they terminate in free nerve endings. They are now accepted to be primarily mechanoreception, so they respond to pressure and mechanical tension, along with pain reception. They also seem to have a huge influence on fluid dynamics.
The Interstitial receptors respond to slow deep sustained pressure, just like the ruffini. So again the foam roller becomes the go to method. It has been shown that their stimulation increases parasympathetic activity. Global muscle relaxation is the outcome. This is the goal for most people dealing with chronic pain, loss of ROM or increased recovery.
The Thoracolumbar fascia (TLF) is an important structure for movement and stability in the human body. It intimately blends the latissimus dorsi with the gluteal complex, thus linking the arm to the leg.
In the awesome book, Fascia by Schliep, it is suggested it also has a few more roles. It is a sheath around muscles to reduce friction, facilitate blood return to the heart, provide an exoskeleton for other muscles to attach and finally, to protect blood vessels from mechanical damage.
It is finally being researched as a potential pain source for "non specific low back pain." For that to fit the bill it would need to contain enough sensory fibers. Even in 2006, this was not even thought to be looked into. Recently, experiments have been conducted on animals and the data is showing that there are indeed enough sensory fibers to convey nociception (pain.)
What I found most revealing about these experiments was that the researchers concluded that DOMS (delayed onset muscle syndrome) showed in human trials the fascia around the over exercised muscle become more sensitive then the actual muscle.
A way to train this I believe is a take away from Mike Boyle's book "Advances In Functional Training."
Force is transmitted from the ground through the leg to the hip via the biceps femoris (hamstring) and glute max. The force is then transferred across the SI Joint into the opposite latissiumus dorsi. For this reason, all rowing motions except the inverted row are performed with only one foot in contact with the ground. One foot on the ground and the load in the hand opposite that foot, the athlete must now engage the biceps femoris and glute to transfer force from the ground via the pelvic stabilizers and the hip rotators. (big thanks to Stu McMillan for sharing his notes with me) PS. make sure to check out his blog.
In doing the above mentioned, you will be strengthening the Thoracolumbar fascia.
The Pyramidalis is a very small triangular shaped muscle that originates off the pubic crest. Its function is to tense the linea alba. The line alba is the line in the rectus abdominis.
Fascially, this muscle I believe holds important tension relationships between the adductor fascia and the abdominal fascia.
It is essentially a crossroads between the opposite adductor and the opposite oblique muscles. This is sometimes referred as the anterior oblique system.
Find your belly button. Slowly palpate lower until you hit bone. You will be on the pubic crest. Slowly rub back and forth. One side is usually more tender. This would be the one to target. This muscle can play a contributing factor to pubic area pain, abdominal pain and groin pain. Hockey and soccer players will often present with this.
I usually have the patient or athlete do this on their own as it's in a pretty sensitive area.
This weeks continuation of small but important muscles that can create unusual pain is the Popliteus. This small muscle is a triangular shape that is on the back of the knee. From the picture you can see it has attachments on the tibia, the fibula and also onto the lateral meniscus. Fascially it sends strips into the arcuate popliteal ligament.
Functionally, its action is to "unlock" the knee. When the foot is on the ground as in walking and running, it laterally rotates the femur to allow flexion to happen. It's a very weak flexor. With the thigh fixed, leg free to move, it rotates the tibia medially. (think sitting) It's also a big player in keeping the femur from tracking over the tibial plateau when weight bearing.
I have found a lot of knee pain can occur when this muscle is tight that will mimic a lateral meniscus sprain. It is usually more present with running downhill or going downstairs. It's also a player when a patient/athlete can't quite achieve full leg extension. They usually don't even realize they have lost this last 5-10 degrees of motion.
We are born with lots of muscle spindles in this muscle. This means the brain is using this muscle to let it know what the knee joint is doing in space. I believe if it's tight, we lose some of this kinesthesia for the joint.
Females need to get out of high heels when this is tight. Essentially you are walking downhill with each step. This will just aggregate symptoms.
If you back of the knee pain that gets worse with downhill type activities think Popliteus.
Once a week, for the next few weeks, I am going to highlight one small muscle that is often overlooked in treatment for pain and body dysfunction. I have found, through clinical practice, these muscles can have big dividends in return to play/life pain free.
I guess my definition of small and overlooked is a muscle you don't target to train in the weight room. The first muscle I'm targeting is the Anconeus. Whens last time you've heard, "I'm training my Anconeus today."
I call this muscle the triceps little helper. It has attachments on the lateral epicondyle and the olecrenon of the ulna. Like the triceps, it helps to extend the elbow, but I believe this is a very minor roll.
It, along with the medial triceps head and supinator, helps stabilize the elbow in pronation and supination. It accomplishes this by abducting the ulna in pronation. EMG has revealed that it contracts with all index finger movement.
Another crucial role, with elbow extension, it pulls on the joint capsule to keep it from getting pinched. (Things that can alter joint capsules, I'm starting to believe have more important roll in pain management. Muscles that stabilize, as other things move, I think also have a vital roll.)
If you are dealing with lateral elbow pain as therapist or athlete, don't forget this muscle. Small, but important.
I recently had the chance to have a few long conversations with a podiatrist that is pretty famous in my area of Grand Rapids, MI. He long ago quit doing surgeries in favor of adjusting the bones of the feet to provide "long lasting relief."
He said it came from doing "to many surgeries for a bunion or neuroma and seeing it come back a few years later."
His explanation for how he thinks a neuroma develops is one of the best I've heard. My personal understanding was that the common neuroma between the 3rd and 4th digit of the metatarsal was from the compression that happened from a tight toe box in a shoe. He extrapolated on this concept.
When the cuboid bone becomes misaligned, the foot on impact can no longer lock the lateral line of the foot for stability on impact. This allows for the foot to actually increase the degree of pronation that occurs. Now, because of this the metatarsal bones rotate. The lateral 2 rotate laterally, the medial three rotate medially. With this the plantar nerve is put under quite a stretch, thus irritating it.
Your body has an ingenious way of protecting itself. It grows a protective coating. Picture, scraping your hand every day. What happens? A callous forms. Irritate the plantar nerve with each step, a callous will start to form around that structure. You get a Morton's Neuroma.
Here is a very interesting article that I was given about half a year ago. If you work with athletes and patients it's a great article to save and read. It's called "The Architecture of Connective Tissue."
It challenges the notion of how ligaments, muscles and tendons tie in and relate to each other. The old standard of tissue in parallel is not correct, they are in series.
I was reminded of it the last few days because I found this video on Youtube that highlights a bit of what the article covers. Very interesting stuff. Take away this quote, "What you see in Netter (anatomy book) isn't there. Enjoy!
Here is about as cool of a photo that I've come across in terms of showing what you can do with staying strong and active as you age. I've talked before about carrying muscle into your later years is your Health Insurance Policy. Stay strong. It would be very cool to see this study with a weight lifter.
For the past few months I have been working on a small theory with the triceps muscles. I see a lot of shoulder type injuries in my office here in Grand Rapids. Everything from frozen shoulder, rotator cuff inhibition, labral surgeries and impingement's. One thing I've started to notice is that the long head of the triceps is weak and under developed and that the medial head has adhesion's.
Let's review a little anatomy. The triceps brachii has three parts, hence the tri. The bicep has two parts, hence bi. Want bigger arms, do triceps work, 2/3 of your arm is triceps. The triceps is made up of the lateral, medial and long head. The lateral head, most outward portion, gives the famous horseshoe shape seen on people. The medial portion is in the middle, and lies underneath the other two. These two portions attach from the humerus into the ulna. The last portion is the long head, you guessed it, the longest of the triceps. It's the most medial. What makes this muscle different is that its origin is actually into the scapulae. All three will extend the elbow, but the long head will actually adduct the arm in a similar fashion as the latissimus dorsi.
So back to my observations. After doing soft tissue work to the medial head, it usually brings a feeling of lightness to the shoulder or elbow joint. I am starting to view this muscle as an upper body shock absorber, in the same fashion the vastus lateralis is a shock absorber for the lower body. (This is why triceps strength is big time important for mountain bikers!)
Now in people that don't have shoulder issues, but do lots of overhead work, pressing, or throwing or the patients/athletes that bounce back quicker, the long head seems more well developed. The long head may have fascial anatomy with the teres minor muscle. It is considered part of the deep arm line in anatomy trains research. Having strong connections with the rhomboid muscle. Functionally, the long head works to keep the under part of the shoulder joint stable. It works to prevent displacement of the humeral head down and back.
The long head will not work in simple pressing exercises. It is actually pretty dormant in standard pressing and overhead work. The long head needs to be stretched to get a full workout. Its secondary function as a humeral adductor allows it to get good work in with doing back work. To isolate the long head, doing an exercise such as a skull crusher with combined pullover type movement, has proven to be effective.
Here is Arnold doing a famous bodybuilder pose. The under hang is the development of the long head. I would bet that Arnold didn't have many shoulder problems!
Regardless of whether you have been injured by an acute accident or have been diligently damaging the tissue through repetitive activity, certain muscles will always get inhibited when the joint sustains some type of trauma. Macro or Micro.
Trauma or dysfunction to the neck will allow the deep neck flexors (longus coli, longus capitus) to become inhibited. They are your cervical stabilizers. When they don't pull their weight, you're looking at the scalenes and levator scapula becoming tight.
Shoulder trauma will almost certainly bring about inhibition of the subscapularis. Subscap is one of the 4 rotatore cuff muscles. Often the other rotatore cuff muscles (teres minor, infraspinatous, suprasinatous) will become tight.
Low back dysfunction/trauma will shut off the deep multifidi muscles. We are learning more and more about this muscle. It was once thought that it had rotatory capability. We now know it's primarily flexion/extension and that its primary roll is proprioception. Sometimes the errectors will tighten to stop movement.
I also see lots of glute max inhibition with lower back pain. It's hard to say if it was there before the injury though. Needless, it needs to be addressed after low back dysfunction.
Knee trauma is always followed by the inhibition of the vastus medialis oblique. VMO for short. This little tear drop shaped muscle plays a healthy roll in patellar tracking and in proprioception. It will call on the muscles of the pes anserine to tighten up to help out with medial stability.
Ankle trauma will have peroneal muscle inhibition. This guy is part of your lateral stabilizing unit. It also has a big roll in proprioception. When you feel like you have "weak ankles" this muscle isn't stabilizing you.
You may wonder why your body automatically inhibits certain muscles. The answer is it's trying to save your joint. If it doesn't provide the information and stability to the joint, it thinks you will hopefully stay off it.
When you continue to use it, that's when the onion of compensation starts to grow. Other muscles get tight. That's why when you are working on someone or being worked on, you fix one thing, and another thing shows up. Pealing the onion back to get to the original problem. You constantly stretch a muscle that in reality is staying tight to help you. So understand that stretching something that is tight, may in fact be doing more damage then help.
These are the main guys I see with joint trauma and weakness. Next week I will go over some recovery strategies I use to help break the compensation patterns.
The interossei muscles of the foot have two layers, a dorsal layer and a plantar layer. They are conveniently named dorsal interoseus and plantar interoseus and are the deepest layers of the foot. (There are four layers.) There are four dorsal and 3 plantar muscles.
They lie between the metatarsals and have some interesting properties. The first dorsal interoseus has attachments into the peroneal sheath and some have attachments into the long plantar ligament. They have extensive fascial connections into a lot of soft tissue around them.
Why is this important? In two words, Shock Absorption. Warren Hammer describes it best. During gait, at forefoot strike, the metatarsals spread out, this in turn loads up the mechanoreceptors in the interossei muscles.
The information relayed from the mechanoreceptors in the interossei muscles as they spread out cause a reflex contraction of the quadriceps. This contraction stabilizes the lower extremity muscles. This is known as the positive supporting reaction.
This is one reason barefoot running has been such a boom lately. Why you hear such revelations about all of a sudden after going barefoot, my lowerback pain is gone. Hip pain is gone. Calf pain...ect.
Ultimately, what you can take away from this can be summed up with one recommendation. Don't wear tight shoes that don't allow your forefoot to expand. Without room for the toes to spread, the initial impulse from the interossei muscles don't occur and ultimately shock absorption is inhibited.
We all know the importance of the side hip muscles glute med and glute minimus. Did you know that although they are hip abductors in isolation they functionally stabilize the pelvis while you run and walk?
Today's post is about the difference between these two muscles and how the tricky rectus femoris (quadriceps) muscle can sometimes get mixed up with one of these guys. (glute min)
The rectus femoris can sometimes have a 3rd head. I know! News to me too. It's not all the time, but worth noting. All of them with 3 heads had attachments with the glute minimus onto the greater trochanter. This suggests a working relationship.
Not only is the glute minimus and abductor and flexor, depending on the hip position it is an internal and external rotator. The glute min also has attachments into the hip capsule. They retract the hip capsule preventing capsular impingement.
The more the hip is brought into flexion the more the anterior portion of the glute min becomes an internal rotator.
From all this it appears that the main function of the glute min is to stabilize the hip while in extension. It does this functionally with the posterior part of the glute min.
Now how does this affect the runner with hip pain? First distinguish where the pain pattern is. Hip flexion, or extension? Under load, passive or active? Feeling of weakness with foot strike? Pinching with hip flexion? Know the anatomy and function and you can figure out whats not working that can be leading to pain.
Runners as a group have weak hamstrings. Most don't run fast enough to really strengthen them. How many times have you went into a weight room and seen a long distance athlete train hamstrings or posterior chain work? I can tell you, hardly ever. I have seen some elite distance runners living in Chula Vista, CA Olympic Training Center train them. But, that type of attention to detail is one of the reasons they are there.
Sprinters can sometimes run to fast and strain them. They have the opposite problem. They may train them, but train them improperly, or think they have trained them enough to run mid 10's in the 100m.
The hamstrings are made up of three muscles, semitendinosis, semimembranosis and the biceps femoris. The biceps femoris is actually two muscles, long and short and actually have two different nerve innervation's. The adductor magnus, a huge muscle, is often times referred to as the fourth hamstring and should be trained as such.
Charles Poliquin believes that the hamstrings are mostly fast twitch and should be trained with 3-6 type reps. His take on coming back from a hamstring injury are first rate in my opinion. Usually you do a lot of reps so that fatigue doesn't come into play. He reasons that it is the fast twitch fibers that get strained. As such it is these fibers that need to be strengthened using heavier weights and lower reps.
Franz Bosch, a biomechanist, wrote the book Running: Biomechanics and Exercise Physiology in Practice. This is a great book! I highly recommend you own it if you work with runners and sprinters.
He believes before weights or reps are thought about, coordination is obtained. This simply means the exercise is done technically perfect, correct tension is maintained on the hamstrings at all times, control over the speed when reactive work is done, and any synergistic muscles that work with the hamstrings are working correctly. The big take away is the hips and knees must be working together correctly. He believes that that the majority of exercises should be done standing knees extended with the weight shifting though the hips as this stresses the hamstrings the best.
As a general rule, if your standing on two legs doing an exercise it is the dorsal muscles (erectors) that are the limiting factor, when you switch to one leg, it becomes the hamstrings. So one legged variations are a big theme if you want to attack the hamstrings. Just try a single leg back extension. You will feel the difference.
Here is Oregon Strength Coach Jim Radcliffe demonstrating one of these qualified exercises. I read Jim say he once got on a plane and took the red eye back just to hear Franz Bosch present for an hour. Anyone that has seen Oregon play football this year, knows that his athletes are fast and explosive.
I was reading a few weeks back and came across this interesting study about Chronic Back Pain. Basically they took 26 people with chronic back pain. For every year of chronic back pain they had an average loss of 1.3 cm cubed loss of gray cortical matter. Patients with chronic back pain had 5-11% less neocortical gray matter volume than controlsubjects. This amount was the about the amount of thegray matter volume lost in 10-20 years.
I'm sure with most studies you have to consider a few things. There is awesome new research showing how exercise and aerobic fitness can increase new brain synapses and brain health. So the first thing that comes to mind is were these subjects sedentary? Could the lack of movement or exercise, if it was applicable, contribute a large portion to the decrease gray matter rather then just the chronic pain?
Either way, chronic back pain is something that should not be put up with. Find some help. Get a good hands on manual therapist and start incorporating smart exercises that will help the back for the long term.
The Tibialis Anterior is the thick muscle on the front part of the shin. It is the primary dorsiflexor of the foot. Last years Performance Enhancement Seminar in Indianapolis, Mike Robertson, stated that it's the least trained movement in training.
Anatomically it originates off the upper lateral half of the tibia bone and off the interosseus membrane. It runs down and inserts on the medical cuneiform and first metatarsal. It functions to hold up the medial longitudinal arch and dorsiflex/invert the foot. It forms a fascial sling with the peroneal muscles as well. It is innervated by the deep peroneal nerve, L4,L5.
Functionally it resupinates the foot thus helping hold the arch up. If it doesn't perform that function well, the deeper calf structures such as tibialis posterior take up the slack and can in turn develop deep knots and tightness. Again, one of the prime maxims of therapy, treat the body, not the site of pain.
I came across a great article entitled the Neuro-biomechanics of Sprinting. In the paper it stated that faster sprinters sent the message to the anterior muscles to dorsiflex faster, and slower sprinters sent the message much later. Some of the faster sprinters even sent the message during the midstance phase. They state. "This finding further validates the concept of anticipatory firing or reprogramming the athlete's nervous system to send the dorsiflexion message sooner."
From a therapy standpoint, I like to try to remove all adhesions in the tib. ant. muscle as well as the extensor hallucis muscle. From a strength coach view, I'm playing with different ideas on how to get that neural reprogramming in the weight room. Can it even be done? Do you have any drills/exercise you can do in the weight room to facilitate better dorsiflexion that will carry over to sprinting?
Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults.
That is the title of the article in pubmed that looked at people with shoulder pain, but absolutely no neck pain. After the neck was examined and adjusted, the painful abduction arc of the shoulder was reexamined in different people and it was much better in terms of ROM and in a pain scale. It goes to show that the body is one piece as Dan John is fond of saying. Treat the body, not just the pain.
Looking at groin pain from a different view point can many times be helpful. There are a lot of different mechanisms of injury that can cause pain/dysfunction in the adductor group. One that is often ignored or quite simply not know about is the fascial role the rectus abdominis (RA) can play.
The fascial sheath of the adductor muscles is tensioned proximally by muscular fibers from the RA. The RA inserts at the pubic crest. A small medial strip of the tendon from both sides crosses in front of the symphysis pubis and fuses with the fascial sheath of the adductor muscles.
Thus, if you have some adhesions or shortening in the RA muscle, (think countless crunches) you can develop an adductor dysfunction. An example is an athlete cutting where the adductor really has to stabilize. When this happens your "core" muscles are really fighting hard to prevent motion, so if there is a tightening in the RA there will be an abnormal amount of tension pulling into the adductor. Recipe for groin pain. Another great reason and scenario to look at the whole picture, not just where you're feeling pain.
