Technique Tuesday 7- Hip abduction in side lying

Hi everyone,

Here’s the latest edition. You know the drill.

Until next Tuesday or a new post

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

#TechniqueTuesday 1- Quad & Hip Flexors Stretch

The intention of #techniquetuesday is to highlight mistakes and demonstrate corrections for common exercises that I see often. For the very first one, we will discuss everyone’s favourite, the quadriceps stretch and the hip flexor stretch. Here goes-

Do it right and do it often.

Until then

Pursue Excellence

Abhijit Minhas

(BPT,MS,CMP,FMT)

My thought process on improving hamstrings flexibility

To say that I wanted to write a blog post on hamstring flexibility would be incorrect. In fact, this is a issue I avoid like the plague. Why? I’ll tell you. I have pretty tight hamstrings. And since I make all the videos on this blog myself with my friends and not just throw in some you tube video of someone else doing these exercises, I’m nervous to look bad. And my hamstring flexibility makes me look bad, at least in my head. But then again, there’s also frustration. The frustration of doing repeated static stretching and not really getting much outta it. Not to forget, I have tried to be aggressive thinking if I yank on that muscle, maybe it will finally give. What it has often given me is pain instead of flexibility,  and soreness. I’m sure many of you will agree with me, that for the subset of people who are on level 0 on path to becoming a yogi, this process is discouraging. So we avoid it. I can’t argue with the fact that if we keep up this torture, we might get better, but I know many people who have not made significant strides with this approach, myself included.

The reason I wrote this blog is because I had a few of my readers respond to my previous blog post reporting that one of the major reasons they were unable to hip hinge was due to those disobedient, stubborn hamstrings that were preventing people from hip hinging. So essentially this blog came from a need to hinge better. It would be great if one could touch their toes but that’s not up in the front on the priority list. The point is to hinge from your hips to learn correct lifting form so you don’t throw your back out.

If you have been part of my writing journey so far, you know that I don’t like interventions that are too painful. After all, a lot of ‘hands on’ intervention that we do is desensitizing the nervous system. Why cause deliberate discomfort (with good intentions of course) to ‘release things’ only to set the warning alarms off on the CNS. I’m not saying this is the only way, I’m saying its an easier, non/less threatening option. Hence I tread the path of lesser resistance.

So without much more blabber, here are some lesser threatening, novel approaches to improving hamstring flexibility. I like to wrap the mobility band on the hamstrings and do my neural glides, SLR’s, some hold relax etc. I will let you be the judge, practice these strategies and retest your hinge,dead lift, possibly toe touch etc.

Here’s the first one-

 

image1

Here’s another strategy-

Right side-

image2

Left-image3

Worth a try?

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

Hips Don’t Lie- The Hip Hinge

Greetings

I know I know, the title is a cliché but I couldn’t help myself. Dealing with patients with low back pain is our bread and butter as physios. Not that we don’t see other stuff in the office but all of us have seen more clients with low back pain then we can count. For all you physio student that are readers of this blog and have not yet treated patients you still know what lies ahead of you; a lot of sore, achy backs.

For some time now I have introspected on how we treat low back pain and have come to the realization that we are fairly good at treating various causes for low back pain when our patients come see us in the office. We often  measure our outcome depending upon how low could we bring the pain down on the pain scale and get our patients back to their ADL’s. However, an aspect we often unintentionally neglect is keeping people pain free and out of our offices. In other words training our patients in lifestyle modifications and on how they should move better. Not all of us though, I have had the pleasure of meeting and working with some physios that hammer the above two points well. For them the whole spectrum of treatment for a person suffering from low back pain does not end at manual therapy/modalities etc to relieve pain and then strengthen back/core etc. This is just half the job done. These physios take multiple visits just to teach lifestyle and behavior modification strategies so their clients stay pain free and learn to move well. We all can learn something from this. This blog post is on one such example. Lets dive right in.

Let me paint a clinical picture we often see- Patient comes in with low back pain, no H/O trauma, pain from repeated bending forward or lifting etc, pain has a gradual onset, no major red flags etc etc. Fairly common scenario. We dig into our tool kits and do a great job in getting the person almost or completely pain free and then prescribe strengthening exercises. We spend a few visits in this. Finally, when its time for discharge, we go over the do’s and don’ts, show them how to maybe lifting things of the floor or bending forward correctly etc and then its goodbye. I have done this in the past and have had lengthy debates with other physio friends about how this seems to be a norm. What we ought to do instead is to spend more time/visits to show them how to bend forward correctly/lift correctly so they can protect their backs.

Enter one of the most underutilized movement pattern that everyone must be able to perform- THE HIP HINGE.

The hip hinge is an excellent movement pattern to disassociate the hip from the rest of the back/torso, an good position to lift  heavy things off the floor without stressing the lower back and its associated discs which would otherwise put us at an increase risk of injury (refer to the work of one of the best back research and rehab specialist Stuart McGill to learn more), a great movement to train some of the strongest muscles of the body- the glutes, hamstrings, a very important athletic movement to produce explosive power for movements  like jumping, sprinting etc (the glutes muscle is stretched and in a good position to produce great force for athletic performance). The list is quite long. Hence its imperative that we not only master it ourselves, but make sure our patients can execute it well and most importantly, that they utilize this in their day-to-day lives. That only means one thing- practice.

Cuing

Wrong cuing– Before we proceed, lets talk about what we have been doing incorrect for a while. When we ask our patients to bend forward and lift something off the floor we often say thing like ‘keep your back straight and bend from the knees’ or bend your knees and lift the object of the floor’. There are a few things wrong with this- first this que sounds like a squat and as we all know a squat is one of the most complex movements. Not everybody will be able to perform it well. Secondly, there is no mention of the hips. Moreover, if our patients lack ankle dorsiflexion or/and have knee pain, good luck with having them do this. What ends up happening is that they go back to their default lifting pattern and sooner or later they will be back to see you.

Here’s an example of bad lifting form-

Bad form

The squat-

Enter The Hip Hinge-

I’m pretty sure your tired of reading so scroll down for a video on how to hip hinge.

The hinge-

Now go out there and lift heavy things, the right way.

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

My current thought process on fixing Scapular Winging

Since my blog post on shoulder part 1 and 2 that you could read Here and Here, I have received a lot of questions on scapular diskinesia and recommendations on managing it. As I did not really cover it in my previous blog post, this blog post will be dedicated to just that.

Scapular dyskinesia, which means abnormal movement of the scapula can present itself in different forms but most commonly manifests itself as ‘winging’ of the medial or inner border of the scapula. ‘Winging’ means that the inner border of the scapula lifts off the rib cage. This could happen during a simple overhead arm elevation (open kinetic chain) or during an exercise like a pushup (closed kinetic chain).

In an ideal healthy shoulder complex, the scapula and the ribcage work like new lovers; always close to each other and ‘almost’ inseparable. The important task to kindle this romance is primarily bestowed upon the serratus anterior (SA) along with the rhomboids and lower traps. However, sometimes these muscles misbehaves creating some trouble in paradise in this relationship. The serratus anterior is supplied by the long thoracic nerve and on observation of winging in your patient, its prudent to check for some kind of long thoracic nerve issue by doing a neck screening.

However, in my experience if there is no H/O traumatic injury, systemic illness etc that might effect the long thoracic nerve; we might be dealing with an inhibited SA. In the past I would quickly get to work by strengthening SA with some of these classic exercises for strengthening.

  1. Theraband SA punches
  2. Theraband and pulley Rows
  3. PNF for lower traps
  4. ‘Y’, ‘T’ exercise.

This strategy could be a hit or a miss. It could work for some deconditioned/older patients who have general muscular weakness and strengthening the SA, rhomboids and lower traps  could fix the problems. Makes sense right. However, very often its a miss. Picture a client who is fit, could perform pushups until the cows come home, and is nowhere close to having muscular weakness but still shows signs of winging with arm elevation or with other CKC exercises. What do we make of this??

What this means to me is that the SA is unable to reflexively hold that medial border and inferior angle down on the rib cage during certain movements. In other words, its unable to provide the stability through the full ROM. It could be either an inhibited muscle unable to generate enough force to hold that shoulder blade down due to bad ribcage-scapula position or maybe a timing issue where its not firing well at certain periods through the ROM or more likely a combination of both. Hard to be exactly sure here.

But the key here is stability. In Human kinetics, I believe this means the ability of the body to hold the correct form through full ROM. And here lies the problem. Almost all the above exercises work on a single plane at about a 90-120 degree of arm in flexion. Hate to state the obvious but are they functional? Will they train the muscles to hold that scapula in a good fixed position on the rib cage in a overhead position in OKC exercises? My experience is mostly negative. How about you?

So where do we go from here? Below are some of the strategies that I have incorporated recently that I find extremely useful and better than the traditional exercises stated above. I demonstrate this in videos below on (1) myself  as I have some left scapular winging with arm elevation and (2) on my colleague and fellow Physio who is involved in competitive dragon boat racing.

In the video below, I do a Dumbell press of 40lbs with a plus (protraction) to demonstrate how my left SA struggles to hold the load compared to my right.

 

 

Below is a video of me doing an arm elevation test which demonstrates winging and how I correct it.

 

 

By pushing on the wall and protracting my shoulders, I am getting into a ‘locked ribcage’ position and reflexively activating my SA to hold that medial border down by creating a good congruent ribcage shoulder blade position. No theraband exercises to strengthen the muscle might be needed in my case. Just a favorable position for my SA to work reflexively.

Need another example? Sure. My colleague is a perfect example of a candidate who is not weak, in fact she is very strong and trains hard to compete in dragon boat racing. You think she’d have a weak serratus? Or that you could fix her winging with a theraband? I’m sure you know the answer.

 

 

Here I must report, she does not have any pain, just C/O weakness. Her winging does not seem to be excessively abnormal, it could be well within a certain normal range of winging which most of us might have but asymmetrical to the other side.

 

Now, I like to be a little more specific depending upon the clients needs when prescribing exercises to tackle scapular instability. To give a few examples, I’d prefer more OKC exercises for swimmers, volleyball players, rowers, cricket bowlers etc and CKC for gymnastics. Often, both as the situation demands. Here are some examples of my preferred exercises-

Closed kinematic chain-

  1. Cat Cow

 

 

 

 

2.  Quadripod knee lift

 

 

 

 

3. Plank plus-

 

 

 

 

4. Pushup plus

 

 

Open Kinematic Chain exercises-

  1. Kettlebell press supine

 

 

 

 

2. Kettlebell Overhead press- Now for some of my favorites, the press. Another excellent way to fix a winging problem if noted in a OKC movement is to load that pattern and let the shoulder fix the abnormal pattern by itself. Sound a little like RNT? I think so true. (While I don’t demonstrate winging with a press but more with arm elevation, I’m sure you have seen clients that show instability with pressing. If there is no pain, the best way to fix the instability is by… thats right, pressing but with a load. Try it out

 

 

 

Not convinced that pressing heavy load will fix shoulder winging/ instability during flexion? Watch the next video and reassess your thought process. Hopefully I can convince you to give it a shot.

Kettlebell press with opposite arm-

 

 

So, What do you think?

 

3. Arm bar-

 

 

 

Watch those muscle trying hard to reflexively stabilize. Its oddly satisfying.

 

Time to wrap this up guys, but before I leave you here’s something to ponder about. For long we have thought of scapular instability to be closely related to sub acromial impingement. Not trying to be the devil’s advocate here but recent research has shown that scapular instability might not have a major role in impingement or pain in the shoulder (https://www.ncbi.nlm.nih.gov/m/pubmed/24174615/?i=2&from=/16015238/related). However, I take this with a grain of salt and always keep in mind that there are fallacies and shortcomings with research and this does not mean that it cannot be a cause of the above. Alas, such is research. I will still work on fixing this problem with my patients as I am looking for symmetry on both sides of the body not just for injury prevention but also for better performance.

Hope this blog helps.

 

Until next time-

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

 

Reference-

1. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. Ratcliffe E, et al. Br J Sports Med. 2014.

MY CONTINUOUS LEARNING CURVE- REACTIVE NEURO-MUSCULAR TRAINING

Often introspecting my strengths and weaknesses within the realm of the rehab world, I had realized that one area that I needed to put some extra work into was to innovatively select and prescribe exercises for my patients. For a very long time all my attention and energy was focused upon learning new manual therapy techniques and improving my diagnostic skills. However, it didn’t take me too long to realize when I first started working as a physical therapist in NYC that simple SLR’s, knee extension and back extension exercises etc were not going to cut it when dealing with a relatively active clientele. I had to be able to prescribe progressively challenging exercises and to give clear cues and master the nuances of proper exercise execution. I was also in awe of some of my american physio colleagues  that I worked with. They were so easily able to progress or regress an exercise, tweak it to their patients needs and provide alternative exercise options to train a certain body part. I wanted to be able to do all of this and not be restricted to being just a ‘manual therapist’.

While on this path I came across RNT. It stands for reactive neuromuscular training. I have found it very beneficial and find myself prescribing it often. So lets start by describing the main principle behind it. We often find our patients falling into a dysfunctional movement patterns when performing exercises. To correct them,  we rely on verbal or visual cues. Often these cues are enough to correct the dysfunctional pattern. However, sometimes even though our patients understand these cues, the body is still unable to correct itself. We are so used to moving in a certain way that its hard to break that dysfunctional neuro muscular pathway that is embedded in our brain. This often manifests itself when our patients might say something like ” I understand what you are asking of me, but I just can’t seem to be able to do it” or “my body just refuses to move that way”. This can often lead to disappointment and frustration for both you and your patients. If you have found yourself in this position, RNT can be extremely useful.

Instead of relying on cues that might not work or may sometime be too complex and confusing, we can use external force to push the body even more into that dysfunctional pattern! Yes, you read it right, physios and trainers often describe this as “feeding into the dysfunction”. By doing that, you now let the body figure it out on its own what it needs to do to get out of that dysfunctional movement pattern. The body reacts to this external force by self correcting itself by firing the right set of muscles to seek stability and control. What a novel way to retrain a movement patterns and neuro muscular pathways. The external force can be applied either manually, using elastic therabands etc. They are plethora of possibilities and it gives you many opportunities to get creative. Below are two examples of applying RNT to two popular exercises- the lunge and the over head squat (OHS). Ok, so less writing, more watching. Here goes-

The Lunge-

 

 

 

The Over head squat-

 

 

These are just two examples to begin with. I’ll cover more exercises in a following blog post. What are your thoughts on this form of training? Do you incorporate this in your practice? If you are interested to send some of your own videos of using RNT in your practice and would like them to be featured on this blog in the following post, please leave a comment and we can talk more.

Keep the dialogue going, I like where this whole thing is headed! I have interesting thing lined up for you in the next few blog entries. Stay tuned and if you like the content, subscribe to get the next post to your email.

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)