CategoriesCorrective Exercise Exercise Technique

Rotation Helps Improve SI Joint Pain: A Doctor Even Says So!

Today’s guest post comes courtesy of Dr. Erika Mundinger[footnote]Fun fact about Dr. Mundinger. She was apologetic for taking so long getting this article to me because, as she explained, she was “competing in a skydiving competition last weekend.” To which I replied, “No worries at all! And chalk “competing in a skydiving competition” on the same list as “stuff I’d do AFTER french kissing a great white shark.” She’s a woman of many talents! And obviously more adventurous than myself.[/footnote], who’s presentation on how to deal with SI joint pain (specifically how ROTATION can help!) at The Fitness Summit a few weeks ago really impressed me.

I asked if she’d be willing to help me out while I was away, and she was more than happy to oblige. 

Enjoy!

A couple of years ago, a fellow physical therapist at the clinic where I work asked with a quizzical and concerned look, “What do you think of that Jefferson deadlift everyone is doing at your gym? Lifting and twisting?” My response evoked an even more quizzical look — that in my four years coaching the Jefferson deadlift, I had yet to see someone get hurt.

Now I know that a PT saying it’s OK to lift and twist is bold and brazen. But lets be clear, I’m NOT saying this:

 

What I am saying is that I’ve seen rotational movements, when trained properly, actually help clients and spine patients get out of pain.

When I see clients and patients with a back injury that results from twisting it’s not necessarily because they were twisting in the first place. Often it’s because they were trying to twist, bend, or reach into a range of motion not available to them.

In layman’s terms, they were trying to move beyond their limits. So, my contention is that instead of avoiding rotation in training, we can find safe ways to use rotation to help get people out of back pain — and potentially prevent back pain at all.

So since we naturally move in to rotation why would we not want to train rotation?

One clear answer is because if we lack mobility we could get hurt lifting in to rotation. But does that mean we should NEVER place a client or ourselves in to these positions? Or should we start training rotation so that when they find themselves in this position again the chance of getting hurt is minimized?

I vote for the latter.

Lets back up for a moment and take a look at how the spine and pelvis move together. When you move for day-to-day functional activities, are you moving in singular, robotic motions? When you squat down to pick up something off the floor are you assuming the same back squat position you do at the gym? Typically one foot is slightly forward, one foot back, the front foot may be more flat on the floor with the other foot raised on to a toe, and there’s a slight twist in the spine and pelvis. In fact our pelvis twists with every single motion we do.

Take a look at walking, for example, as one foot is forward and one foot backward the pelvis sits forward and down on one side and up and back on the other.

The hips, pelvis, and spine move together in a three-dimensional pattern. And as a result we have a three-dimensional system that stabilizes our pelvis as our joints bend and rotate.

Posterior Sling

The posterior sling involves the erector spinae, multifidi, and thoraco lumbar fascia. As they contract, they tilts the sacrum forward and pull upward, locking the SI joints in to place with a vertical force vector.

Posterior Oblique Sling

The posterior oblique sling involves the glute max, glute med, biceps femoris combined with the opposite lat create a diagonal force compressing the SI joint together.

Anterior Oblique Sling

The anterior oblique sling involves the external oblique, internal oblique and transverse abdominis with the oppsite adductors compress the pubic symphysis and stabilize the anterior pelvis.

If we lack mobility, or if we have a muscle imbalance in one or more of these slings, the stabilizing force of our pelvis can neither allow for mobility when we need it, nor stabilize where we need it. This causes more load to be placed on the spine and SI joints, possibly leading to injury.

Now let’s be clear about one thing: If there is a lack of mobility at the pelvis and spine, there is also most likely a lack of mobility at the hips. It would certainly be irresponsible of us to address one area without addressing the other.

However, the beauty of training rotation is that we get to address many of the sticky spots because in a 3-D system, we can’t move one without the other.

As always, if the exercise is uncomfortable, don’t do it. Furthermore, if the exercise feels great on one side but not so great on the other — don’t be afraid to train only one side. Forcing a motion on a side that feels uncomfortable will also cause injury.

Typical question: “But won’t I be uneven?” My typical response, “You’re already uneven, which is why we are now having this little chat.”

Here is an example of someone who trained Jeffersons with the intent of improving motion. Upon first attempting Jeffersons, one side felt great while the other side, well, not so much.

When looking at spine, pelvic, and hip motion we could see that an underlying scoliosis was one contributor to the problem. So he trained Jeffersons on just the side that felt comfortable. With time, as motion started to improve on that side, so did motion on the other and gradually he was able to perform the movement on both sides. The results were very impressive.

Not only did his general strength in rotational patterns improved, but so did the position of his spine. (photo reprinted curtesy https://www.dellanave.com/follow-your-body-to-better/)

So how do we do this?

Obviously if there is an imbalance, and certainly if there is a pre-existing injury, the last thing we are going to do is perform a loaded rotational movement. It is no secret that rotation places more load on the facet joints and requires more work from muscles increasing torque. But if we start with the motion itself, unloaded, or lightly loaded, with modifications were necessary, we build a solid platform on which progression can occur.

More Rotational Deadlifting

 

As Tony mentioned in a previous post, rotational deadlifts challenge the transverse plane of mobility, not to mention help fire up those oblique slings we use for diagonal stability. But what if it hurts to this, or you don’t have mobility to do this?

The above video is a great modification for beginners of this motion or those who have some trepidation in approaching this movement.

Valslide Curtsy Lunges

 

Don’t feel limited to rotational picking-up of things. Rotational lunges also provide a great opportunity to gain motion, not to mention they are a good butt burner.

After I taught this exercise at the Fitness Summit, a comment I received a lot via email/text/twitter from the attending trainers was “My clients love to hate this motion.” They love it because it feels so good, but hate it because the glutes are on fire, but then love it again because the glutes are on fire.

I have seen those with SI dysfunction quickly relieve symptoms performing this movement, even unloaded.

And Of Course the Jefferson

This is such a great exercise because it really caters to where our asymmetries in the pelvis may be.

You can stagger your stance if deadlifting with an even stance is hard. You can reduce shearing forces on the SI joint that can occur with single plane deadlifts because ALL three slings are engaging. And it reduces torque on the spine that a conventional deadlift can create because the load is directly under your center of mass, not in front of it.

David Dellanave of the Movement Minneapolis has great coaching and training tips HERE.

Summary

Ready to start twisting?

The first step is: Don’t be afraid to play around with rotational movements. Pick some exercises you already know and like, then start by staggering the stance a bit, or add even a few degrees of rotation. Follow what feels good.

Disclaimer: These are not exercises to push through, and this is not the time to pick the heaviest weight so you can look strong or boost your ego. That will lead to trouble — trust me. There are very safe ways to do this. If done mindfully, clients can gain not only improved mobility, but overall strength within that mobility. As always, listen to pain, don’t push past your current range of motion, and start where you are, and not where you want to be.

About the Author

Erika Mundinger is a licensed Physical Therapist and a board-certified orthopedic specialist working in the Twin Cities area. She practices orthopedics and sports medicine with advanced training and practice in manual therapies, corrective and functional exercises, and treatment of spinal disorders. She works at TRIA Orthopedic Center, the Twin Cities’ premier ortho clinic, treating athletes from professional to “weekend warrior” levels as well as general orthopedics and is a member of the clinic’s Spine Team, helping to better advance patient access to professionals specialized to manage care of spinal disorders and injury.

In 2002 she received her B.S. in Exercise Science from Montana State where she was involved in exercise physiology research and outdoor sports. In 2007 she received her Clinical Doctorate in Physical Therapy at the Mayo Clinic. She will receive a board certification as an Orthopedic Specialist in March 2015.

Mundinger is also an active member, coach, and physical therapist at the Movement Minneapolis and is trained in the Gym Movement Protocol. She actively applies this biofeedback training with clients and her own patients. She also works with several trainers outside of the Movement to help bridge the gap between physical rehabilitation and returning to fitness and recreation.

CategoriesExercises You Should Be Doing

Exercises You Should Be Doing: Rotational Deadlift

Anyone who’s ever dealt with Sacroiliac (SI) joint dysfunction or pain knows how much of a soul suck it can be.

It’s something that’s very common, but altogether mysterious because it’s such a tricky joint to begin with.

This isn’t going to be a post on SI joint dysfunction. There’s really nothing I can say or add to the conversation that hasn’t already been stated.

HERE’s an excellent post by my boy Dean Somerset which breaks down the anatomy and some programming considerations.

And for the more clinically minded, HERE’s a post by Mike Reinold on the assessment side of things.

Suffice it to say, when it comes to SI joint shenanigans there’s no one universal approach or train of thought as to the best way to rehab it or resolve it.

It’s kind of like driving through Boston. No one really knows what the heck is going on.

Last weekend at The Fitness Summit I had the opportunity to listen to Dr. Erika Mundinger speak on the topic, and really liked what she had to say.

One “delicious Bon Bon” (< – to steal a quote from Mark Fisher) of information I gleaned from her talk was the idea of including more rotational movements as part of SIJ dysfunction rehab/treatment.

Specifically she talked about the Posterior Sling and how, for many suffering from SIJ dysfunction, it’s often neglected. Or, rather, it’s addressed from the wrong vantage point.

For most, sagittal plane movements are going to be money. Most will be able to handle sagittal loading via bilateral squats and deadlifts fairly well. This will generally always be the starting point.

Where that starting point actually is…depends. Some people will be on one end of the spectrum and need to learn how to perform a basic hip hinge and hammer floor based core stability (deadbugs, quadruped drills, etc).

Others will be able to be more aggressive and perform more traditional DL and squat exercises.

 

HOWEVER, as Dr. Mundinger noted, it’s these very sagittal plane (flexion/extension) dominant exercise that may be jacking up people’s SI joints further.

Sometimes people gain too much rigidity in the sagittal plane and it causes it’s own set of issues.

Hypermobility and laxity is a common “correlation” with SIJ dysfunction, and it makes sense to build more stability in that area with said movements. But Dr. Mundinger’s commentary about including more transverse plane (rotational) movements made a lot of sense to me.

Which serves as a perfect opportunity to introduce the next Exercise You Should Be Doing.

Rotational Deadlift

 

It’s no secret I love me some deadlifts. There’s no one exercise that gets me pumped up or gratifies me more than the deadlift.

In every sense: it’s you vs. the bar.

It helps build bulletproof athletes and makes men out of boys (women out of girls?).

Either way, it’s a staple movement and one I feel is about as versatile as they come, whether you’re an athlete or regular Joe/Jane, someone interested in powerlifting or just looking to move well and feel better……..

…..the deadlift can accomplish a lot.

FULL DISCLOSURE: Rotational Deadlifts WILL NOT get you yoked.

Sorry meatheads.

[Cue hilarious video I found on the internet now……NSFW]

 

For those still reading….lets continue.

I do feel it’s a variation that many people can incorporate into their training repertoire injured or not, but one that obviously has increased merit with those suffering from SIJ pain.

What Does It Do: As alluded to above it gets you out of the sagittal plane, and as Dr. Mundinger suggested (much to the GASPS of her colleagues), it relieves some of the stress off of the SI joint and challenges it in the transverse plane.

Of course this is going to be a case-by-case scenario, and it’s important that someone OWNS sagittal plane before introducing rotational movements.

But it makes sense – at least to me – that constantly hammering the same pattern(s) over and over and over again could be detrimental. Adding in (some) rotation can be exactly what the doctor ordered.

Pun intended.

Dr. Erika Mundinger

Key Coaching Cues: for some, you’ll have to tame your inner meat-head. This IS NOT going to be an exercise where max-effort is the goal.

Start with a KB on one side and sit (rotate) INTO the hip. Grab the handle as if you were trying to melt it in your hands (this will force the shoulder to pack itself through a process called irradiation) and then “deadlift” the bell up to waist height.

For some people I may even have them “hover” the bell above the floor a couple of inches for a few seconds to help them maintain tension and to keep proper spinal position.

You’ll then reverse the action and rotate into the opposite hip, coming to a complete stop on the other side.

(Again, sometimes, I’ll have people hover for a few seconds above the floor).

And that’s pretty much it.

There are ways to progress this movement. You can perform with TWO kettlebells or you can even perform it as a 1-legged variation.

Give it a try and let me know what you think.

UPDATE: scratch that, you can go beast mode on rotational deadlifts. You win this time David Dellanave.

CategoriesUncategorized

Managing Laxity in Lifters and Athletes – Part 2

Note from TG:  Continuing on from yesterday’s post, today in part deux strength coach Joe Giandanato takes the reigns and talks about his own battles with laxity and how’s he’s been able to manage his symptoms and pain through dedicated strength training as well as some attention to detail with other things.

For those looking to geek out on anatomy and assessment talk (me, me, me!!), Joe breaks down ligamentous verbiage, talks about rate of force development, as well provides some sage words on medical treatment.  For the record:  it does NOT include watching old Jean Claude Van Damme movies like Blood Sport or Kickboxer or Double Impact.

OMG – those movies were so awesome.

And don’t roll your eyes at me – you know you watched them back in the day.  Don’t kid yourself!

Anyways, I’ll let Joe take it from here.

Challenges of Dealing With Lax Athletes

Perhaps one of the greatest challenges I’ve faced as an athlete, lifter, and coach is dealing with ligamentous laxity. I’ve found through my years as a coach and personal trainer that athletes and lifters with ligamentous laxity need to be “slowed down” in the gym. They must master first bridging and planking variations to find a stable core and hips before progressing to barbell exercises.

I’ve found that tempo training works well, especially when the eccentric or isometric is accentuated. Prolonging both help provide the athlete or lifter greater proprioceptive benefits along with a smoother transition to more advanced exercises.

Nine times out of ten, I’ll usually scrap static stretching in the post-workout portion of the training session and in its place, I’d have the athlete perform lower threshold activation exercises for the muscles of the hips, shoulders, and upper back as well as those encircling the knee. (such as what?)

 

I’ve found these areas to be the most problematic and they’ll typically require the most programming attention. As you’ll soon read, working with athletes with ligamentous laxity can be highly rewarding. Many times, these are explosive individuals who are shrouded by inefficient movement patterns and in some instances dysfunction and pain. With sound programming and proper care, these individuals can blend the best of both worlds – elasticity and strength, unearthing the explosive athlete within.

Joe’s Story

My brief story involves a lifelong love-hate relationship with congenital laxity. My athletic career actually began in a gymnastics studio as a five year old who was enamored by all of the things the older neighborhood girls were capable of. Though my stint in gymnastics didn’t last very long, I remember being just as flexible as all of the girls in class. As I continued my athletic pursuits, which included soccer, basketball, and eventually football, I began to notice that my extreme flexibility had become a detriment of sorts.

Although there was an incredible amount of spring to my step and I was typically one of the faster athletes on the field or court, I was also one of the weakest and most susceptible to joint injury.

Once my mediocre athletic career concluded, which consisted of a brief stint of walking on my local college’s soccer team and flirtations with semi-pro and minor league football, I solely dedicated my extracurricular efforts to the iron.

Although I competed in an unsanctioned push-pull meet a number of years ago, I’ve struggled to keep my body intact long enough to make a concerted attempt in a full powerlifting meet.

The unraveling of my musculoskeletal health triggered an extensive amount of reflection and research. For the past decade I had been bogged down by a cranky sacroiliac joint. If anyone has suffered from SI joint issues, you’ll know that virtually any activity or posture has the capacity to piss that joint off.

SI joint issues aren’t conducive to the “big three” and they certainly don’t lend themselves to productive training sessions.

My maligned speculation of what was causing it was limited to muscles. Although no muscles connect the ilium to the sacrum, the joint itself is governed by the musculature of the lumbopelvic hip complex. A faulty firing pattern could lead to a lateral or anterior pelvic tilt influencing movement of the SI joint.

When the sacrum tips forward, it nutates, when it tips rearward it counternutates. When the SI joint loses its ability to nutate and counternutate effectively, biomechanical compensations occur, which are typically accompanied by pain. Initially, I made the mistake of zeroing in on the muscles responsible for my pain and decreased strength while I overlooked the ligaments.

Ligament A&P Briefer

Ligaments are strong, fibrous bands of connective tissue which connect bones to each other across all joints. Ligaments are composed of both solid and liquid components. The solid components include multiple types of collagen as well as elastin, actin, and proteoglycans, which are glycosylated proteins that play a number of roles in connective tissue health, relevantly the regulation of collagen fibrillogenesis and stimulate cell growth.

The liquid components are mostly comprised of water, which influences cellular and viscoelastic functioning. I should also point out that ligaments are not independent of our body’s neurovascular network as the epiligament, or outer ligament, has a rich supply of proprioceptors and blood.

Individuals with congenital laxity typically have ligaments that are loose, or for a lack of a better term, “stretchy”. These stretchy ligaments do more than allow laxity sufferers to perform parlor tricks such as stretching a muscle beyond a normally safe end range, they can pull joints out of centration which alters proprioceptive abilities as Miguel alluded to before.

Since stretchy ligaments do not allow an individual to maintain joint stability, much less establish it in first place, then joint health will erode over time. Individuals with congenital laxity are at a greater risk for developing osteoarthritis, degenerative disc conditions, and patellofemoral issues. They are also more susceptible to joint sprains likely due to compromised proprioception.

Benefits of Being Lax

However, having ligamentous laxity doesn’t relegate you to the good girl/bad girl machines tucked away in the corner of the gym. Lax individuals can ramp up rate of force development due to their enhanced elasticity. RFD isn’t just limited to a muscle’s force generating capacity.

RFD is also linked to the contributions of the parallel elastic component (PEC) and series elastic component (SEC). Anecdotally, I have found that trained individuals with laxity are more proficient in absorbing force during eccentric movements, which is likely why many lax pitchers can hurl ched as they gather elastic energy during the windup and cocking phases of the pitch.

Assessing Laxity

Typically congenital laxity is assessed via the Beighton Scale. The test features nine domains which include: bilateral passive thumb apposition, bilateral pinky dorsiflexion, bilateral knee hyperextension of at least 10 degrees, bilateral elbow hyperextension of at least 10 degrees, and bending at the waist and placing your hands on the floor while the knees are locked out. Scoring 4 points will earn you a laxity diagnosis.

Registering a 9 out of 9, like Miguel did in his self-administered exam, will get you enshrined in the laxity hall of fame. As thorough as the test may seem, it is rather limited as it overlooks a number of potentially problematic joints.

Watch as my physician, Dr. Hartman assesses me on the table and demonstrates the examination to Miguel and three medical students who are getting napalmed with knowledge.

 Medical Treatment

Receiving treatment from Dr. Hartman has been a godsend. When I first visited him a few months ago, nagging SI joint pain had flared up again rendering mundane ADLs such as bending over to tie my shoes, colossally painful. The closest thing I came to squatting and deadlifting was from a spectator’s perspective, observing my athletes perform these lifts while I was writhing in pain, hunched over a power rack.

While medical management of laxity isn’t necessary for everyone, I can personally attest that Dr. Hartman’s treatments have worked wonders for me. Though pedestrian by powerlifting standards, I can crank out sets of deep squats with 405 and conventional deadlifts with 500 pounds on command. Though there’s still a lot of room for improvement on my end, I have come a long way through Dr. Hartman’s care.

One of the treatment modalities that Dr. Hartman utilizes is prolotherapy. Prolotherapy or “prolo” for short involves injecting a hypertonic dextrose or saline solution into the joint. The injection incites an inflammatory response which promotes tissue repair, thereby improving ligamentous integrity and reducing or eliminating musculoskeletal pain.

Medical research indicates prolotherapy as an effective treatment option for those with laxity of the anterior cruciate ligament (4) and knee osteoarthritis (5). Another study suggests that prolotherapy is effective in treating lower back pain in conjunction with additional interventions (6).

If you’re interested in what a round of prolotherapy treatment entails for the SI joint, check out the video. If you’re squeamish, it’d be in your best interests to avoid the 1:09 mark in the following video.

REFERENCES

1.“Clinical Application of Neuromuscular Techniques, Volume 1: The Upper Body [Hardcover].” Clinical Application of Neuromuscular Techniques, Volume 1: The Upper Body: Leon Chaitow, Judith DeLany: 9780443062704

2. Lephart, Scott M., and Freddie H. Fu. Proprioception and Neuromuscular Control in Joint Stability. [Champaign, IL]: Human Kinetics, 2000. Print.

3. http://posturalrestoration.com/products/cd/

4. Reeves KD, Hassanein KM. Long-term effects of dextrose prolotherapy for anterior cruciate ligament laxity. Altern Ther Health Med. 2003;9(3):58-62.

5. Rabago D, Patterson JJ, Mundt, M, et al. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2013;11(3)229-237.

6. Yelland MJ, Del Mar C, Pirozzo S, et al. Prolotherapy injections for chronic low back pain: a systematic review. Spine (Phila Pa 1976). 2004;29(19):2126-2633.

About the Authors

Miguel Aragoncillo, B.S., CSCS, H.F.S, is a strength coach at Endeavor Sports Performance in Pitman, NJ. Miguel is also a Personal Trainer in the Philadelphia area. Miguel enjoys short sprints on the beach, lifting heavy things (sometimes even in competitions), and dancing on the weekends. You can check out his musings on his blog HERE, as well as follow him on Twitter @MiggsyBogues.

Joe Giandonato, MS, CSCS, FSBSCC is the Head Strength and Conditioning Coach and Fitness Director at Germantown Academy in Fort Washington, PA. Giandonato is also a Personal Trainer at the University of Pennsylvania, Department of Recreation. He also serves as the Senior Sports Science Editor on joshstrength.com, a website dedicated to strength athletes and those desiring improved body composition and performance.

In 2012, Giandonato was named a fellow of the esteemed Society of Balding Strength and Conditioning Coaches, hoping to one day join the ranks shared by Tony and Eric (Cressey).