Angel’s Struggle with Back Pain

I love helping people get permanent relief from back pain. My own struggle with mysterious and debilitating back pain is what got me interested.

When I was 20 I was a pretty extreme martial artist and acrobat. I trained several hours a day 5 or 6 days a week. Jumping, twisting, kicking, flipping, handstanding, falling down, and getting knocked down.

Remember photos that you had to get developed?

One of my few pictures from 20 years ago. Practicing Capoeira tricks on the beach in Florida

Then one day I started to have back pain. There was no particular incident. It came on slowly and got worse and worse day by day until it was hurting all the time. I couldn’t sit for long periods, I couldn’t sleep, I couldn’t stand, and I even stopped training in martial arts because I was afraid that was making it worse.

I went to the doctor and got an X-ray of my spine which showed a normal, healthy spine with no injuries. My doctor sent me to physical therapy. I didn’t know much at the time, so I just went to the closest PT to me. It was a huge disappointment.

The physical therapist looked at me for 5 minutes and told me I needed to strengthen my core. What?! Since the age of 5, I’ve been a gymnast, dancer, exercise fanatic and martial artist. I can literally do planks and sit-ups all day long and you think my core is weak? I had no other great ideas so I did what they told me to do. You know, pelvic tilts. Laying on my back and tilting my pelvis. Laying on my back and marching my legs. Doing squats with my back against the wall. If you think these exercises would do nothing for an athlete, you are very correct.

The physical therapist had her student work with me. He wore very nice suits, came in and told me what exercises to do and then left me alone to do them. But he carried himself very well when he did it. And he had a stylish watch too. Very snazzy. Anyway, needless to say, I did not get better.

Then I went to the chiropractor. He said I needed to come in 2 times a week for 6 weeks so I did. He smelled like cigarettes and seemed pretty unhappy. He never said much. I found it a strange “health” care experience. I got short term relief from the treatments but then the pain came right back.

I went back to the doctor. They did a bone scan and an MRI. Thousands of dollars later, guess what….all tests were negative. There was nothing wrong with my back, it just hurt!

I gave up on getting rid of the pain and went back to doing what I loved. I lived with the pain for about 3 years. Then I went to physical therapy school at UNC-Chapel Hill.

I got to see a great PT there. On the first visit, she figured out that my back hurt because one of my hips (on my dominant kicking leg) was weak and stiff. She gave me exercises to do and they took care of my pain almost right away.

As long as I did the exercises, I was fine. The problem was the exercises were boring, time-consuming and didn’t get my whole body fit. So I would have periods of time where I would give up on them and spend more time doing other things and then my pain would come back. Then I would get back to the exercises. It felt good at least to have a way to feel better.

Then in 2009, I discovered functional fitness and CrossFit. I started doing true strength training. It turned out that heavy squats and deadlifts helped my back pain just as much or more than the boring PT exercises and they also got me super fit, strong, healthy and with more energy than ever.

Because of my own struggle with back pain, I never want anybody to go through what I did - the years of not understanding why I was having pain, the wasted time and money on treatments that were not effective. My experience taught me the importance of

1) A correct diagnosis

2) Looking at the whole body for the cause

3) Spending time with patients and making sure they are getting better

4) The importance of building strength in order to decrease pain

Through practicing physical therapy for 13 years, I’ve also learned the importance of hands-on techniques like massage, spinal manipulation, joint mobilization and dry needling for decreasing people’s pain. My first priority when working with people in pain is to get their pain levels down. Hands-on therapy is usually very helpful for pain. Then I start with whatever exercises people can handle, and I build up from there.

I try to get people as strong as they are willing to let me. That’s why I’m in a CrossFit gym - so that I can have access to all the equipment for building people’s strength and fitness. Building strength makes people’s bodies resistant to injury and pain, plus it makes them happy and healthy. It’s a win-win.

However, with exercise and fitness, I meet people where they are at and not try to be too pushy about my style. If they like yoga, pilates and stretching, that’s fine. I like those things too. I try to make people’s exercise programs enjoyable for them so that they will actually do it.

Thanks for reading about my experience with back pain. I’m grateful for it because it has helped me understand what many people go through and motivates me to be helpful.

Should I train through pain?

Most of us sports and fitness enthusiasts have trained through pain. Usually with thoughts like “I can’t lose my progress. I have to keep training to lift heavier, compete in the competition, lose weight, win the game, etc. I can ignore the pain and keep training.” Unfortunately, you can’t override your nervous system and tissue healing system.

Think you can ignore your pain and force your muscles to work? Think again. It’s the same as asking your heart not to beat- you can’t control it. When you have pain in an area, your nervous system will change your ability to use your muscles. Some muscles will get shut down, some will get extra activated. The muscles’ ability to control the movement of your joint will decrease. This will just potentially worsen the original injury.

The areas of your brain that control the painful body part literally change immediately when you have an injury. The longer you keep pain in an area, the more changes you will have to your brain and the nerves that go between your muscles and brain. You think you are making progress by training through pain, but really you are just making longer lasting changes to your nervous system that become more difficult to change over time.

Check out the picture of the brains above. Your brain has specific areas that correspond to specific parts of your body. On the left is a healthy brain, on the right a brain with face pain. See how the face gets huge and starts taking over other parts of the brain? Now everything is all mixed up. Something similar happens every time we have pain in an area of our body. The longer we keep pain there, the more mixed up things get. So address your pain as soon as you have it, unless you like having your brain all scrambled up like an egg.

Your soft tissues like tendons also decrease in health when you continue to aggravate them. See the picture on the left of a normal tendon and an irritated tendon with tendinitis? Don’t worry about what all those labeled things are. Just know that these changes are bad, painful and cause the tendon to be unhealthy. Why do you want a healthy tendon? Because unhealthy tendons can tear! Now you are having surgery. Not fun. Also healthy tendons make you stronger because your tendon connects your muscle to the bone. Want a strong muscle with your weak, abused tendon? Not gonna happen.

So I should never have pain when I workout?

No, that’s not true either. Most of the time (unless it’s a broken bone or a completely torn tissue) the only way to heal an area is to load it APPROPRIATELY. You can take time off and rest, but if that tissue already has some changes to it (probably does) then the only way to make that tissue stronger is to LOAD IT. Does a muscle get strong and healthy by resting it? Can you make a muscle strong by massaging it? No! And the same is true of tendons, ligaments and joints. Load stimulates your body to make things stronger.

How do I know how much pain is ok?

When working with a nagging pain where you know there is nothing severely torn or fractured, these guidelines can be helpful. The pain is ok if:

  • The pain is not greater than 3-5 on a 0-10 scale while performing a movement
  • The pain does not get worse as you continue the movement
  • After the movement/exercise/workout/training session, you may have increased pain but it is back to normal within 24 hours or 48 hours max.
  • Over weeks of training, your pain is gradually getting better

I don’t care if it hurts, I’m going to do it anyways

Ok, ok but why? Are you a professional or Olympic athlete? Probably not! So my fellow recreational athletes, what is that makes you do that extra-heavy deadlift, run the 10 miles, or do one hundred pull-ups even though it hurts? What is it that stops you from putting a lighter weight on the bar or scaling down your movements? Taking a day off to stretch and recover? I can tell you from my personal experience, it has been wanting to keep up with other people and prove to myself and my gym mates that I can do it. But every time I have realized that it wasn’t worth it. Being unable to sleep due to shoulder pain. Being unable to perform overhead lifting for 2 weeks. Or being unable to sit due to back pain. Each time I do something like that, I get a little smarter- I hope!

I hope this article has helped you to understand the consequences of pain and how to work with it to move forward, not backward! Don’t worry what other people think. They don’t have to live in your body and they are not going to take care of you if you end up with a serious injury or problem. Remember that training smarter is going to take you farther. It may not feel like it today, but in the long run it will pay off!

How to test your shoulder mobility – Part 1: Overhead Shoulder Mobility

For our bodies to work their best, we have to have

  1. Enough movement aka Mobility at each joint and
  2. Enough strength and coordination to control the movement.

Overhead Reach or Shoulder Flexion

Full Mobility= able to put your arms straight up overhead.

Think you got it? Not so fast! You need to test to know for sure. Many people think they have full mobility but actually lack a little (or a lot) of motion.

Lack of full shoulder flexion can cause 3 problems:

1) Pinching or “impingement” of shoulder structures in the overhead position = shoulder pain and tendinitis

2) Shoulder muscles have to work too hard in the overhead position = shoulder pain and tendinitis, excessive fatigue in the overhead position, and less than optimal lifting performance

3) Leaning backward when reaching or pressing overhead = back pain when lifting overhead, especially heavy weights

The first picture to the right shows the arms not quite all the way overhead. In the second picture, the lifter brings her arms straight up by bending her back. This can cause increased pressure and pain in the low back.

Ready to test your Overhead Shoulder Mobility?

Test 1: Overhead shoulder blade reach

Raise your arm up and try to bring it behind your head and touch the top of your opposite shoulder blade. You pass if you can do this easily WITHOUT PAIN. If you cannot reach your opposite shoulder blade, or you really struggle to do it, or you have pain, then you have LIMITED MOBILITY.

This test is a combination of 3 different shoulder motions. You need to test further to see which specific motions you lack. We will look at that in future articles.

Test 2: Overhead against the wall

  • Grab a dowel, broom or PVC pipe
  • Sit with your back flat against a wall. This is so that you can’t cheat by arching your back to get your arms overhead.
  • Hold your stick with your hands just outside shoulder width
  • Press overhead, keeping your elbows straight
  • The back of your hands should be able to touch the wall

Did you pass? If so, CONGRATULATIONS!!!!!

If not, there are several different reasons your shoulder may lack mobility. We will cover them on future articles, but some possible reasons are:

  • Tight muscles: Latissimus dorsi (Lats), Pectoralis minor (Pecs), Teres Major, Subscapularis
  • Tight shoulder capsule
  • Limited thoracic mobility

Do you lack shoulder mobility or have shoulder pain? Come see me before it gets worse! I’ll figure out the root cause, eliminate your pain and show you how to fix it. Click below if you are ready to be pain free and feeling great.

Schedule an Appointment or Free Consultation

Knee Osteoarthritis Pain Relief without Surgery

Over the last 12 years as a physical therapist, I have heard hundreds of people say some version of -

“My knee hurts because I have arthritis and there’s nothing I can do about it.”

When I hear this I feel sad and excited at the same time. I’m sad because I know this is FALSE and that for every patient who tells me this, there are 10 others who never even come to physical therapy. I also feel excited because I know there’s a really good chance that I can help the person sitting in front of me to decrease their pain, decrease pain medications, return to the activities they love and avoid surgery.

Many people come to me with x-ray results that show signs of osteoarthritis. I don’t stress about that because I know that 50% of individuals with positive x-rays do not have symptoms. It is possible to have a bad looking x-ray but have no pain and have a working joint. I also know that the x-ray results do not in any way determine how the person will respond to physical therapy. It can be disappointing and hard to believe that our high tech imaging methods can’t give us more helpful information. But hopefully it’s also relieving to know that you are not defined or limited by your x-ray results.

“If my ugly x-ray is not causing my knee pain, then what is?”

One answer is thigh muscle (quadriceps) strength. Studies have shown that thigh muscle weakness is associated with knee pain regardless of x-ray findings. Having strong thigh muscles has even been shown to protect against having knee pain regardless of x-ray findings. In other words, you could have a terrible looking x-ray but have strong thighs and have no knee pain. Or you could also have a perfect x-ray but still have weak thigh muscles and knee pain.

“Can I really get relief from knee osteoarthritis (OA)?” The answer is “Yes!” Physical therapy has been proven to decrease pain, decrease medication use and allow people with knee OA to return to meaningful activities while avoiding or even preventing surgery.

Schedule a Free Consultation by Phone or In-Person

Physical Therapists (PTs) uses some of the following techniques to help people with knee OA:

Strength Exercise

  • PTs modify exercises to avoid increasing joint pain.
  • Exercise gradually builds over time to increase strength without aggravating pain.

Low-impact aerobic exercises and walking

  • PTs work with you to find the right type and amount of aerobic exercise to increase the health of your joint and your endurance for daily activities

“Hands On” Techniques or Manual Therapy

  • PTs use their hands to increase the mobility of joints and muscles and to decrease pain
  • These techniques are performed to the patient’s tolerance and should NOT be painful
  • This is many people’s favorite part of the treatment session!

Have been told that you have arthritis and there’s nothing you can do about it? I would really love for you to give Physical Therapy a try. At worst, you’ll gain some strength and knowledge. At best you could get rid of your pain, get back to doing the activities you love, and stay independent.

Call (828)675-6875 to set-up a FREE phone or in-person consultation. Visit our website to learn more about our practice www.BigIvyPT.com

Group photo of senior friends exercising together
3D render of a medical image of close up of knee joint

Why Deep Squats Are Actually Good For You

So we’ve all been told that the “right” way to squat is toes pointing forward, lowering the hips to no deeper than knee level and strictly keeping the knees behind the toes, awkwardly leaning forward as we feel we are going to lose our balance backwards.  This is kind of weird considering how we have to move to get down on the floor, to pick something up from the floor, to poop on the ground (in previous generations or now for some of us), or how people sit and hang out in places where chairs aren’t common.  I won’t go into how this weird idea of a squat got introduced to the popular mind but I do want to go over some aspects of the deep squat, why it’s good and how it can benefit us.

The Actual Correct Way to Squat

Ok I just couldn’t resist this amazing image of what the human body can do. I would have to say this is definitely this yogi’s correct squat technique. Continue on below to learn more about correct squat technique for the average human body.

According to authors Comfort, McMahon, and Suchomel in “Optimizing Squat Technique- Revisited,McMahon”, based on a thorough review of scientific evidence “a full depth squat, with a natural foot position, approximately shoulder-width apart, with unrestricted anterior movement of the knees, an upright trunk, with a forward and upward gaze is recommended.”

Boom! So that’s it, but read on if you’d like to know a little bit more about why.



Forces on the Knee

Forces on the knee are higher when you squat lower, right?  No, actually the highest levels of stress on the knee are seen at around a 90 degree knee angle which corresponds to a squat to parallel. It turns out that as we allow the knees to bend and hips to sink below parallel in the squat, the anatomy of the knee allows enhanced load distribution and enhanced force transfer with lower compression under the knee cap.  Our knees were actually built for deep squatting.  Go figure. So when we squat to parallel, we are actually stopping our momentum and restarting in the zone of highest forces.  Bad. So go lower and turn the movement around when the forces are lower. Good.

Load Concerns

The whole point of squatting is to increase strength, right? That means using a heavy enough weight that our muscles get fatigued which will cause positive adaptations. Doing a deep squat fatigues our muscles faster with a lighter load than doing a half or quarter squat. This means that we can use a lighter weight to stimulate strength adaptation. A lighter weight means less compression on our spines, hips, and knees.  Good.

Keep the Knees Behind the Toes or Your Knees Will Explode

A common myth of squatting is that we must at all costs keep the knees behind the toes.  Funny how this doesn’t feel natural at all but we have decided this is the “right” way. This awkward squat actually increases stress at the hips and spine. When we do a squat to parallel and force the knees to stay behind the toes, we have to lean our chest  forward in order to avoid losing our balance backward. When we do this with a weight at the shoulders, this causes increased “anterior shear” forces at the lumbar spine.  

An anterior shear force in the lumbar spine is a force that could cause a vertebra to slide forward on top of another vertebra if not held strongly enough by the spinal joints, ligaments and muscles.  The lumbar spine is not as resistant to shear forces as other forces. These forces can cause failure of the stabilizing joints of the spine, possibly leading to spondylolisthesis- the slipping of one vertebra forward on another.  However, I don’t want to introduce a lot of fear here about anterior shear forces. Please keep in mind, when we progress weights at the right speed and with the right form, the spine itself as well as the muscles around it, will gradually become stronger and more resistant to all forces.   

Real Life Examples in Weightlifters

You may assume that weightlifters who are consistently squatting with massive amounts of weight would have high rates of injury because of all the forces they are putting on their knees, right?  And they probably have a ton of arthritis and joint degeneration over the years, right? Actually, NO they don’t! Turns out that the body is not an inanimate machine that just wears out as you use it.  No, the body actually gets stronger and tougher as you use it. Think about it- if you were to start doing a lot of shoveling without gloves, would the skin on your hands simply wear away to the bone, or would your skin thicken up into a callus?  Case in point, the knee joints of weightlifters were found to have thicker cartilage than the knees of untrained individuals. Thicker cartilage shows increased stiffness that corresponds to increased tolerance to mechanical stress.

What about injuries?  One study found Olympic weightlifters had 3.3 injuries per 1000 training hours over a 6-year period.  Another study found that Olympic weightlifters had a lower prevalence of injury than US basketball players, US track-and-field athletes, American football players and US gymnasts.  The point here is that yes athletes do get injured, but weightlifting has inaccurate bad rep as being particularly dangerous or injurious. I would also propose that when people perform correctly instructed weightlifting as part of a fitness routine, this injury risk will be even lower because we are not pushing for maximum weights at any cost.  Fitness participants are generally just trying to be healthy, and don’t have to push the body to the absolute limit.

Benefits of Deep Squats

Decreased injury risk:  Squatting past parallel increases the challenge to the gluteus complex and hamstrings.  This helps avoid dominance of the quadriceps muscles during sport and life activities. Quad dominance is thought to increase injury risk so it’s something to avoid.  Deep squatting may also strengthen structures of the knee, again protecting against injury.  

Stay independent longer: We need the ability to squat to get up and down from the floor, get off the toilet and pick things up from the ground.  Training the deep squat will help us to stay independent longer as we age. This is why older adults especially should be practicing the deep squat under as much load as they are safely able.  

Improved performance:  Studies show deep squat training increases vertical jump moreso than half and quarter squat training.

Look good in your jeans:  So if we are working the gluteus complex more in a deep squat, we are going to be building that highly sought after booty.  Honestly I wish that wasn’t even a thing that people cared about. But if it gets people into fitness, and then they get the side benefits of feeling better and being happier, then I’m all for it.  

Learning to Squat Correctly

Technique is important. If you’re not sure if you’re squatting correctly, head to a physical therapist to learn. In fact, come see me specifically. I love teaching people how to squat. As a physical therapist, I can assess what’s holding you back from doing the perfect deep squat and work with you to fix it.

References

Hartmann H, Wirth K, Klusemann M. Analysis of the Load on the Knee Joint and Vertebral Column with Changes in Squatting Depth and Weight Load.  Sports Med  2013 Oct;43(10):993-1008. 

Fry A, Smith JC, Schilling BK.  Effect of Knee Position on Hip and Knee Torques During the Barbell Squat. Journal of Strength and Conditioning Research, 2003, 17(4), 629–633.

Comfort P, McMahon JJ, Suchomel TJ. Optimizing Squat Technique—Revisited. Strength and Conditioning Journal.  2018 Dec; 40(6), 68-74.