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Lumbo-Pelvic Stability
8 March 2013, 3:42 pm



Welcome to the first post. I'm interested in any feedback, questions or suggestions for future posts...

Over the winter a few folk mentioned to me that they’d been getting some lower back pain when doing core stability exercises – leg raises and what not. I sort of have half a mind to do an article at some point about lumbar spine/pelvic stability. Thought I’d put some stuff on here and (hopefully) get some feedback, and maybe one day put it into a more structured form. The essence of lumbo-pelvic stability is that if you can’t control the position/stability of your lumbar spine when, for example, doing leg raises/planks, you’ll transfer a LOT of shear force across the lumbar vertebrae, which will result in pain. We have a system of muscles that allows us to keep our spine still when we are moving our limbs – simple. However, during strenuous movements we tend to ‘use’ spinal movements to initiate limb movements; when we get tired, we are simply unable to stabilise our spines, leading to ‘give’, and often pain.

Therefore, there are two important aspects – decreasing the likelihood of pain/injury, and making sure we are targeting the muscles that generate movement/power, not using spinal movements to compensate.

Aims:

·        Understand the anatomy of the spine, and what constitutes ‘normal’ spinal alignment.

·        Understand how to alter and monitor spinal alignment.

·        Understand how abnormal spinal alignment and lack of control can produce pain.

·        Understand how to control spinal stability during training, to make sure we are targeting the muscles we want to actually train.

There is a bit of a caveat here: when you are trying a boulder problem, and trying to get your foot on a distant hold, the aim is NOT to concentrate on trying to keep your pelvis still – do everything you can to get that foothold. However, when you are training and doing your leg raises, by using correct form/technique, you will minimise injury risk and increase training effect on the muscles you want to train.

So, a bit of basic anatomy.Look at the three pictures below. The triangle is the pelvis, the curved line is the spine. The first picture shows lumbar neutral – the pelvis is flat, the spinal curves are smooth and natural. The lumbar and cervical spine show their natural forward curve (lordosis); the thoracic spine shows its natural backward curve (kyphosis). The second picture demonstrates a posterior pelvic tilt, which removes the lumbar lordosis, increases the thoracic kyphosis, and hugely exaggerates the cervical lordosis. The third picture is an anteriorly tilted pelvis. You can see it leads to a very tight bend at the base of the lumbar spine.



These altered curves put increased compressive and torsional stresses on the vertebrae, joints, ligaments, discs and other structures, depending on whether  they are on the ‘inside’or ‘outside’ of the bend.

Most of us, when we sit – on a sofa, driving, at a computer– go into a slumped posture. This is a posteriorly tilted pelvis (picture 2), which pulls the lumbar spine out of its natural lordosis. This is why, when we stand up (after prolonged sitting) or get out of the car our lower backs feel very stiff and achy. The other problem with this posture, is that it exaggerates the thoracic spine kyphosis, which results in two things: 1) Increased tension across the thoracic spine and 2) a ‘poking chin’ posture – in order to look forwards we need an exaggerated bend in the base of our cervical spine (neck), which causes pain there too. It also alters the biomechanics of our shoulders, increasing the likelihood of shoulder instability, but that’s something for another day…

At other times, for example when lifting, or doing leg raises, we use lumbar spine extension – exaggerating the curve at the base of the lumbar spine – to initiate movement. Similarly, when doing ‘plank’ type exercises or press-ups, we allow our pelvises to tilt forwards, again exaggerating the curve at the base of the lumbar spine.

Basically, if you can’t control the position of your lumbar spine, you are likely, at the very least, to have localised pain, which will limit your training and make it less effective.

What can we do about it?

The first exercise is about teaching your brain what is actually happening back there. There is a thing called proprioception – our brain’s ability to know the position of a body part without seeing it (we know whether our elbows are bent or straight with our eyes closed, for example). However, most of us have very little proprioceptive awareness of our lumbar spine/pelvic position.

Exercise no 1: The Pelvic Tilt

The easiest position to try this exercise is in ‘crook lying’ – see the video. Basically, you are trying to tilt your ‘hip bones’(iliac crests) backwards and forwards. You shouldn’t feel that your abdominals need to work. It should feel very easy in terms of effort. At first, you may feel you need to concentrate quite hard! When you can do this in crook lying, try it in sitting – on a dining room chair or something flat and solid. The aim is to do it without moving your shoulders/thoracic spine. Either holding your iliac crests or placing a hand in your abdomen and lumbar spine (see video) will allow you to monitor the movement.

Just doing this periodically when you are driving or sitting at your computer can be very soothing and prevent that all-encompassing ache when you finally get up.

There is also a thing called ‘lumbar neutral’, which is kind of the ‘optimal’ position for your lumbar spine, (There is no ‘optimal’position really, it is a very dynamic, complex set of joints which actually need to be kept fairly mobile) and it is the position that you’ll need to be able to control when doing the core stability exercises. To find lumbar neutral, tilt your pelvis forwards (sit up) as far as you can comfortably, and then backwards (slump down) as far as you can. Do this a few times, and then stop in the position that is about a third to a half of the way down.

Again, once you have it mastered in sitting, try it in standing. It looks a bit creepy, but if you have a job where you do a lot of standing, it can help to relieve low back pain. Again it is essential that you can find and maintain pelvic neutral in standing for many of the core exercises. If you do any weight training, it is the position you need to maintain to protect your back, and to ensure you are using the muscles you want to use. Cyclists, it is a good habit to practice pelvic tilts on long bike rides, to ease lumbar spine stiffness.

Muddying the water.

Unfortunately, it’s not as simple as all that. There are a few muscles attached to the lumbar spine and pelvis, and over time these will have adapted their lengths to your normal resting postures, so you need to do some stretching as well! The main culprits are the hip flexors and the hamstrings.

A habitual anteriorly tilted pelvic position will result in shortened hip flexors, so you need to stretch them. They attach directly to the lumbar spine, so if they are short they will put direct tension on the lumbar vertebrae. This is why many people get back pain when they lie flat. It is also why activation of the hip flexors, when doing leg raises, causes lumbar spine pain if their action is not countered by good core stability. See the stretch below – it incorporates a pelvic tilt, so you need to know how to do it.

The hamstrings are connected to the pelvis. If they are tight, they will pull the pelvis into posterior tilt, particularly with the legs straight out in front. Doing L-sits for example – the hip flexors are working overtime to keep the legs up, and they’re pulling the lumbar spine one way; the hamstrings are on tension and are therefore pulling the lumbar spine the other way. A recipe for pain. Again, make sure you stretch them.

OK, where are we? We can control our pelvic position, our hip flexors and hamstrings are nicely stretched. Now for a few very simple (not easy) exercises to help understand the concept of core stability.

It is not:

·         About working your abdominals, getting a six pack and doing front levers (although it may help with that)

·        About working yourself HARD.

It is about:

·        Learning to control the position of your lumbar spine while you move other parts of your body, lift things, hold positions.

·        Gradually increasing that level of control, so that ultimately, you can do very strenuous core work without having a negative impact on your spinal well-being.

Exercise no 2: Single leg lift-outs

This is really to demonstrate the mechanics of lumbar control, and to teach your brain the concept of maintaining spinal position while carrying out another task.

·        Lie down on the floor in the crook lying position;

·        Find lumbar neutral – flatten your back against the floor;

·        Lift both feet off the floor – you should feel that this would cause your lumbar spine to arch away from the floor if you didn’t counter it – do so. Keep your back flat against the floor.

·        Slowly, extend one leg – keep that back flat on the floor. If you feel your back arching, bring the leg back.

·        Once the leg is fully extended, bring it back and do the same with the other leg.

·        If you found this easy, do the same thing with both legs together, but don’t allow your back to arch.

·        Hold the extended position for a count of 5, return and repeat.

·        Stop before failure, only go as far as you can without your back arching.

Exercise no 3: standing single leg lift

This, again, is about demonstrating how we usually use spinal movements to initiate limb movements, and is about teaching your brain how not to do this. It will also give you the movement pattern for controlling lumbar spine position when doing leg raises.

Before you start this exercise, try this: In standing, without thinking about the movement, lift one knee up towards your chest. Now do it again, in the same way, but thinking about what your lumbar spine is doing. I imagine you flexed forwards when lifting your leg up, and extended when you brought your leg down.

Here’s how to do it while maintain lumbo-pelvic stability:

·        Find lumbar neutral in standing.

·        Slowly lift one knee towards your chest, concentrating on keeping your lumbar spine still. Only lift as far as you can without flexing forwards.

·        Make sure you maintain the lumbar spine position all the way down – do not arch your back as you lower your leg.

·        Repeat with the other leg.

·        If you found this east, try with a straight leg.

Next time you do leg raises, whether on a pull up or dips bar, try to think about keeping your lumbar spine still.

Exercise no 4: Waiter’s Bow

This is a ‘warm-up’ exercise for the plank. Forgive me for being boring, but it is about learning to control the position in a ‘non-strenuous’situation, and converting it to a strenuous situation. It is surprisingly difficult, for such a conceptually simple movement.

·        Find lumbar neutral in standing.

·        Simply bend forwards from the hips, i.e. keeping the lumbar spine still.

·        Make sure you do not extend the lumbar spine as you straighten up – this is the most difficult part!

·        Again, only go down as far as you can, before you ‘lose’ the stability.

Exercise no5: The Plank/press-ups

OK, you’re ready for the plank. It’s an idea to do some press-ups, again to get your proprioceptive system firing. Just get in the press-up position, and do some press-ups without letting your lumbar spine move.

Now try a plank – do some pelvic tilts in the plank position– and find pelvic neutral. Make sure you maintain this position, and don’t allow yourself to drift into anterior pelvic tilt (increased lumbar spine lordosis). A good way to do this is to actively contract the muscles in your buttocks.

That’s probably enough for now. Practice the pelvic tilts, and think about your pelvic position when you’re driving, sitting at your computer or watching TV. Think about your lumbar spine position when you’re doing any core exercises. It should improve pain, if you get any, and allow you to work the muscles you want to more effectively.I’ll try and put some progression exercises up if people are interested. Any feedback gratefully received (yes, I know, the videos are awful!)

Source: Physiotherapy for Climbers

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"Elbows" - an introduction
24 March 2013, 7:21 pm

Climbers' elbow, Font elbow, tennis elbow... the perennial, unresolving bain of many a climber causing pain, limited training, years passing by. Sound familiar?

Disclaimer: self-diagnosis and treatment via the internet is not a recommended way of solving your problems. If you have on-going, persistent, or any sort of troublesome injury, you should seek face-to-face professional advice. You'd do it for your car, do it for your body.

This post is meant to be "educational", and perhaps give you an understanding as to why self-diagnosis of "tendonitis" (the default self-diagnosis from what I can tell), and the resultant mis-treatment, unsurprisingly, leads to non-resolution of a seemingly simple problem.

Furthermore, this stuff is NOT evidence-based - it is my theory as to the common cause of 'Font elbow'. Anecdotally it seems to hold some water, and the advice on how to prevent it is good advice anyway, and ought not to do you any harm!

It is a huge subject: the complexity of the physiology of the cervical & thoracic spine, the shoulder girdle, the actual shoulder (gleno-humeral) joint and the arm means that problems breed problems - biomechanics veer away from 'normal', resulting in compensations, altered movement patterns and structural changes. I'm going to try and tackle the subject as a series of short posts - please feel free to comment/ask questions, which I can try to answer as we go along...

The aim of this post is to introduce my thoughts on "cause", and provide some basic anatomy. I hope it makes sense and isn't too laborious.

OK, as far as climbers are concerned, I believe there are two main causes of lateral (outside of the) elbow pain. There is genuine lateral epicondylitis (Tennis elbow). This is characterised by a definite point of tenderness (pain) on the lateral, bony point of the elbow. The pain may extend down into the posterior (rear) portion of the forearm, and will be acutely exacerbated by resisted wrist/finger extension. This, I believe, is RARE in climbers. There is a definite, evidence-based treatment programme for it, and you should seek professional help to have this outlined for you.

The other type of lateral elbow pain is a diffuse deep ache that affects the lateral part of the elbow and upper arm/lateral bicep. It may extend down into the forearm, but does not have a definite 'point' of pain. It usually comes on with squeeze-type bouldering moves, or manteling - hence its nickname of Font elbow. If you suffer with this, just the thought of topping out on classic Fontainebleau 'blobs' will bring tears to your eyes!

It is my belief that this type of problem is brought about by instability at the shoulders: the use of pecs when doing these types of moves pulls the head of humerus forwards in the 'socket', and it impinges on the structures running over its anterior (front) aspect. This leads to referred pain further down the arm. Classic impingement occurs with overhead activities, causing impingement of supraspinatous, but that is not applicable here. It is why, however, this type of anterior impingement is rarely diagnosed - it does not fit a commonly observed picture. Like many sportspeople, climbers put unique strains on the body, but there is virtually no research, literature and therefore understanding of these unique problems.

The main aim of this series of posts is to give you some idea about normal movement at the shoulder joint. What you have in the body is movement muscles and stabilising muscles (and some muscles that do a bit of both). For normal movement, what you need is correct alignment (posture, if you like) at ALL joints, and dynamic control of ALL joints (i.e. maintenance of alignment through movement). The classic 'agonist/antagonist' model does not fit. Again, knocking out a few intermittent press-ups to "even yourself out" is not going to help you much.

The shoulder complex can be split into 2 main 'joints' - the 'scapula-thoracic junction' and the 'gleno-humeral joint'. Very simply, the scapula is a 'floating' docking point for the arm. I shall deal with scapular stability in the next post, but it's a very complicated thing to achieve, and (if it's an issue) unlikely that you can do it without professional help. I shall mainly outline what can go wrong, and how to identify if yours are not working quite as they should.

The gleno-humeral joint is what you think of as your shoulder. The humerus is the bone that forms the upper arm, the glenoid is the 'socket' that the humerus attaches to. The glenoid is part of the scapula.



OK, so what are the likely problems that climbers will get suffer from with the gleno-humeral joint? Fundamentally, problems at the shoulder can basically be split into 2 main catergories - stiffness or instability, although often these will occur simultaneously. My view is that instability at the gleno-humeral joint is a very common, and very debilitating problem for climbers. I think it is the MAIN CAUSE of climbers' elbow problems, i.e. NOT tendonitis.

Some background. The upper limbs are evolved for relatively low-load, large range activity - scratching your neck, wiping your bum, picking fruit from trees, throwing spears. Fortunately, our ancestors did a lot of climbing in and, swinging from, trees, so our shoulders can adapt back to this, but fundamentally, our shoulders are designed to allow large range of movement. They are inherently unstable. The muscles we use to stabilise them are much smaller and weaker (and tire more quickly) than the muscles we use to move our arms. The muscles we are talking about are the much talked about, but little understood, rotator cuff.

The rotator cuff is made up from 4 muscles: supraspinatus, infraspinatous, teres minor and subscapularis. The best way to decribe their action is as 'guy lines'. The shoulder is described as a ball and socket joint. It is, in fact, a beach ball and saucer joint. The humeral head is huge, the glenoid is a small, flat plate. Unlike the hip, with its deep socket, it has minimal structural stability.The large muscles that move the arm - deltoid, pectoralis major, latissimus dorsi are pulling the humerus out of the glenoid. The tiny rotator cuff is working like stink to not let that happen. Needless to say, it's a losing battle.

In the picture below, imagine you are looking at somebody lifting their arm sideways. The black arrows show the action of deltoid. Unopposed, this would cause the head of humerus to 'roll' upwards out of the glenoid. The red arrow shows the action of the inferior rotator cuff (infraspinatous & teres minor). The act as guy lines, providing a downward force, and causing the head of humerus to 'spin' in the socket - maintaining alignment.

[tr][td][/td][/tr][tr][td]Schematic diagram showing action of rotator cuff[/td][/tr]

[/table]So what can we do about it? Firstly, those theraband exercises that you see people doing are the first line of defence against gleno-humeral instability. See the videos below. They should be an essential part of any climber's training regime. As with all exercises, you need to do some high load sessions to build strength, but also using low load as part of your warm up to get the muscles activated and ready to go. These exercises are primarily for infraspinatous & teres minor (the inferior cuff), which are the key muscles that maintain humeral head position.

 

 

?The other element that is important is the role of the posterior capsule in gleno-humeral alignment - and this is likely to be something that you haven't encountered before. There are 2 elements to it.

No 1: capsule length. The capsule is a piece of fibrous connective tissue that surrounds the joint. It helps with stability. In fact the ligaments are thicker parts of the capsule (a ligament is a non-stretchy piece of connective tissue that prevents excess movement at a joint).

 

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The posterior capsule is quite prone to shortening, and this will cause the head of humerus to sit too far forwards in the glenoid. The video below will show you how to work out if yours need stretching, and how to do it. A quick word on stretching. You must differentiate between stretching to warm up, and stretching to increase range. When warming up, you don't want to overstretch the muscles/soft tissues - it will increase the likelihood of instability and make the muscles less efficient (muscles must be under tension). When warming up, you are just getting the muscles ready to work in their available range (i.e. gentle stretches, not trying to push past the current maximum range).

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?No 2: Rotator cuff trigger points. Trigger points are sections of the muscle belly that go into spasm, usually from prolonged or excessive work. If you have a prod around in the areas indictaed below, you may find some points that are "exquisitely tender" (as the textbooks say) when you press into them. They probably indicate that your rotator cuff are working pretty hard. This section of the muscle becomes 'non-contractile', making the muscle weaker. They also produce pain when the muscle contracts, so will further decrease the muscle effectiveness by a phenomenon called 'pain inhibition'. Get rid!!

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To alleviate them, just press into them for 10 seconds or so (you may feel them relax), and then do the stretch in the above video (scarf stretch). They will come back, but with time and plenty of trigger point massage and stretching, they should improve.

The video below shows a way to begin to understand the 'correct' position of the scapula. I will attempt to undertake a more detailed post on the scapula and scapula stability, but this little exercise is important, and will allow you to start to gain control of your scapulae.

The video below gives some advice on resting position of the shoulders, in terms of lateral rotation. Many climbers stand with their shoulders protracted and inwardly rotated, which also causes the elbows to hang in a slightly flexed position. Now imagine the position of your arm when climbing - often the shoulder is laterally rotated, raised above the head and the elbow is straight, i.e. the opposite extreme. By standing with the shoulders laterally rotated, the elbows extended, you can help to lessen the difference between these 2 positions.

 

Hopefully, this will give you a basic understanding of the gleno-humeral joint, and how to try and keep it more stable. Next time we will look at the role of the scapula, and after that I would like to talk about the implication that shoulder instability has on the nerves of the upper limb.



Source: Physiotherapy for Climbers