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)

In The Spotlight- ‘Hip Extension’

Welcome back

As we already know, the problem of glutes amnesia has reached epidemic proportions. Our lifestyle is not like what it used to be. More work gets done sitting on our behinds all day than ever before. Spend too long in sitting  and we slowly start to lose the important movement of hip extension. In this blog post I would like to discuss two conditions that I have often seen in the past which can be directly or indirectly related to loss of hip extension (both lack of active control and loss of ROM). Seen in the general population and often perpetuated in runners. Lets begin-

  1. Low back pain– while the causes for LBP could be endless, we will discuss the role of inhibited glutes and lack of proper hip extension in LBP. If we spend  8+ hours a day sitting on a chair (hip flexion), the glutes will be in an overstretched position and often inhibited. To add to those woes, the hip also gets stuck in a flexion position with classic ilicaus and psoas tightness. Now to maintain a upright posture and to compensate for tightness caused by excessive prolonged hip flexion which would put our trunk in a forward lean,  the back extensors have to work harder to keep us upright. This often manifests as an increased lumbar lordosis (low back curvature). Prolonged time in this position can cause increase in tone of the lumbar erectors and could potentially cause low back pain. I see this often with recreational runners or those who are new to running. During running, if your hip do not go in to enough extension, the back begins to arch and the erectors being part of the posterior chain have to work extra hard. Remember the body is a great compensator but over time this catches up. This, I believe is often one of the common reasons why recreational runners come to see us for low back pain with running.  If you are an athlete or a runner, this is not the best situation for running.  Your glutes have lost their VIP status.  No one likes weak glutes, unacceptable.
  2. Plantar fascitis– I often find people with plantar fascitis have well developed calf muscles. It appears like its ‘calf raises’ day everyday for these folks however on further questioning you may find that they might not have been doing any calf strengthening exercises. If such is the case, I implore you to  check for their active hip extension in walking or running especially during the midstance, heel off and toe off of the stance phase. This is the time when the leg should start to cross back behind the body due to hip extension. This is the primary movement that propels us forward. Now if the body lacks this crucial movement, due to weakness of the glutes max or tightness of the ilio-psoas etc the calf seems to become a more significant driver to push the body forward. Now multiply this a few thousand times a day (even more if you are a runner) over a few weeks, months or years and we have a overworked calf complex. As we all know, the calf exerts a pull on the plantar fascia (remember its a two joint muscle) and that irretates the PF blah blah, we all know this. So improving active hip extension and utilizing the full potential of the glutes is crucial to give the calf a break and in turn might relieve some stress of the PF.

The take home message is simple-  Hip extension is a crucial movement for many daily activities and a lack of which might cause LBP or PF. When treating these conditions, don’t make the mistake of running after the symptoms like I have so often in the past. Here’s a little video to give you an idea of my thought process when analyzing hip extension in running.

 

(PS- this is not the only thing I look for, I’m only focusing on Hip extension here).

You know the drill.

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

#Technique Tuesday 4- The Lunge

On this edition of #techniquetuesday we will discuss the Lunge. The lunge is a great  lower body exercise that works some of the major muscle groups of the legs- the Quads, the Hammies and the glutes. In addition to this, it also trains dynamic single leg stability and motor control and depending upon the variation you chose to perform one could also throw in half kneeling stability work and eccentric quadriceps work into the mix. All in all its a great exercise.

However, it doesn’t seem to be the most enjoyable exercise as many seem to hurt themselves while doing it. So lets try to do em right.

Avoid these common mistakes-

 

 

WATCH OUT FOR-

  • Knees going past the toes
  • Heel lifting of the floor

 

 

 

 

WATCH OUT FOR-

  • Knees going past the inner border of the foot (aka excessive valgus)

 

 

INSTEAD TRY THIS- 

 

TRY TO –

  • Shift your weight back on to your heel with the heel of the front leg flat on the ground.

 

 

 

TRY TO –

  • Keep your knees aligned over your feet

 

VARIATION-

The above lunge exercises seem to work the anterior chain with the focus on quadriceps (Don’t get me wrong, you are still working all the muscles). As a variation, to get more of my posterior chain muscles (Hamstrings, glutes) or to avoid straining sore knees/quads I like this variation-

 

Keep at it, do it right and do it often. Until next time

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

 

 

#Technique Tuesday 3- The Plank

Welcome back,

The week ahead is long and there is much to do, its only Tuesday. So we like to keep it short and sweet on #techniquetuesday. Today we discuss the plank.  Plank is a great core exercise but often faulty techniques negates the true benefits of the exercise. In my mind, the true purpose of the plank is to engage the core to brace and protect a ‘neutral’ spine. However, I often find when performing a plank that the hold time supersedes good form. There’s a lot of excessive arching, ribs flaring out,  more than desired hip flexion, cervical extension etc all for the sake of getting that extra 30 seconds. Here are some example-

In the pictures below you will see (clockwise)-

  1. Excessive thoracic kyphosis (Rounded upper back), rib flare, excessive  cervical protraction (chin sticking out).
  2. Excessive thoracic kyphosis (Rounded upper back), excessive lumbar lordosis (arched lower back), rib flare, excessive  cervical extension (head turned up).
  3. Excessive hip flexion.

WATCH OUT FOR THESE COMMON MISTAKES!

 

Try this instead-

 

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Remember, the spine is not perfectly straight so a little ‘natural’ arching is acceptable. A cue I often use is to gently pull the front rib cage down towards the feet, I’m not a big fan of the cue ‘drawing the belly button towards the spine’ because it interferes with normal diaphragmatic  breathing (which is important for proper core engagement).

If the plank off the feet/toes is hard, regress it to ‘off the knees’ like this-

 

Do it right and do it often. Until next time

Pursue excellence-

Abhijit Minhas

(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 exercise selection (strength matters 3)

Welcome back

Let me start by thanking so many of you on sending your valuable feedback on the last blog, made me feel I certainly  picked up the right topic. So far we have established why we need baseline strength for almost everybody and what are the training principles for it. On the third part of this series post I would like to keep it short and power packed. What are some of the exercises that will have the maximum impact on upper and lower body strength and are functional. The word ‘functional exercises’ has been thrown around a lot these days but to me the meaning is simple. These exercises will have carryover benefits to certain ADL’s, hence more functional.

If you were able to convince your client that lifting weight could positively impact his/her health and he/she agreed but has a very busy day and can only spare 30 minutes a day to exercise, what exercises would you chose? If some athletes come to you during off season, tell you that  they want to get stronger or increase their overall muscle mass and that they can only spare 1-2 months before they shift their focus back on sports skills, what would your exercise selection look like then? Remember time is not on your side and the clock is ticking, your clients demand the maximum training bang for their buck. In such a situation, here are a few things to take into consideration

FOCUS ON-

  1. Bigger muscles. You know what I am talking about- the glutes, the hammies, the quads, the lats, the pecs. Your biceps, triceps, calf, forearm muscles are not the obvious choice. (Tik toc remember you don’t have the luxury of time).
  2. Compound multi-joint exercises- why not use one exercise that works on multiple joints and perfect that movement rather than spending time and energy on 5 different isolation exercises to target the same amount of joints/muscles. I think it’s a no brainer.
  3. Exercises that mimic sports movements/ADL’s- aka ‘Functional exercises’.
  4. Body weight exercises over machine exercises- Machine exercises are not ‘functional’. Here’s an example – you could train your quads with a knee extension machine in the gym or train it with a squat. Now, how often do you need to squat in a day, to pick stuff off the floor, sit in a toilet seat etc. How often do your athletes need to squat? To jump, to dive etc. I don’t need to elaborate here. How often do you perform the knee extension movement while sitting on a chair, what do you use that for? Is there a sport that requires athletes to sit and extend their knees? I certainly can’t think of any. Also remember that when performing body weight compound multi-joint movements you are not just training a physical attribute of overcoming resistance but as these movements are complex, you are also creating new neuromuscular pathways to develop a skill. Kind of sounds like motor learning, doesn’t it?

Without further adieu, here are my current favorite exercises for strengthening/fitness –

  1. The squat-
  • Targets multiple big muscles like glutes, quads, hammies, erector spinae, core etc.
  • Functional in ADL’s and sports movements.
  • Translates to higher vertical jump.
  • Positive effect on blood hormonal levels of serum insulin like growth factor, testosterone and growth hormone.

2.  The dead lifts-

  • Very functional- trains the hip hinge pattern.
  • Great upper and lower body strengthening exercise.
  • Targets even greater number of muscles than the squat- glutes, quads, hammies, erector spinae, lats, traps, grip muscles.
  • Similar positive effects on serum testosterone and GH like the squat.

3. The Kettlebell swing-

  • Strengthen posterior chain and the core.
  • Great exercise to teach the hip hinge pattern for people with low back pain.
  • Trains the cardiovascular & muscular system, balance & coordination, core stabilization and hand and eye coordination.

4. The pull up-

  • Great exercise to build upper body strength in ‘pulling’ movements.
  • Works on multiple muscles- the lats, scapular stabilizers, elbow flexors, grip muscles etc.
  • Multi joint exercise with good metabolic effect.

(Sorry I don’t have a video of me doing this exercise yet. This is my weakest link in upper body strength and I have struggled with it for years. I can perform a few bad pullups but I cannot perform a single good ‘strict’ pull up. I am currently training for it with assistance weights and bands. I will put a video of them shortly for those who struggle in this exercise like me. Just like this blog loosely following my journey of learning, I plan to have a parallel journey of performing 10 strict pullups and sharing it with you. I am not sure how long it will take but I will update often. I also welcome anyone who would like to embark on this journey with me, send me a message and we can talk more.)

5.  The Military press/Shoulder press-

  • Strengthens shoulders, arms, core, scapular stabilizers.
  • Builds strength in overhead movements with carryover in ADL’s.

6. The Dumbell/barbell bench press-

  • Great exercise to build upper body strength in ‘pushing’ movements.
  • Works on pecs, arm and core muscles.

 

By no means is this list exhaustive. There are a lot of other exercises out there that have great benefits which I have not mentioned here. Training athletes for more sports specific exercises can be a book in itself and I will write more on it in the future. However, if you look at most of the exercises above, they have something in common. They all focus on training more than one muscle/joint at a time, target the larger muscles and have some carryover to what we do in everyday life. For this first post on exercise selection, I am sticking to the ‘KISS’ principle.

KEEP IT SIMPLE SILLY

I welcome you to share your thoughts on some exercises you like.

Until next time

 

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

Strength Matters

Hi everyone

When I was working as a physiotherapist in India, the bulk of my interventions were primarily electrotherapy based modalities in rehabbing people with disability. As I look back now, while there is a place for electrotherapy (but very little, in my opinion), overly relying on these modalities had a negative impact on my learning curve and overall development as a therapist. It steered me away from interventions like manual therapy, corrective and functional exercises strength training, injury prevention and improving quality of life. Anytime I was uncomfortable and didn’t know what was going on with my patients, electro therapy seemed like a ‘safe space’ to fall back on where I could tell my patients that the ‘machine would reduce the inflammation’ and to ‘give it some time’ to avoid questions I couldn’t answer or problems I couldn’t treat.

I started learning and utilizing the aspects of strength training, functional exercises and injury prevention when I volunteered with the strength and conditioning coach of Long island university’s athletic teams, learning from coaches training high level UFC fighters and boxers etc. Today’s blog post is dedicated to one such neglected aspect of overall rehabilitation which is  strength training. Not just pursuing the goal of getting our patients stronger but working on this attribute ourselves.

To build on this case further, before anything else, I would like to ask you all a question, who in your opinion will not benefit from getting stronger?

  • Some would say children (not you though, you know better than that). While there is scientific evidence to prove that loading a child with weights could be detrimental to the growing epipheseal plates, there are a lot of ways to incorporate strength training in children. Body weight exercises is a good example. Not only is it a good exercise to build strength but it also helps with learning skills. Learning requires repetition and this helps create new neuro muscular pathways. These pathways help ingrain movement patterns in them. After all, why are we able to brush our teeth so well with our dominant hand and struggle when we tend to do the same activity with the other hand. Do you think that the toothbrush is heavy that makes it so difficult? Of course not, it is because we have used our dominant hand a gazillion  times and that motor patter has now been mastered by our brain which makes the task smooth and effortless. By keeping them away from some sort of a ‘reasonable’ training program because  we fear it will ‘impede their height’, we delay the foundation on which we would like to build upon. We should look at China as an example, they start training their athletes at a very young age. The early years are spent perfecting skills without putting too much stress on the body and when the time comes these children are better prepared to handle exercises and out perform their peers. No wonder they win the number of gold medals they do at the Olympics.

 

  • Some might say older people (though I cannot imagine who). Lifting weights could be one of the best things that could positively affect grandma and grandpa’s health. We know some of the major effects of aging are sarcopenia (losing muscle mass) or weaker bones with older adults and what better way to slow down these processes than lifting weights? (No, not going on leisurely walks). While aerobic exercise has its benefits, its not the preferred form of exercise to mitigate the negative effects of age related sarcopenia or osteoperosis.

 

  • People trying to lose weight? I think they are excellent candidates for lifting heavy weights. When trying to lose weight, what we are truly trying to achieve is losing body fat. Instead of  slow paced jogging on a treadmill for 1 hour, how about doing high intensity sprints for 1 minute and then walking for 1 minute to recover and repeating it for maybe 15-20 minutes ( of course, rule out any pre-existing heart conditions). High intensity training seems to have a better outcome in burning fat as it puts a higher demand on the metabolic system and the intermittent slow and fast running causes heart rate variability which is  good training for one’s cardiovascular system. But we are missing the icing on the cake (sorry, bad example when we are talking about losing weight but I love chocolate cakes). Lifting heavy weights increases muscle mass and size. Now when someone asks you what that has to do with losing weight you are in a position to educate them that bigger muscles needs more blood and nutrients (energy) and this increases their overall metabolic rate. So people with more muscle mass tend to have higher basal metabolic rate even at rest. This means even when they are not working out, their bodies our burning more energy than a person who has less muscular mass.

 

  • How about athletes? No debate here. A good strength training program can help a football players outrun his opponent, gives the cricket fielder that explosive power to dive  higher for that ‘highlight match turning catch’, a batsman the rotatory power to smash that ball outta the stadium (and win that price money cheque $$$) etc, the list is endless.

 

  •  Even us physios.  Keeping aside the obvious benefits of strength training to meet the rigors of our job, we are more likely to be consulted  by fitness and gym enthusiasts if they know that their therapist shares their passion for working out. If the last time we entered a gym was in our second year of BPT education, it would be hard to convincing our patient who blew out his back squatting 80 Kilos that we are the right therapist for him; and rightly so, if we have never felt that load ourselves, how could we be in the best position to help others? After all, don’t we learn from experience? Here in the US/ Canada, I have seen this all to often. Runners will seek out therapist who were former runners, athletes injured playing a specific sport will look for therapists who were athletes themselves, people hurt in the gym lifting weights will try to look for a therapist who has some experience in bodybuilding type of exercises etc etc.

 

  •  How about that skinny guy trying to impress the girl in his class? Gaining a few extra pounds of muscle mass won’t hurt at all.

To know the nuances of strength training and to be creative in program design is paramount for a sports physiotherapist in India, because unlike north america and many other parts of the world, where athletes have a entire team of professionals like athletic trainers and certified strength coaches (I have written briefly about these professionals Here), we don’t have such luxury. We must be a one man sports medicine team. We must be the the guy who prescribes an off season strength and conditioning program to make our athletes run faster, jump higher, lift heavier etc and educate about injury prevention, and despite all this if the athlete does get injured (which most likely they will) we must now put on our therapist hats and get to our treatments. Hence, the importance of the  knowledge about good exercise selection and prescription cannot be overstated.

To cut a already long story short, almost everyone could benefit from lifting heavy weights. However, what are these exercises that make our patients functionally stronger, faster and can also be incorporated by athletes for their individual sports specificity. It cannot be bicep curls, triceps extensions, abdominal curl exercises, lat pull downs etc (these are more of body building exercises) that might help somewhat, but there are better ways. My intention with this blog is to take it in a new direction where I cover both aspects of what a physiotherapist might encounter,

  1. Topics which are purely based on physical therapy rehab, like new assessments and techniques that I find beneficial.
  2.  Topics on S&C (strength and conditioning) and exercise prescription for health and performance in otherwise healthy individuals.

In my following blog post, I will discuss about certain exercises, training principles  for building strength and basic terminologies that are often incorrectly used like hypertrophy, strength and power. Until then.

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)