CategoriesAssessment Rehab/Prehab

Neck Pain and Headaches: The Link and How To Find Relief

Whenever one of my clients or athletes walks in and starts to say something to the effect of “hey, my neck is really bothering me…..”

….I immediately put my fingers in my ears and start yelling “lalalalalala, I can’t hear you.”

Okay, kidding.

Neck stuff can be tricky if not terrifying, and I know my limitations as a strength coach. 90% of the time I refer out to clinicians more qualified in this department, but that doesn’t mean there aren’t some “first step” actions I can take to hopefully help and provide some relief.

In today’s guest post by Dr. Michael Infantino he provides some insights that are well within many strength coaches/personal trainer’s scope of practice.

Copyright: remains / 123RF Stock Photo

Neck Pain and Headaches: The Link and How To Find Relief

Today I want to help you figure out if your neck is the source of your headache and how to treat it. Headaches, similar to many other diagnoses, can lead you down a rabbit hole of confusion.

So many subtypes of headaches exist that it becomes overwhelming to actually go about treating them. Luckily, the link between your neck and headaches is becoming more recognized.

I regularly see patients who are referred for suspected cervicogenic headache. Cervicogenic headaches imply that the neck is the cause of your headache.

This can be tricky because most headaches will actually result in some type of neck tension. This isn’t to say that treating the neck in these scenarios is a waste of time. It may resolve neck pain.

It just isn’t the answer to resolving your headaches.

Assuming that your headaches are cervicogenic in nature, what is the next step? Treating your neck pain is only one piece of the puzzle. We need to get to the route of the problem. Blaming your headaches solely on your neck is somewhat naïve. You need to consider how your lifestyle may have resulted in your neck pain and headaches.

Remember, everything affects everything. When our neck hurts we start wondering what ligament, muscle, nerve, disc or bone may be injured. Often times neglecting the actual cause of neck pain.

Injury and inflammatory processes local to the neck can occur for a multitude of reasons. It is not always secondary to trauma. Most of us start wondering if we slept in a bad position the night before or think back to a neck injury we sustained twenty years ago.

“That must be the problem! I used to play way to hard in pee-wee football [#glorydays].”

Instead, we need to consider the BIG 3. Sleep, nutrition and exercise. Ask yourself these questions.

How has my sleep been?

How about nutrition?

Have I been neglecting exercise or neglecting recovery?

Most problems start with sleep, nutrition and exercise. If you are missing the mark in any one area expect problems. Missing the mark in multiple areas? Now we have BIG problems.

How To Diagnose Cervicogenic Headaches?

Here’s your sign…

  1. Headache triggered by sustained postures.
  2. Neck pain that triggers a headache.
  3. Neck pain and headaches that are located on one side.
  4. Less than 30 degrees of upper cervical range of motion.

It is more common for cervicogenic headaches to be located on one side of the head, but not always. In some cases, people will sustain a whiplash injury or concussion. Headaches associated with these injuries are often multifactorial. However, we have often seen improvements by treating each suspected cause.

Treating your neck in these situations tends to do wonders.

Considerations For All

Posture… blah, blah, blah. I know we hear about it all the time.

You need to be cognizant of your posture.

This doesn’t mean that you need to sit at attention all day.

My biggest pet peeve is hearing that an “ergonomic specialist” told you that you needed to sit like a statue… all day. “Tall, chin tucked, flat back, shoulder blades pinched…” You’re kidding right?

As always, “poor posture” is not necessarily the culprit when it comes to pain.

Staying in one position for too long is the problem.

This doesn’t mean you have free reign to sit like the Hunch Back of Notre Dame. Studies have shown that a forward head position can increase the frequency of headaches (C Fernández-de-las-Peñas, 2006).

We often overlook the fact that our posture can have a huge impact on how we feel. Picture someone that is sad or depressed. What does their posture look like? Now think of someone confident and enthusiastic. What does their posture look like? How you position yourself can really play into how you feel physically and emotionally.

Tip: Change position every twenty minutes. Taking a walk can do wonders. Drinking a lot of water can force bathroom breaks. If you are stuck in a car shift positions often. Add some neck motions, some back arches, etc.

Be creative… and safe.

Flexibility

With a forward head posture normally comes tense muscles. Doing a quick scan to see which neck motions and shoulder motions feel more limited can make a huge difference.

Multiple studies have found a correlation between cervicogenic headaches and tightness of the sternocleidomastoid, upper trapezius, scalenes, levator scapulae, suboccipitals, and pectoral muscles (Page, 2011).

The picture below keeps things relatively simple.

Stretch the tight muscles and strengthen the weak ones. We will give more guidance on this in the next section.

Strength

Strengthening the neck has shown to improve neck pain and cervicogenic headaches.

Pain, poor posture and trigger points can alter the strength, endurance, timing and proprioception of the muscles around your neck.

Once you address trigger points and flexibility, restoring strength and endurance around the neck can happen relatively quickly.

The more research we have, the less specific it seems we need to be with these exercises (Ask, 2009; Jull, 2009; Gross, 2009; Van Ettekoven, 2006). Studies have shown that specific neck and upper body strengthening can be just as effective as general strengthening (Anderson, 2011).

Some medical providers will argue for the use of “deep cervical strengthening” using a biofeedback cuff.

A what!?

This is basically a rigged up blood pressure cuff. I love using this with patients because it teaches them how to realign their neck without using a lot of big muscles. If you do not have a blood pressure cuff have no fear. Gently performing chin tucks while attempting to avoid large muscle contractions will do.

[Watch the Neck Pain and Cervicogenic Headache Strength video below for more details on chin tucks].

Breathing

Telling someone they need to breath a specific way comes with some challenges.

We don’t always know why they have adopted an upper chest breathing strategy. It could be postural or even developmental. Some of us adopt certain postures because of work requirements or cultural norms. Other times it could be related to how we breathe; mouth vs. nose breathing.

Studies show that mouth breathers more commonly present with forward head posture.

It seems that a forward head position helps increase respiratory strength by using neck and chest musculature (Okuro, 2011; Int J Neiva PD, 2009).

So a forward head position is good?

No, this is a compensation that leads to increased tension and trigger points.

The emphasis placed on diaphragmatic breathing has been great over the past few years. We also need to make sure people are learning how to perform nose breathing. Besides helping improve oxygenation and preventing forward head posture, it has many other wonderful benefits. Since this is not the main topic of today I digress.

 

How To Test & Treat Yourself

The goal here is to keep things QUICK and DIRTY.

We will go through (1) motion and (2) strength testing.

Do you need to do all of these tests?

Absolutely not.

The benefit of testing and retesting is to see if you are actually making change. If your motion and strength improve after a couple weeks without resolution of headaches we need to go back to the drawing board. Consider seeing a skilled medical provider.

If you are short on time just go right to the “Ouch Test.” This is when you roll some inanimate object on your neck in an effort to identify trigger points. With a smile on your face of course.

Motion and Tissue Quality Testing:

 

1. Flexion/Rotation Test

The goal here is to see if your upper cervical rotation is limited in one direction. Cervicogenic headaches are usually attributed to dysfunction at the upper three cervical levels.

Flex your neck and rotate your head in an attempt to identify a “tighter side.” Keep in mind that what you feel isn’t always real. Give it a shot and consider using a friend to assist or a video camera to identify the direction you are limited in.

If you can’t get your chin to touch your chest we already know your neck needs some work.

2. Rotation/Flexion Test

If you had trouble getting your chin to your chest this test will help you identify if one side is tighter. This time you are rotating and then attempting to touch your chin to your collarbone.

This lets us know if upper cervical flexion is more limited on one side than the other. If you are limited, the assumption is that the opposite side cervical musculature is limiting you. To measure, see how many fingers can fit between your chin and collar bone.

Having objective measures will help you see if you made progress after treatment.

3. Follow The Map

Sometimes a roadmap is helpful for identifying the muscles that may be contributing to your pain and headaches. Being familiar with muscle referral patterns can help remove a little anxiety related to your pain. It helps prevent you from always thinking the worst when pain sets in. With a road map it is easier to get to your destination.

4. The “Ouch” Test

This is a more simple way of identifying which muscles may be triggering your headaches. Use your fingers, a roller stick, Thera-cane, lacrosse ball or whatever to identify tender regions around the upper neck and shoulders.

If a spot actually recreates your headache, you struck GOLD.

If you identify a tender region that does not recreate your headache, it would not hurt to treat it anyway.

5. Strength Testing

 

Chin Tuck and Lift Test

  1. Lying flat on the ground or in bed, place on hand underneath your head.
  2. First perform a small chin tuck and then remove your hand from behind your head without changing position.
  3. Men should be able to maintain this position for at least 40 seconds with minimal shaking local to the head and neck.
  4. Women should be able to maintain this position for at least 30 seconds with minimal shaking local to the head and neck (Domenech et. al, 2012).

Treatment. Let’s Get To Work.

1. Soft Tissue and Joint Treatment

Our goal here is to restore motion to the upper cervical region and resolve any trigger points.

 

2. Strength Treatment

We believe in being better than the average.

Your goal is to be able to hold the chin tuck and lift position for 1 minute, in a curl up position. We work on short duration holds with repetitions to help avoid excessive soreness.

Please do not be a hero and do long duration holds each time you exercise.

This recommendation is not for your general strength routine, only for this rehabilitation plan.

Goal: 1 minute hold in curl up position.

Retest: At the end of each week.

Protocol [See strength video above for demonstrations]:

Phase 1: Chin Tuck and Lift. 5 second holds for 10 repetitions. (5x/week)

When you can perform this with ease and no pain move on.

Phase 2: Chin Tuck and Lift. 10 second holds for 10 repetitions. (5x/week)

When you can perform this with ease and no pain move on.

Phase 3: Curl up + Chin Tuck and Lift. 5 second holds for 10 repetitions. (5x/week)

When you can perform this with ease and no pain move on.

Phase 4: Curl Up + Chin Tuck and Lift. 10 second holds for 10 repetitions. (5x/week)

Headache Diary: Become A Good Detective.         

Using a headache diary is a great way to identify the source of your headache.

If you want to be a good detective you need to take some notes. Noting the time of day, triggers (specific activity, specific movement you made, foods you ate, your mood, etc.), symptoms that preceded your headache, medications used and how you found relief.

Achieving 1% gains in various regions of your life, on a daily basis, is a surefire way to resolve most health issues.

Overview

The link between cervical dysfunction and headaches is often overlooked.

Basic maintenance that includes soft tissue work, strength, awareness of posture and proper breathing could be the fix you need. The medical community as a whole has been getting better at addressing the cause of headaches rather than covering them up with medication. Putting a spot light on the fundamental components of health should always be the answer.

Getting sleep, nutrition and exercise right is often the answer to most disease and illness. This will make your life much simpler, not to mention how much better you will feel.

Interested in a FREE home exercise plan. Click here to get started today!

About the Author

Dr. Michael Infantino is a physical therapist. He works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.

 

CategoriesCorrective Exercise Program Design Rehab/Prehab

Bicep Tendonitis? When In Doubt Check These 5 Muscles Out

Today’s guest post by Dr. Michael Infantino of RehabRenegade.com covers an often glossed over culprit of shoulder pain….the bicep tendon.

It can be an annoying area to treat/work around and when not addressed can derail anyone’s training for a long time.

However, an injury with the bicep tendon isn’t always as tumultuous as it may seem, and sometimes can be tackled with some simple fixes. 

Enjoy.

Copyright: myvisuals / 123RF Stock Photo

 

Bicep Tendonitis? When In Doubt Check These 5 Muscles Out

Knowledge and wisdom are not one in the same. A profound statement for an article that is going to discuss pain at the plain old bicep tendon. The reason I bring this up is because an endless amount of information is available to you through the internet.

When you search bicep tendon pain you will likely run into 100,000 articles that talk about pain local to the bicep tendon. I could make an argument that less than 1% will discuss techniques that you can implement to independently resolve your pain.

That is our plan for today.

Before we start drawing up a six week rehabilitation plan for your shoulder or sending you to the nearest orthopedic surgeon, lets attempt some quick fixes. Please, do not mistake a quick fix with a half-hearted attempt.

Refrain from replacing the whole roof when a few shingles will do.

Step one is making sure you are an appropriate candidate for this article. Let’s rule out a bicep tendon rupture!

Schedule an appointment immediately with an Orthopedic Physician if:

1. You heard a sudden “ pop” at the shoulder, along with swelling and bruising around the bicep.

This typically occurs when you are trying to “man up” and carry something that is a tad bit too heavy for you. Often a result of your best friend refusing to pay for a moving company.

2. You have a nice “Popeye” deformity at the bicep.

This doesn’t imply that you have impressive biceps. It means you tore the bicep tendon.

Other Reasons For Concern:

Weakness and pain local to the bicep when flexing the bicep or rotating your palm up to the sky with the elbow partially bent. This does not indicate a rupture, but a partial tear is still possible.

I don’t think I tore my bicep tendon. What else could cause irritation to the bicep tendon?

It is common for the bicep tendon to be a pain generator because of its location. The bicep tendon is often impinged between the humerus and surrounding structures in the shoulder (usually the acromion and the coracoid process).

Keep in mind that impingement is normal.

We have nice “cushions” named bursae that are built to tolerate this compression. It is when this compression becomes too frequent or too intense that we see injury occur at the bicep tendon. We tend to see this in people who perform a lot of overhead activities in athletics or with work requirements.

It hurts when I rub my fingers across the bicep tendon. Doesn’t this mean it is a bicep tendon problem?

Simply rubbing your finger across the bicep tendon is not an accurate way to diagnose a bicep tendon injury. This is the most common mistake I see by medical providers and those with a certification in WebMD browsing. This is not a specific or sensitive test for diagnosing a bicep tendon injury. (Gill, HS)

What is the best way to determine if the bicep tendon sustained an injury?

The gold standard would be an ultrasound from a physician (Skendzel, JG). Isolating the bicep is the next best method. Resistance to the bicep, or lowering yourself in a reverse grip pull up is also useful information.

It is possible that you have developed some inflammation local to the bicep tendon. Most of the special tests specific to the bicep do not have great statistics. We can make a more accurate diagnosis by considering how you sustained your injury and the movements that provoke your pain.

Could pain at the front of my shoulder be related to something else besides the bicep tendon?

Absolutely. Muscles throughout the shoulder and neck can refer pain to the front of the shoulder. The same way that organs can refer pain to different regions of the body.

Let’s check out 5 muscles that commonly refer pain to the front of the shoulder.

 

Note From TG: A lacrosse or tennis ball work well for all the drills demonstrated in the video, but my preferred “tool” is the ACUMobility Ball by ACUMobility.com.

Use the coupon code GENTILCORE at checkout for an additional 10% off your purchase.

Deltoid

People often forget that the muscle fibers of the deltoid run over the bicep tendon. When you feel pain while pressing around the bicep tendon it may actually be an irritated deltoid.

Biceps

Another no brainer if you are having pain around the bicep tendon. Overuse of the biceps or a quick force applied to the biceps (eccentric force) can cause trigger points to develop in this muscle. If you notice increased discomfort around the bicep some soft tissue work and a few days off from the “gun show” should help.

Pectorals/Subclavius

The real problem here could be too many chest days and not enough leg days!

Poor resting posture during the day and poor technique with exercise are often the true culprits. Falling into a slumped position on a regular basis can put the pectorals in a shortened position.

This faulty posture can lead to excessive impingement, as well as increased tone and trigger points in the pectoral muscles.

The subclavius runs deep to the pecs. It attaches between the clavicle and the first rib, often referring pain to the front of the shoulder. You can usually address this spot while working on the upper fibers of the pecs.

Scalenes

These muscles run on the front, side and back portion of your neck.

The scalenes are one of the many muscles responsible for moving your neck. If you tend to adopt a forward head posture or a slight tilt of the head to the left or right these muscles may be engaged more often than necessary.

Having a forward head posture means that you are passively hanging on these muscles for support during the day. This can lead to increased tone and trigger points. We also tend to see issues in the scalenes show up following a whiplash injury.

The scalenes are also involved in breathing. If you tend to be an upper chest breather these muscles may be taking a beating. Keep in mind, adopting this breathing style can lead to increased tension in the neck and thorax, as well as feelings of anxiety. After you do some soft tissue work, be sure to be more aware of posture and work on accessing your diaphragm.

Infraspinatus

The infraspinatus in one of the four infamous rotator cuff muscles.

It runs right on top of your shoulder blade.

Dysfunction in this muscle tends to show up regularly with shoulder pain. Trigger points in the infraspinatus are a problem because they alter timing and strength of this muscle (or any muscle). This alters normal mechanics at the shoulder with overhead activities. Often leading to an unstable shoulder with excessive impingement taking place.

We wrote another article in the past that discussed how referred infraspinatus pain also resembles carpal tunnel syndrome. This is not the easiest muscle to treat on your own, but don’t skim over it.

Final Consideration:

In some instances, performing soft tissue work around the shoulder will do the job just fine. This does not mean we can overlook the pieces that may have contributed to this injury in the first place. Your goal is to control what you have the ability to control.

What can you control?

1. You can normalize the tissues surrounding the shoulder.

Treat local trigger points, normalize muscle flexibility and reduce stiffness. The goal is to restore normal shoulder mechanics to the best of your ability. Treating muscle stiffness and trigger points helps optimize the timing and strength of the muscles around the shoulder to enhance stability.

2. You can also modify your activity for the time being.

If a certain activity worsens your pain, back off. It is possible that your shoulder is inflamed and needs some time to recover. This is not a fast pass to weeks off from the gym with your best friend Netflix. This means more attention on soft tissue work and flexibility. You also want to gradually return to exercise. Experiencing some discomfort during exercise is ok.

“Poke the bear, but don’t take it to dinner.”(in reference to pain)

– Adriaan Louw

 Interested in a FREE Mobility Program to treat pain at the front of the shoulder? Click here

About the Author

Dr. Michael Infantino is a physical therapist. He works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.

 

 

 

 

References

Gill HS, El Rassi G, Bahk MS, et al. Physical examination for partial tears of the biceps tendon. Am J Sports Med 2007; 35:1334.

Skendzel JG, Jacobson JA, Carpenter JE, Miller BS. Long head of biceps brachii tendon evaluation: accuracy of preoperative ultrasound. AJR Am J Roentgenol 2011; 197:942.

Stephen M Simons, MD, FACSM, J Bryan Dixon, MD Section, Biceps tendinopathy and tendon rupture
Uptodate.com

Taylor SA, O’Brien SJ. Clinically Relevant Anatomy and Biomechanics of the Proximal Biceps. Clin Sports Med 2016; 35:1.

CategoriesRehab/Prehab

What Your Doctor Never Told You About Arthritis

Today’s guest post comes courtesy of physical therapist Dr. Michael Infantino, and covers a topic every human in the history of ever has had to deal with.

It’s good. You should read it.

Enjoy.

Copyright: staras / 123RF Stock Photo

What Your Doctor Never Told You About Arthritis

Physician: “Welcome. Thanks for coming in for your appointment this morning. It says here that you are having shoulder pain. Is that correct?”

You: “Yes it is. I didn’t think anyone actually read that intake form. I am glad that I took the 30 minutes to fill it out in the waiting room. Also, thank you for taking me back only 45 minutes later than my scheduled appointment time. That’s way better than my previous appointments.” [In a sarcastic tone.]

Physician: “Well there could be a host of reasons that you are having shoulder pain. Did you fall recently? And how old are you? Did you know that most 40 year olds have arthritis?”

You: Inner dialogue, “No, I didn’t fall. Fall? What am I 90 years old?” “I exercise regularly Doc. It hurts sometimes when I am bench pressing or doing shoulder press. Can’t think of any specific incident when it first started hurting.”

Physician: “Did you ever consider not lifting weights? It may be rewarding to have those big muscles, but it could increase your risk of injury. Look at me. I do 20 minutes of stationary biking each day, no pain… try that.”

You: [Scratching your head] Again, inner dialogue, “He is kidding, right? I would rather beat my head into a wall than stationary bike for 20 minutes.”

Physician: “Ok, lets do some testing on you. (Three minutes later) Well, luckily I didn’t find anything that resembled a rotator cuff tear or instability. You also don’t seem to be missing much motion so we can throw a frozen shoulder diagnosis out the window. Why don’t we have an X-ray done?”

You: “Ok Doc. You are the boss… this should tell me what the problem is, right?”

Physician: “For the most part, yes. We can see if you have any bone spurs or arthritis. Remember what I said about old people right? They get arthritis.”

You: “Old? I am 40 bro!”

THE FINDINGS:

Physician: “It seems here that you have some arthritis in your shoulder. This explains your pain. You could try taking some anti-inflammatories. Exercise might help to. Here is a list of rotator strengthening exercises that we use. Have at it! If this doesn’t work come back in a few weeks and I can inject it with cortisone.”

You: You think to yourself, “Shoulder exercises? I work out my shoulders all the time. Is the Doc saying I am weak? Am I going to be popping anti-inflammatories my whole life?”

As doom sets in you start to think about all the moments you have taken for granted.

The joy you get from bench pressing and the euphoria that bicep curls provide. The ease in which you were once able to perform the perfect landmine press, never having to worry about your shoulder.

 

You start questioning past decisions. If I only would have strengthened my rotator cuff muscles earlier or just road the stationary bike like the DOC.

As you are drowning in self-pity the pause button is pressed, and some random guy pops out to provide what might seem like a cheesy infomercial.

Random Guy: “Hello! I am aware that your physician just made arthritis seem like the death sentence. Before you leave today demoralized, let me give you some facts about arthritis to ensure that you don’t sentence yourself to a lifetime of stationary biking. He tried that line on me once too.”

What is Arthritis and What Does This Mean For Me?

Osteoarthritis is the most commonly diagnosed form of arthritis. Referred to as the “wear and tear” arthritis.

This label holds some truth, but it does not tell the whole story. Living a life enriched by the joys of picking big things up and putting them down may lead to more arthritis than stationary biking.

Surprisingly this is not always the case. In another article, we talk about a study that showed a significantly higher rate of arthritis in a sedentary obese population compared to a lifetime recreational runner.

Osteoarthritis is actually the result of increased inflammation surrounding the joint.

Remember that inflammation is your body’s attempt at healing tissue.

Unfortunately, your joints and cartilage do not always allow for optimal blood flow. Instead of providing healing it just leads to some degeneration. What you need to understand is that many other factors can contribute to arthritis.

This includes:

  1. natural aging
  2. obesity
  3. diet
  4. gender
  5. previous injury
  6. your god given anatomy

Arthritis. “The Get Out of Jail Free Card.”

Arthritis seems to be that “get out of jail free card” for most clinicians.

You show up complaining of pain without any recent trauma. You don’t recall dropping a barbell on your chest or hearing a pop after throwing a no-hitter… for your co-ed softball league.

It seems like your rotator cuff and labrum are safe and sound.

We strive to avoid wrinkles like we strive to avoid arthritis.

So what usually happens next?

Your medical doc whips out the “big guns” of course.

In this case that would be an X-ray, MRI or ultrasound.

Come to find out you have a little bit of arthritis at the shoulder.

Lets stop for one second.

For some reason we imagine this life where we defeat the natural aging process. We strive to avoid wrinkles like we strive to avoid arthritis. Wrinkles may be a source of pain just as much as arthritis is.

More importantly, having arthritis does not necessarily mean you are going to have pain.

It wasn’t until some brilliant people started putting people without pain under X-ray that we realized something extraordinary.

They have arthritis too, but no pain!

One study found that arthritis and degeneration of the spine progressively increased with age. However, that is generally NOT true with pain. People also complain of back pain more frequently in their 40’s to early 50’s (Louw, 2017). From there it steadily declines despite the fact that arthritis steadily increases.

More than 90% of 60 year olds (without complaints of pain) will present with some form of degeneration around the spine (Brinjikji W. et al).

As much as we hate to hear it, we need to remember that inflammation does not create pain. It just warns the brain that we may have a problem.

The brain determines whether or not you feel pain.

People who have had limb amputations because of rheumatoid arthritis (another form of arthritis triggered by an autoimmune disease) continued to feel stiffness in a limb that was no longer there (Haigh et al).

Basically, phantom limb pain.

This reinforces the idea that part of your discomfort is also because of a sensitized central nervous system. Your brain and nerves get all hyped up the longer your pain lasts. This is why pain management and physical therapy are focusing on finding ways to desensitize your central nervous system. This includes things like graded motor imagery and helping people understand how pain really works.

It is Time To Do Your Best Sherlock Holmes Impersonation.

With what you know now, how terrible would it be if arthritis were blamed for your pain without considering other causes?

We may go through the rest of life thinking that nothing that can be done.

On top of that we think, “if I have arthritis now how bad will in be in ten years from now?”

You may even consider canceling your gym membership and living in a bubble. Before it gets to this point try to enhance your self-awareness. Consider what activities may be contributing to your pain. Poor programming, bad technique and lack of focus on mobility.

These are all low hanging fruit.

Other considerations for reducing inflammation:

  1. Diet
  2. Sleep
  3. Exercise
  4. Physical and Emotional Stress

Failing at any of the categories listed above can elevate local joint inflammation. Potentially leading to pain. People neglect the importance of a diet that minimizes inflammation. We have a general idea of the foods that cause more trouble (breads, pastas, dairy, sugar, red meats, and so on).

Losing weight, minimizing alcohol intake, not smoking, exercising and cleaning up your diet is usually sufficient for getting on the right path.

Many recommendations for herbal supplements and vitamins exist. But don’t think that taking some turmeric and fish oil will override the bowl of ice cream you take down every night.

Or the occasional soda with lunch.

We also know that being deficient in certain vitamins can result in increased levels of inflammation. In a study that looked at the relationship between knee pain and arthritis, “people with knee osteoarthritis who were obese but had healthy vitamin D levels were less disabled than people who were obese individuals but had insufficient vitamin D levels.”

Make sure you consult with your doctor before implementing any vitamin supplementation.

More is not always better.

Consuming too much of one vitamin could cause toxicity or alter the effectiveness of other vitamins (Glover et al).

If You Are Already Making All the Right Lifestyle Choices and Still Having Pain What Can We Do?

Muscle can often be the source of a lot of the aches and pains we experience. Inflammation at a joint or trigger points in a muscle both increase those danger signals back to the brain.

Our goal is to decrease those danger signals in as many ways as possible.

That could be treating the muscle, reducing stress, getting more sleep, improving our diet and so on.

To start moving in the right direction we can benefit heavily from seeing a professional.

Who exactly?

It really depends on your preference.

A lot of overlap exists between massage, physical therapy, chiropractic, acupuncture and so on these days. Many of these disciplines are using similar services when it comes to hands on treatment.

For example, cupping, joint mobilization, manipulation, soft tissue manipulation, instrumented assisted treatment, active release techniques and more. Other disciplines besides physical therapy are also using exercise. Doing your research, and finding out which provider specializes in your injury is more important than ever.

Been There, Done That and Still No Success?

This is when I would look to a medical doctor, preferably someone that specializes in orthopedics or sports medicine. Knowing that you have been through conservative care already they will most likely recommend an X-ray, ultrasound and/or MRI.

Caution: Ignorance is sometimes bliss. This is when you are going to see what your joint really looks like. It is not always pretty, and “degeneration,” “tears,” “bone spurs” are not always synonymous with pain. Do not let these findings immediately make you think that surgery is necessary.

  • 2/3 people over the age of 70 have pain-free rotator cuff tears (Milgrom, Schaffler et al., 1995)
  • 50% of people with knee arthritis have no reported pain (Bedson and Croft, 2008)
  • 35% of collegiate basketball players without reported knee pain have notable abnormalities on MRI (Major and Helms, 2002)

The doc offered a cortisone injection… should I do it?

Cortisone tends to be used more commonly with knee and shoulder pathology. It has been shown to be effective at reducing pain. The goal is to reduce inflammation local to the joint.

“Yea, but isn’t inflammation a good thing?”

Great question.

Yes, it can be, but excessive inflammation can cause increased stress on a tissue, enhancing those danger signals. Ultimately resulting in more pain.

Could cortisone cause more damage?

It is possible that excessive use of cortisone can weaken tissues leading to possible tissue injury. What is “excessive use” defined as? That part varies depending on who you ask. Learn a little more about cortisone injections from the Cleveland Clinic.

Should I take Aspirin (anti-inflammatories)?

Anti-inflammatories may be effective as reducing local inflammation.

Some studies have shown that cortisone may be more effective, but not in all cases. Anti-inflammatories like aspirin are not meant for long-term use secondary to its harmful effects on the gastrointestinal system.

“Possible risks of all NSAIDs include: stomach problems (such as bleeding, ulcer, and stomach upset), kidney problems, high blood pressure or heart problems, fluid retention (causing swelling, such as around the lower legs, feet, ankles, and hands), rashes, or other allergic reactions.” (Rheumatology.org).

As always, consult with your physician.

The doctor gave me a home exercise plan for my shoulder. Will this work?

It depends.

As we mentioned earlier, exercise that does not increase pain can be beneficial.

To keep it simple, “motion is lotion.”

Movement also increases local blood flow, which can help reduce inflammation.

Cardiovascular exercise can reduce pain through endorphin release (self made pain killers). Keep in mind that working through pain on your generic rotator cuff strengthening program will get you no where. Not to say that working through a little pain is a bad thing. The assumption that a weak rotator cuff is the culprit is often misguided.

Interested in a FREE Shoulder Mobility Program to help reduce pain? Click here.

Overview

Arthritis is not a death sentence.

It also does not mean that you need to resort to stationary biking and aquatic therapy.

Arthritis is as normal as developing wrinkles when it comes to aging. Before you blame your pain on arthritis consider the low hanging fruit that you are not addressing. If you need a little boost get a second pair of eyes on you at the gym. Also consider seeing a medical provider that can do some soft tissue and joint mobilization.

Low Hanging Fruit:

  1. You weight
  2. Diet
  3. Sleep
  4. Exercise Routine (programming and technique)
  5. Self Care Practices (mobility work and rest)
  6. Stress (physical and emotional)

About the Author

Dr. Michael Infantino is a physical therapist. He works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.

 

 

 

 

References

Arroll, B., & Goodyear-Smith, F. (2005). Corticosteroid injections for painful shoulder: a meta-analysis. The British Journal of General Practice, 55(512), 224–228.

Bedson, J., & Croft, P. R. (2008). The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature. BMC Musculoskeletal Disorders, 9, 116. http://doi.org/10.1186/1471-2474-9-116

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.

Glover T, Goodin B, King C, Sibille K, Herbert M, Sotolongo A, Cruz-Almeida Y, Bartley E, Bulls H, Horgas A, Redden D, Riley J, Staud R, Fessler B, Bradley L, and Fillingim R. (2015). A cross-sectional examination of vitamin D, obesity, and measures of pain and function in middle-aged and older adults with knee osteoarthritis. Clin J Pain; 31 (12); 1060-67.

Haigh RC1, McCabe CS, Halligan PW, Blake DR. Joint stiffness in a phantom limb: evidence of central nervous system involvement in rheumatoid arthritis. Royal National Hospital for Rheumatic Diseases, and Department of Medical Sciences, University of Bath, UK.

Liu-Bryan R, Terkeltaub R. Emerging regulators of the inflammatory process in osteoarthritis. Nat Rev Rheumatol 2015; 11:35.

Louw, A., Zimney, K., Johnson, E.A. et al. Aging Clin Exp Res (2017) 29: 1261. https://doi.org/10.1007/s40520-017-0731-x

Loeser RF, Goldring SR, Scanzello CR, Goldring MB. Osteoarthritis: a disease of the joint as an organ. Arthritis Rheum 2012; 64:1697.

  1. Major and Clyde A. Helms. MR Imaging of the Knee: Findings in Asymptomatic Collegiate Basketball Players. American Journal of Roentgenology 2002 179:3, 641-644

Milgrom, Charles & MB, Schaffler & Gilbert, S & van Holsbeeck, Marnix. (1995). Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. The Journal of bone and joint surgery. British volume. 77. 296-8.

Serdar Kesikburun, MD, Arif Kenan Tan, MD, Bilge Yilmaz MD, Evren Yasar, MD, Kamil Yazicioglu, MD. Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy: A Randomized Controlled Trial With 1-Year Follow-up

Up To Date: Pathogenesis of Osteoarthritis.

CategoriesStuff to Read While You're Pretending to Work

Stuff To Read While You’re Pretending To Work: 12/22/17

I’m sure I’m in the same camp as everyone else in that I’m scrambling to get some last minute Christmas shopping done.

Speaking of which, now that we have a kid and this is his first Christmas, I think I can buy an X-Box, have Lisa open it as a present, and say it’s for the family, right? RIGHT?1

Okay, time to get to shopping. Wish me luck and MERRY CHRISTMAS & HAPPY HOLIDAYS TO EVERYONE!

Copyright: gregorylee / 123RF Stock Photo

But First

1. Coaching Competency Workshop – Dallas, TX

A week from today I’ll be in Dallas, TX putting on my Coaching Competency Workshop.

I’ll break down assessment in addition to troubleshooting common strength-based exercises such as deadlifts, squats, shoulder-friendly pressing, to name a few.

This is ideal for any personal trainer, coach, or regular ol’ Joe or Jane looking to learn more on my coaching process.

Details are located on the flyer above, and you can purchase HERE.

2) Mark Fisher Fitness Presents: Motivate & Movement LAB

I’ve had the honor of presenting at two previous iterations of the Motivate & Movement LAB (the brainchild of MFF’s Harold Gibbons) and it’s unequivocally one of the most unique events in the fitness industry.

Think: TED Talk, but with deadlifts and lots of f-bombs.

Anyways, the next LAB is this coming February, and will feature myself, Dan John, Pete Dupuis, my wife (Dr. Lisa Lewis), and several of the MFF coaching staff including Brian Patrick Murphy and Amanda Wheeler.

3) Spurling Spring Seminar

JUST ANNOUNCED: I’ll also be making a cameo up in Kennebunk, Maine this Spring for the Spurling Spring Seminar.

It’s not until April, but you can save BIG now ($100 off) by purchasing an (early) early bird ticket by clicking the link above.

[Link also provides details on all the presenters and topics covered]

There aren’t many industry events that come into this neck of the woods, so hope to see you there!

Stuff To Read While You’re Pretending To Work

Do Your Bodyweight Exercises Suck Compared To Your Loaded Ones? – Marianne Kane

I thought this was an interesting article as it’s a phenomenon I see quite often: a client crushes his or her’s barbell squats or deadlifts, only to struggle with, of all things, push-ups.

One Common Myth That Will Keep You In Pain – Michael Infantino

Wow – this was/is a deep article.

Grab a cup of coffee, you’ll need it.2

Merry Christmas, Bob – Chris Shugart

I read this article for the first time waaaaaaay back in 2002 or 2003 or something like that.

Whatever the case: smart phones and social media didn’t exist.

It’s still one of my all-time favorite articles and one that Chris reposts on T-Nation each year.

Social Media Shenanigans

Twitter

Instagram

CategoriesAssessment coaching Corrective Exercise

The Gym Is a Pain In My Neck: Two Movements To Cure Them All

When it comes to neck pain, as a strength coach, I (generally) don’t touch that with a ten-foot pole. It’s case dependent of course, but more often than not, if someone I’m working with walks in with a some significant discomfort in their neck I 1) start hyperventilating into a paper bag and 2) immediately refer out to a someone who has more diagnostic and manual therapy skills.

This is not to say, however, that there aren’t any avenues to take if you’re a personal trainer or strength coach. It’s not like you can’t do anything. In today’s guest post physical therapist, Dr. Michael Infantino, goes into great detail on some things to consider if you ever find yourself in this predicament.

Enjoy.

Copyright: olegdudko / 123RF Stock Photo

The Gym Is a Pain In My Neck: Two Movements To Cure Them All

Are you struggling with neck pain?

Does the gym make it worse?

Do you find yourself looking at a lot of informative websites for ways to resolve these issues, but wish it were compactly put in one place?

Does this sound like an infomercial?

Well it’s not!

But for just $29/month you can… just kidding.

This article is here to solve all of those problems. Neck pain is often blamed on poor form when exercising. This is absolutely true. Unfortunately this does not answer a crucial question, “why?” Discovering WHY your form is poor is the goal. On top of that, people often fail to recognize other human errors that are contributing to their symptoms. We will provide a guide for figuring out why you have neck pain and how to resolve it.

In most cases, pain attributed to the gym can be tied to the following:

  1. Limitations in the necessary mobility to perform a movement
  2. Limitations in the skill needed to perform a movement
  3. Limitations in the capacity to perform a movement (Strength and Endurance)
  4. Human error [Electrolyte and Fluid balance, Self-Care, Rest, Sleep, Breathing, Posture, Medication and Fear.]

Limitations in MOBILITY: 2 movements to cure them all!?

Limitations in your ability to put yourself in optimal positions during almost any upper body movement are a result of two movement limitations.

Limitations in these positions can lead to a host of different complaints. For the sake of time we are going to pick on NECK PAIN. If you are struggling with one exercise you are likely struggling with another, you just might not realize it.

Position #1: Shoulder Extension Test

Movements: Push Up, Pull Up, Row, Dip, Pull Up (top), Jump Rope, Punching someone in the nose because they have one of those weird miniature poodle mixes.

Attempt to perform the ^^THIS^^ motion

Instructions: Keep the neck retracted while extending the shoulders just beyond the trunk without the following:

  • Increased forward head position
  • Forward shoulder translation
  • Shoulder shrug

 

If you are unable to replicate the picture above you likely have a MOBILITY problem.

If you can’t perform this motion when you aren’t under load, you will definitely struggle when you are. Especially with repeated repetitions and the addition of weight.

Target Areas for Treatment

Soft Tissue Mobility

  • Pecs
  • Serratus Anterior
  • Upper Traps

 

Stretches and Joint Mobilization

  1. Chin Retraction

 

  1. Thoracic Extension (arms overhead)

 

  1. Open Book Stretch

 

After working these bad boys out I want you to RE-CHECK the test position.

Is it better?

If not, you need to keep working on it.

Assuming you now have the necessary MOBILITY to perform this motion, we need to make sure you have the required SKILL with the particular movement you are interested in.

 Skill: the necessary strength, stability and coordination to perform the most basic form of a loaded movement (pull up, push up, dip, row, etc.).

Are you able to maintain a good position in the:

  • Bottom of your push up
  • Row
  • Top of your pull up
  • Bottom of your dip
  • Jump roping
  • As you load the arm for a hay maker!

We aren’t as complex as you might think. Many of our daily activities are broken into a few movement patterns.

Follow this sequence:

  1. Create the mobility necessary to perform the pattern in its most basic form. (In this case, Position #1 and #2).
  2. Ensure you have the skill needed to perform your desired movement (Push Up, Pull Up, etc.)
  3. Build capacity with that movement (Endurance and Strength).

If you don’t have the skill to perform a specific exercise or movement, you need to practice. Look at the above definition of skill to make that judgement. If you don’t have the baseline strength to perform one good push up, pull up, dip or row, see below for regressions that will allow you to maintain good form as you work your way back to mastering these moves.

Here are some ideas:

Push Up: Inclined position (Ex. against weight bench or counter), knee push ups

Pull Up: Assisted with a band, inverted row

Dip: Assisted with a band, bench dip

Row: Kind of an outlier since this move typically doesn’t require body weight. Use a weight that allows good form. TRX Row and inverted row are body weight options. Adjust the angle of your body to reduce the difficulty.

 

The goal here is to demonstrate the ability to maintain proper form throughout each movement with a regression that is appropriate for you.

Joe Muscles next to you may need to take 50 lbs. off his 200 lb. weighted belt during his pull-ups to maintain good form. You may need to work on getting one pull up with good form without any extra weight.

Most of us have one or two good pull ups in our bag of tricks to whip out for an “impromptu” Instagram post. Preventing injury is going to require you to build the strength and endurance to exceed Instagram’s one-minute time cap. DAMN you Instagram!

Adding repetitions and weight to the regression will help you work your way back to a standard pull up, row, dip, push up, etc.

I can’t emphasize this point enough.

We all have high expectations of ourselves. Neck pain after 10 reps is not necessarily a “push up” problem. It may be the fact that you did three other exercises before push ups that started to fatigue the neck. The push up was the breaking point. You need to have a realistic expectation of your current ability, or capacity.

Position #2: Overhead Test

Movements: Overhead Press, Pull Up (bottom position), Snatch

Instructions: Lie on your back with knees bent. Tuck chin (neck flat to ground) with arms flat to the ground in the start of a press position. Press arms overhead by sliding arms along the ground.

Common Faults:

  1. One or both arms come off the floor at any point in time.
  2. Compensatory forward head or extended neck position to keep arms on floor
  3. Compensatory spine arch to keep arms on the floor

 

Assuming you repeatedly tried to replicate this position without success, once again we have a MOBILITY PROBLEM.

Target Areas for Treatment

Soft Tissue Mobility

  • Pecs
  • Lats
  • Rhomboids

Stretches and Joint Mobilization

  • Chin Retraction
  • T-Spine Drop In (or T Spine Extension)
  • Open Book Stretch (Add: External Rotation at Shoulder)
  • 1st Rib and Scalene mobility

 

After finding the weak link, it is time to RE-CHECK. If it looks better, great let’s move on. Similar to Position #1, assuming you now have the pre-requisite MOBILITY to perform this motion we need to make sure you have the SKILL necessary.

*If you are having trouble improving your mobility or resolving pain, seek the advice of a qualified medical provider or fitness professional.

Can you maintain the same control and form during your overhead press, snatch, hang position of your pull up (or any variation- kipping pull up, toes to bar)? If not, we need to REGRESS the move. Unlike the shoulder extension position, many of the overhead exercises can be regressed by reducing the weight or working on single arm presses instead of two arms. Other regressions include:

Regressions:

Overhead press: Landmines (Tony goes into more depth in this article).

 

Snatch: Cleans, Single arm overhead kettlebell squat, single arm overhead lunge

Pull up (bottom): use a resistance band for support, inverted row

Human Error

Now that you have mastered Position #1 and #2, it is time to make sure that you are limiting HUMAN ERROR.

I think everyone should have someone in their life that serves as an extra pair of eyes. Even the best fitness trainers and medical providers in the world have a hard time being objective toward different areas of their own life. Barbers don’t cut their own hair, right? Not positive about that one. Either way, you can’t go wrong with some quality feedback!

Most of us are quick to blame the boulders in our life when it comes to pain, but we overlook the pebbles.

With pain we can’t overlook the pebbles.

The pebbles are diet, water intake, sleep, and self-care habits.

Patients usually tell me that they are doing “better than most” or that they are “pretty good” about optimizing these areas of their life. It isn’t until their spouse shows up to the appointment that we get the whole truth.

I love it!

Proper Fluid and Electrolyte Balance

Paying attention to what you consume pre and post workout is important. Proper fluids and electrolyte intake prior to exercise can help delay muscle fatigue and cramping.

Many people can get by with less than optimal effort when it comes to this category. However, if you are having neck pain you need to give yourself the best chance at success.

“At least 4 hours before exercise, individuals should drink approximately 5-7 mL·kg−1 body weight (~2-3 mL·lb−1) of water or a sport beverage. This would allow enough time to optimize hydration status and for excretion of any excess fluid as urine” (Sawka, 2007).

This is not always possible, I understand. Do your best. Some is better than none.

Warm Up

Proper warm up is also important.

Engaging in a warm up that gradually increases heart rate and muscle flexibility is a great way to prime the muscles. Dramatic increases in blood pressure and heart rate can lead to less than optimal muscle performance and increased risk of exertion headache during your workout.

Your warm up should be focused on getting the heart rate up; along with preparing the body for the movements you are going to perform during your workout (squat, push up, deadlift, clean, etc.).

Maybe you should try out THIS warm-up?

Recovery

Taking the time to stretch and do some soft tissue work after exercise will help reduce muscle soreness in the days following your workout (Gregory, 2015).

Leaving your body more prepared for the next workout. It is a great way to improve muscle extensibility and eliminate trigger points that aren’t allowing your muscles to perform effectively (Lucas, 2004).

Adequate rest is also important for recovery.

Going hard every day and not getting adequate sleep does not allow your body to grow and repair itself. Neglecting proper recovery leads to a less than optimal immune system and central nervous system.

Sleep deficits can also lead to an increase in the intensity of pain and alterations in mood. This is some serious shiznit. Can’t express enough how important this category is. I am a huge fan of the “grind.” It just sounds cool. You aren’t meant to grind everyday though, so please take some time to recover.

Breathing and Posture

Proper breathing is something that is often overlooked, but may be contributing to neck pain.

Gritting it out is cool, I highly recommend it. It builds character.

However, regularly holding your breath or clinching of your teeth when exercising can lead to increased tension around the neck. This could end up resulting in tension headaches as well.

Many of us without realizing it spend most of our day performing shallow breaths. We often over utilize the neck musculature. Shallow breathing into the chest can increase tension in these muscles and even increase feelings of anxiety.

It is recommended that people learn how to perform relaxed diaphragmatic breathing to reduce tension in the neck muscles. Staying in sustained postures throughout the day can also be contributing to your neck pain.

Many studies continue to show that sustained postures throughout the day (typically with office workers), especially with a forward head position, can increase neck pain and headaches (Ariëns, 2001).

Symptoms are also more common in people that hate their job.

Really off topic, but it is true …

Consider how stress in your life (emotional or physical) is amplifying your feelings of pain. Emotional pain and physical pain are HEAVILY connected. Check out this video by Tony to learn a little more about proper breathing strategies.

 

The Advil Fix

This may not seem to fit with the other categories.

Nonetheless, it is super important.

Side effects related to over the counter anti-inflammatory use are becoming common knowledge. Every now and then I run into someone that isn’t aware of the potential risks of regular use.

Popping over the counter anti-inflammatories (i.e. advil) before or after your workouts IS NOT recommended.

It’s like sweeping the dirt under the rug.

“The most common side effect from all NSAIDs is damage to the gastrointestinal tract, which includes your esophagus, stomach, and small intestine. More than half of all bleeding ulcers are caused by NSAIDs, says gastroenterologist Byron Cryer, MD, a spokesperson for the American Gastroenterological Association.”

Fear

One of the reasons that I started RehabRenegade.com was to help share information like this with as many people as possible. Many of the complaints I get in clinic can be fixed SUPER QUICK. Having a basic understanding of how to care for yourself and knowledge of the body can remove the “threat” of pain.

Red flags (serious pathology) represent less than 2% of the cases that are seen in a clinical setting (Medbridge, Chad Cook: Cervical Examination).

The Internet can be a blessing and a curse.

It can either lead you down the right road or scare the living crap out of you. We all know that any injury or illness is usually presumed to be cancer after a late night search on WebMD. Here are some discussions and advice I found on the inter-web related to neck pain in the gym.

Great intentions, but poor advice.

We tend to blame everything on a “pulled muscle,” whatever that means.

Rest?

What year is it?

We stopped recommending straight rest in like 1902.

By all means, take time off from the gym.

This doesn’t give you free rain to lie in bed all day watching re-runs of Game of Thrones.

It’s true… you may have over done it. Your muscles were overworked. Likely leading to a nice amount of local inflammation and some trigger points. The more constructive advice would be to perform some soft tissue work, light stretching and low intensity non-painful exercise to keep that area mobile.

Resorting to pain medication is not a healthy option. Last but not least, mentioning damaged discs and compressed nerves never makes someone feel at ease. Trauma to the neck may be a reason for disc injury. Overdoing your push ups and pull ups is NOT.

Fun Fact: The prevalence of disk degeneration in asymptomatic (without symptoms) individuals increased from “37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age” (Brinjikji, 2015).

Positive findings on MRI are common in people without pain. Don’t get too caught up in images and diagnoses. Do the things we know are healthy. If you hit the gym hard this morning and then followed that up with a CROISSAN’WICH from Burger King, and a cigarette at lunch we have bigger fish to fry.

First and foremost, muscle and joint strain at the neck commonly refers pain to the head. We call this a cervicogenic headache. Rest assured that it is very rare that you have a more serious pathology requiring immediate medical attention. Give the tips in this post a shot, if it doesn’t help by all means see a medical professional. The worst thing you can do is show up to your medical provider without attempting to improve your flexibility, tweak your form or get adequate rest.

If I had a dollar for every time a therapist told someone they had the tightest (fill in the blank) they have ever seen I would be a little better off.

If this poor girl wasn’t worried enough… Now she has the tightest back he has ever seen… really?

As providers we need to be very careful with our words. It is really easy for us to turn neck pain into chronic neck pain.

It is called an iatrogenic vortex.

When people get tied up in the medical system too long they often see symptoms worsen or develop other unexplained diagnoses.

Overview

In most cases, pain attributed to the gym can be tied to the following:

  1. Limitations in the necessary mobility to perform a movement
  2. Limitations in the Skill needed to perform a movement
  3. Limitations in the Capacity to perform a movement (Strength and Endurance)
  4. Human Error [Electrolyte and fluid balance, Self-Care, Rest, Sleep, Breathing, Posture, Medication and Fear]

You could be one small modification away from eliminating your neck pain.

The big takeaway here is to make sure you have the ability to perform various exercises with good skill.

From there, you need the knowledge and self-awareness to know when you have exceeded you capacity.

You also need to look at the big picture to ensure that you are checking the boxes when it comes to living a healthy life. If you are someone that often finds yourself worried or anxious when injury sets in please take a step back and look at the big picture. Use this article to see where your gaps are. If you still can’t get relief please see a medical provider. Nothing makes medical providers happier than working with patients who demonstrate a willingness to learn and grow.

About the Author

Dr. Michael Infantino is a physical therapist. He works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.

 

 

 

 

 

 

References

Ariëns GAM, Bongers PM, Douwes M, et al

Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study. Occupational and Environmental Medicine 2001;58:200-207.

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A.,Jarvik, J. G. (2015). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR. American Journal of Neuroradiology, 36(4), 811–816. http://doi.org/10.3174/ajnr.A4173

Gregory E. P. Pearcey, David J. Bradbury-Squires, Jon-Erik Kawamoto, Eric J. Drinkwater, David G. Behm, and Duane C. Button (2015) Foam Rolling for Delayed-Onset Muscle Soreness and Recovery of Dynamic Performance Measures. Journal of Athletic Training: January 2015, Vol. 50, No. 1, pp. 5-13.

Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166

Sawka MN, Burke LM, Eichner ER, Maughan RJ, Montain SJ, Stachenfeld NS. American College of Sports Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39:377-90.

http://www.webmd.com/osteoarthritis/features/are-nsaids-safe-for-you#3

CategoriesAssessment Corrective Exercise

The 411 On Plantar Fasciitis and How to Make It Vanish

I’m currently with my family taking a little vacation down in Florida.3 I’ll be checking in at some point this week with some content, but on the meantime I’ve got some awesome people pinch-writing for me this week.

Today’s post is written by physical therapist Dr. Michael Infantino on a topic that’s a pain in the ass foot for a lot of people: plantar fasciitis.

Enjoy.

Copyright: sdecoret / 123RF Stock Photo

The 411 On Plantar Fasciitis & How to Make It Vanish

Lets set the scene: It’s a little after 5:00 am. As you open your eyes the sun is just starting to peak through your window. To your right, your husband; to your left, the band Maroon 5 casually playing an old hit. “Sunday morning rain is falling, steal some covers share some skin….”.

Just kidding it’s Sunday morning, rain is falling and you are dead set on getting that five-mile run in.

As you take the first step out of bed, the pain in your heel makes you rethink this whole running idea.

Unknowingly to your heel, your mind knows your day is going to drag if you don’t accomplish this feat.

I know the “drive” that runners possess.

The word “drive” and addictive personality disorder can sometimes be inter-changed, but that’s neither here nor there. This post is going to give you the 411 on everything plantar fasciitis is in as concise of a fashion as possible.

To make life easier we will just say heel pain.

Quick Rundown Of Todays Topics:

  • WHO is more susceptible to developing plantar fasciitis?
  • WHAT is plantar fasciitis? [Sounds like a skin eating disease.]
  • WHAT can I do to treat this damn pain? [I know, I put “WHAT” twice. I wasn’t an English Major.]
  • WHY am I not seeing progress?

 WHO Is More Susceptible To Plantar Fasciitis?

Straight from the Journal of Orthopaedic & Sports Physical Therapy Guidelines for Plantar Fasciitis.

  1. Overweight & Un-Athletic

I know, I know. This sounds awful. No one wants to be called overweight. More than that they don’t want to believe they fall into the un-athletic category.

Prime example: My dad (I love you dad). He has gained some lbs. over the years, and I wouldn’t classify him as an athlete by any means at this stage in his life. Despite my opinion, he still thinks he is SUPER.

His workouts usually come few and far in between. To my surprise, he can never quite understand why his body hurts after his impromptu 3-mile sprint (he calls it a jog) once every 3 months.

  1. Runners

Yay runners! You made it into the JOSPT Guidelines. Victory! Wear this as a badge of honor… I think?

  1. Workers That Spend Increased Time On Their Feet (i.e. factory workers)

  2. Fearful Avoiders

No one wants to admit this characteristic. Regardless, it exists. Many people who actually develop chronic pain fall into this category. Your worries about causing more “damage” to your body often make you think bed rest is still a reasonable option.

I am sorry to say that it is not.

Runners, don’t smirk. You fall into the “overboard” category where your “driven” personality encourages you to push through pain. Because it is weakness leaving the body! Sometimes… not always.

The big takeaway here is to accept the fact that your job, your hobby or your current weight just makes this injury more likely. Knowing that this injury comes with the territory allows you to switch your focus to PREVENTION.

Give Me The Low Down On Plantar Fasciitis.

Research has continuously stated that your heel pain isn’t typically an “iitis,” or inflammation.

Ultrasound actually reveals increased thickening of the fascia near the insertion on the heel (Fabrikant, 2011). This sort of debunks the old “RICE” concept when trying to manage this injury.

It is safer to say plantar fasciopathy.

This could mean either an inflammatory or a degenerative process. Degenerative sounds scary. It isn’t. Changes in tissue quality are normal, not everyone has pain with these changes. [This one’s for you Fear Avoiders].

Diagnosing TRUE Plantar Fasciitis, Or “Fasciopathy.”

  1. 1st step in the morning reproduces heel pain
  2. Tenderness to touch at the insertion of the fascia on the heel

“Both were positive! Am I sentenced to months of night splints, orthotics and stretching?”

Not necessarily. If it is a true plantar fasciitis the research shows that these things can help. They may diminish symptoms, but it’s a Band-Aid.

JOSPT Guidelines

We need to be careful here. Some studies also showed that increased arch height was a predictive factor for pain. Your best bet is to have someone perform a running analysis to see what your foot is doing during the loading phase of running (preferably someone with a ton of knowledge about the human body).

If you don’t display “excessive pronation” or actually lack adequate pronation, an orthotic may not be a good fit. Excessive supination (opposite of pronation) while the foot is in contact with the ground during running or walking could actually be exaggerated with an orthotic.

Leading to ankle sprains.

JOSPT Guidelines

In my experience, night splints are hit or miss. With a true plantar fasciitis it could be a big hit. As I mentioned earlier, it is not actually fixing the source of the problem (the way you move, strength deficits, poor pacing etc). Before you sentence yourself to months of night splinting try to push the RESET button first.

Lets Get Started! Address Limitations In Ankle Mobility First.

1. Trigger Points

Work out those nasty tender points in your calves and the bottom of your feet. Calf trigger points can cause referral pain to the heel and bottom of the foot. Mimicking plantar fasciitis. Trigger points are responsible for reduced mobility, strength and timing of muscles! (Lucas, 2004)

 

BONUS: Self Instrument Assisted Soft Tissue Treatment (better than the roller stick… in my opinion.)

This is more of a soft tissue mobilization than trigger point treatment. It can actually be a great lead in to trigger point treatment. It helps reduce tone in the muscles. It is also a quick way to scan for areas that are more “stiff” and more irritated (increased trigger points local to that tissue). This is why I prefer it to the roller stick.

 

2. Stretch The Calves and Foot Musculature

Stretching feels good and it can help restore motion. BUT do not neglect the importance of strength and endurance at the shin musculature when looking to maintain that new length.

Performing strengthening drills, like the Shuffle Walk (courtesy of The Gait Guys) demonstrated in the video below will prevent increased tone in the calves from returning.

Prescription:

To make this more effective, actively pull the forefoot and toes up as you are stretching.

Pull the toes and forefoot up for 10 seconds (keep the heel down) followed by a 30 second stretch (work into it slow to get the desired effect). Repeat for 3 minutes.

Renan-Ordine R, 2011

3. Attack The Joints

Get the joints in your ankles and feet moving more freely. Don’t forget about motion at that BIG TOE. Without proper extension at the big toe you can forget about actually accessing that new ankle motion.

This means you can’t access that hip extension while running. This equals poor gluteal function. It all goes down hill after that…

  • 1st Toe Mobilization + Shuffle Walks

 

  • Banded Ankle Mobilization With Active Dorsiflexion

 

This one is all over the Internet. From personal experience, having someone mobilize the ankle for you ends up being way more effective. But better than nothing!

  • Self Ankle Manipulation

Great way to get some quick improvements. Combine with the other techniques!

 

Gave It A Go For A Couple Weeks And Still No Change?

The loss of considerable amounts of body fat obviously doesn’t occur overnight. Stick with a guided nutrition plan and exercise routine to work on weight loss without further aggravating any painful regions. This may require modifications in exercise choices for the time being.

If You Are An Avid Runner Or Stand A Lot For Your Job Consider The Following:

  1. Regular Shoe Rotation was found to be helpful in workers that spent more time on their feet. (Werner, 2010)

Your shoes really tell a story. Excessive pronation and supination start to wear down parts of the shoe. This exaggerates pronation and supination at the foot leading to increases in the speed at which these motions occur. Potentially leading to increased risk of injury.

  1. Orthotics/Taping

We discussed this earlier. Orthotics don’t always fix the problem, sometimes they can worsen it. Taping to support the foot or promote increase stability at the foot could be a safer and cheaper 1st step.

  1. Strengthening

The focus is typically on reducing “pronatory tendencies” at the foot. Sounds promiscuous, grrrrr! Tony can help you with that one.

Your ability to land in a good position during the loading phase of running, and continually do that over the course of a run is the primary goal; despite the addition of weight (maybe a ruck sack), speed or exertion.

Running is not an innate ability.

Strangely, I find joy in watching people run. It is easy to tell which people skipped some developmental milestones growing up or didn’t take part in too many athletic events. If you fall into one of those categories I would definitely recommend some training to improve your running mechanics.

  1. Leg Length Discrepancy (LLD)

I was hesitant to mention this because of how common LLD is in symptomatic and asymptomatic populations. However, it is mentioned in one study in the Plantar Fasciitis Guidelines (Mahmood, 2010). In various studies, a LLD of as little as 4-6 mm is considered clinically significant. In rehabilitation and the fitness world neuroscience is getting a lot attention; often disregarding biomechanics. It is probably in our best interest not to sweep this under the rug if we aren’t seeing progress. LLD will have an impact on your mechanics when walking and running.

Lets Wrap This Up!

The important thing to remember is that the recommendations made today are just guidelines based on an overwhelming amount of research. If you are in pain let these tips guide you. Don’t grasp on to them like they are the word of God, Buddha or The Dos Equis Guy. Accept the fact that your job, hobby, weight or lack of athletic ability make you more susceptible to this injury.

Fix the things you can, accept the things you can’t. There is no harm in trying out a cheap orthotic or heel pad for a little relief. If you want to take it a step further see a professional trained in running evaluations to determine needed changes in running mechanics, programming, proper shoe fit and/or orthotic fit. Knowledge is potential power. Go forth and conquer!

About the Author

Dr. Michael Infantino is a physical therapist who works with active military members in the DMV region. You can find more articles by Michael HERE.

References

Cotchett MP, Landorf KB, Munteanu SE. Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review. J Foot Ankle Res. 2010;3:18. http:// dx.doi.org/10.1186/1757-1146-3-18

Eftekharsadat, B., Babaei-Ghazani, A., & Zeinolabedinzadeh, V. (2016). Dry needling in patients with chronic heel pain due to plantar fasciitis: A single-blinded randomized clinical trial. Medical Journal Of The Islamic Republic Of Iran, 30401.

Fabrikant JM, Park TS. Plantar fasciitis (fasciosis) treatment outcome study: Plantar fascia thickness measured by ultrasound and correlated with patient self-reported improvement. Foot (Edinb) 2011;21:79–83.  [PubMed]

Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93:234-237.

Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166

Martin, R. L., Davenport, T. E., Reischl, S. F., McPoil, T. G., Matheson, J. W., Wukich, D. K., & McDonough, C. M. (2014). Heel pain-plantar fasciitis: revision 2014. The Journal Of Orthopaedic And Sports Physical Therapy, 44(11), A1-A33. doi:10.2519/jospt.2014.0303

Mahmood S, Huffman LK, Harris JG. Limb-length discrepancy as a cause of plantar fasciitis. J Am Podiatr Med Assoc. 2010;100:452-455. http:// dx.doi.org/10.7547/1000452

Renan-Ordine R, Alburquerque-Sendín F, de Souza DP, Cleland JA, Fernán- dez-de-las-Peñas C. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management
of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41:43-50. http://dx.doi.org/10.2519/jospt.2011.3504

Werner RA, Gell N, Hartigan A, Wiggerman N, Keyserling WM. Risk factors for plantar fasciitis among assembly plant workers. PM R. 2010;2:110-116. http://dx.doi.org/10.1016/j.pmrj.2009.11.012