Tight abs = lower back pain?

The rectus abdominus = the 6-pack that we all want, strive for and drool over. But tightness/overuse of this show pony muscle can be driving lower back pain.

The rectus abdominus is a broad, flat muscle that runs vertical on the wall of the front of the abdomen. It extends from the pubic symphysis, pubic crest and pubic tubercle to the xyphoid process and costal cartilages of the 5th to 7th ribs. This muscle is important posturally; it's actions include flexing the lumbar spine (like when doing a sit-up), posteriorly tilting the pelvis and assisting in hip flexion. It also assists with breathing, as in forceful expiration (breathing out), keeping the internal organs intact and creating internal abdominal pressure.

Trigger points or tight spots in the lower rectus abdominus have been found to refer pain into the lower back - like a thick band of pain around the lower back and into the top of the glutes. Trigger points higher up near the ribs have been found to refer pain higher up in the back, closer towards the bottom of the scapula.



A. Trigger points in rectus abdominus and their referral pattern in the mid/lower back.

It is important to note that if you have tightness in your rectus abdominus, your iliopsoas (long hip flexor) is most likely going to be tight also.



Trigger points in iliopsoas and referral pattern in lower back and front of hip/thigh.

 

If you are suffering from lower back pain, try releasing both your rectus abdominus and iliopsoas. Lie on with a lacrosse ball, baseball or softball under your abdomen, off to the side, about a fist length away from the belly button. Contract/relax your abs as you lie on the ball and make sure to move it up/down the length of your abs.

 

Another method is to get a heavy kettlebell and place the handle lengthways or crossways under your tummy. Then get on all fours and jam the handle of the kettlebell into your stomach, trying to find any tender/tight spots. Contract/relax your abs as you need to.

 

This is a highly unpleasant and somewhat interesting position to be in; I was told that it's referred to as the "Kettlebell Hump" because that's what it looks like when you're doing it....but it is very effective. (Thanks Antony Lo - The PhysioDetective for this one!!!)

 

Maybe try it in private first....and good luck.





Pull your head in

The past weekend was spent at the Australian Crossfit Regionals watching the best Crossfit athletes from Australia and New Zealand battle it out for for a ticket to the Crossfit Games in July. While for the most part I saw efficient and skilled movement, there was one workout in particular where I saw a number of competitors displaying what I call "poke neck".

Poke Neck aka Upper Crossed Syndrome

Poke neck can be the result of shoulder/upper thoracic mobility issues and/or weakness of the deep neck muscles and scapular stability muscles, otherwise known as Upper-Crossed Syndrome. This syndrome is particularly evident in people who have desk/computer jobs. It has been found that for every inch (or 2.54cm for the metric peeps) your head is forward of your spine, an additional 10lbs (or 4.5kg) is added to the weight of your head (Kapandji, 2008). This additional weight places stress on the muscles of the neck and upper back and can put extra pressure on the suboccipital nerves, causing headaches.

To combat poke neck, mobilize the following areas:
- Thoracic spine
- Neck: particularly upper traps, levator scapula & scalenes
- Chest: pectoralis major/minor

And, strengthen the following areas:
- Deep neck flexors
- Middle back: lower trapezius & rhomboids (Bulletproof shoulders by Crossfit New England is a great resource).

http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&cad=rja&ved=0CC0QtwIwAA&url=http%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DACAz6HFj1xE&ei=UOSmUcHIG8qCkQXM7YGIDw&usg=AFQjCNFrYsBdOTd65IYqEZ6ryttYOm1qVA&sig2=8f8_zkSmcG3e4pa5ZM2S0g

 In addition, have a look at your biomechanics while you are training. Get your coach to film you from the side the next time you are doing a pressing movement, kettlebell swings or thrusters/overhead squat to see if you are excessively throwing your head through at the top of the movement.

Throwing your head through is a green light to a neck injury.

So pull your head in.

Knee pain?

There are a few different types of knee injuries and my goal here isn't to discuss every single knee injury, but more to make you aware of the structures that may be contributing to your pain. Acute injuries, such as ligament tears, meniscus injuries, patellar dislocation etc. are probably not as common in Crossfit as those of more a chronic/repetitive type injury (patellar tendinopathy, bursitis, etc).

The knee is actually made up of two joints: the tibiofemoral joint (the joint between your tibia and femur) and the patellofemoral joint (the joint between your patella and your femur) which are stabilized by the collateral ligaments, cruciate ligaments and mensicus. The quadriceps, gracillis, iliotibial band, popliteus, sartorius, hamstrings and calves provide muscular stability and assist in movement of the knee (flexion, extension and some rotation).

Knee pain can be associated with injury to any of the structures directly connected to the knee, but can also be from other structures upstream (lumbar spine, SIJ, hip) and/or downstream (ankle).

Two of the most common causes of knee pain (anterior/front of knee) is patellofemoral joint problems and patellar tendinopathy. The signs and symptoms of each problem help to distinguish the diagnosis.

Patellofemoral Pain
- comes on with running/weight bearing activity involving bending of the knee
- pain aggravated by activities that load the knee eg. squatting, jumping
- sometimes associated with clicking and "crunchiness" under the kneecap
- knee sometimes gives way
- weak VMO (inner quads)
- tight vastus lateralis (outer quads), TFL
- often associated with foot pronation (flat feet) and valgus knees (knock knees)

Patellar Tendinopathy
- comes on with jumping/change of direction/squatting
- pain is at the base of the kneecap
- pain aggravated by decline board squats
- tenderness of patellar tendon
- associated tightness of quads, hamstrings, possible pelvic biomechanical issues
- calf weakness commonly found

Treatment of each of these conditions varies so it's always best if you get a Physio to do an assessment. Self diagnosis via "Dr Google" can be misleading, not to mention you could be wasting your time barking up the wrong tree. In any case, addressing the tissues around the knee can be a good place to start.

Try rolling out/trigger pointing the quads, hammies, calves, adductors and glutes and see if it changes your knee pain. Make sure to test first (whatever movement causes the pain) and re-test post rollout to see if you have made change. No change = see a professional. Change = keep it up!

Shoulder rotation - do you have enough?

The shoulder is an amazing joint, capable of great things...when it is all functioning properly!

The shoulder is comprised of 4 joints - the sternoclavicular, the acromioclavicular, the scapulothoracic(ScTJ) and the glenohumeral (GHJ). The GHJ is quite unstable due to its lack of bony stability but is held in place by numerous ligaments, the joint capsule and rotator cuff  and scapular muscles.

Normal shoulder ROM is as follows:
Flexion 180 degrees (the top of a push press)
Extension 40-60 degrees (lifting your arm straight behind you)
Abduction 180 degrees (lifting your arm out to the side)
Internal rotation 60-70 degrees (rotating the arm in towards the middle)*
External rotation 80-100 degrees (rotating the arm outwards)*
* tested with the arm abducted and elbow flexed to 90 degrees

In Crossfit (and in normal day to day life) our shoulders also need to be able to hit combined ROM - for example reaching for a seat belt involves shoulder abduction and external rotation, putting your wallet in your back pocket involves shoulder extension and internal rotation.

Lets take a look at the shoulder position in an overhead squat - full shoulder flexion, abduction and external rotation. The overhead squat is a demanding movement that requires not only good mobility and stability at the shoulder joint, but a mobile thoracic spine and hips, plus great core control. Take a look at the two photos below, one of which demonstrates a good overhead position.


   Which one would you rather look like?

 

I often see people complaining of shoulder pain and they are usually missing some degree of shoulder internal and/or external rotation. Lack of external rotation at the shoulders causes you to look like the guy on the right (he's probably also missing full range shoulder flexion and some degree of thoracic extension. I won't get started on the hips...)

Try the Apley Scratch test to see if you have adequate shoulder rotation:

---

Apley scratch test. The patient attempts to touch the opposite scapula to test range of motion of the shoulder. (Left) Testing abduction and external rotation. (Right) Testing adduction and internal rotation.

If you can't achieve full shoulder external rotation due to tight lats, pecs and teres major, your overhead movements are going to suffer. Try mobilizing your lats (foam roller or band), pecs (lacrosse ball) and teres major (lacrosse ball) for 3-4 minutes each side before your next WOD that includes an overhead squat/snatch component and see if you notice a difference.



Hip mobility in Crossfit

So I put out the call yesterday on our MobilizeMe Facebook page to find out what you wanted me to discuss in my next blog posts - and a lot of you asked for hips. So here goes.

Hip mobility is essential for developing a good squat. If you read that article I posted yesterday by Spencer Arnold, you'll see that he mentions mobility a lot. I think a good deal of problems with LACK of hip mobility in the population stems from the fact that we spend most of our day in sitting. Sitting requires about 90 degrees of hip flexion. Squatting requires at least 100 degrees of hip flexion (just breaking parallel), not to mention hip abduction and external rotation.

Sitting is also a PASSIVE activity, meaning that it requires little to no activation of any of the muscles in your lower limbs - you are being held up by the chair (I'm not going to get into a Physics discussion with this statement so don't get all science-y on me :-) Sitting for long periods causes our hip flexors to become short, and our hip extensors to lengthen and become weaker. In essence, we become the shape of a chair.

The Thomas test is a measure of hip flexor length and is shown in the two photos below:

Tight hip flexors - Positive Thomas Test - the knee is higher than the hip




Normal hip flexors - Negative Thomas Test - the knee is lower than the hip with knee flexed to near 90 degrees
 
 
Which of these two do you think would have issues attaining depth in a squat? I'll give you a hint, it's not the second photo....
 

Good hip mobility also includes rotational components; with a squat we are more concerned with the ability to externally rotate the hip/thigh. This puts our hip into a stable position and engages the gluteus maximus. Have you ever seen someone squat and let their knees cave in, then miss the rep or look like they're about to give birth trying to squeeze that rep out? Poor hip external rotation. Now, that can be due to poor mobility or poor hip stability/strength. It's up to your Physio (or really good coach) to figure that one out. But here's a tip: if you honestly, truly, consistently work your mobility and you are getting nowhere, it's a stability problem. All the mobility in the universe won't cure poor stability.

 

So where is this all going - I would have to reiterate what was said in the Spencer Arnold blog post - learn to squat properly from the start and don't add weight until you are proficient. Load is NOT going to help you squat properly. Do your mobility - sit on the lacrosse ball until it no longer hurts (not all at once), get out the band and do hip mobility with the band (it's in the MobilizeMe app and about a kazillion K-starr MWOD's), get up off your ass at work at least every hour. Like I said before, if none of this is working, you need a professional to look at it. Pony up and book into a Physio for an assessment. You can't assess yourself (believe me I have tried and I AM a physio!!).

 





 

Duck feet and squatting

Ever notice what your feet are doing while you're squatting? Probably not, but I DO. And I see it all the time. It makes my ankles, knees, hips and lower back HURT just looking at this.

Poor LEFT ankle mobility

What is actually going on when your feet are turning out during a squat (like the photo above)?

I would generalize and say it's coming from issues at one or two (maybe both) places: your ankles and/or your hips.

For this post, I will concentrate on the ankles.

Squatting requires good dorsiflexion mobility at your ankle joint. In other words, the ability to bring the top of your foot closer towards your shin. Any problems with this means that your body may compensate and find a way around the issue. In most cases, the compensation involves turning the foot outwards.

Lack of ankle mobility may be due to tightness of the calf muscles, the gastrocnemius and soleus and the long toe flexors, or stiffness in the ankle joint/s.

Try this knee-to-wall test to see if your ankle range of movement is adequate:

1. Measure 10cm away from the wall with a ruler/measuring tape and mark the spot on the floor.
2. Place your big toe of one foot at the 10cm mark, with the other leg behind you. Ensure your hips stay square to the wall.
3. Bend the front knee, making sure to keep your heel absolutely flat on the floor. The knee should be tracking over the middle of the foot (and not dropping in towards the midline).
4. If your knee cannot touch the wall without the heel coming off the floor, move the foot forward in centimeter increments and repeat until your knee touches the wall without the heel lifting.
5. Compare to the other side.

   

   Knee-to-wall test

If your score was less than 9-10cm from the wall, you have restricted ankle range of movement.

Try doing some mobility for the sole of the foot, the calves and hamstrings - stretch, foam roller, lacrosse/trigger point ball - prior to squatting. If this fails to make a difference, the problem may be more with restriction in the ankle joint/s. 

The use of an Olympic style lifting shoe can make a massive difference with squatting if your joint mobility isn't so flash. But get that ankle restriction looked at by a Physio. Old injuries like ankle sprains can have an impact on your joint range of movement, so if in doubt, get it checked out!

Deadlifts and Back Pain

Horse & carriage, wine & cheese, Simon & Garfunkel....these things go together. Deadlifts & back pain DO NOT go together. However, more often than not, when I get a Crossfit athlete presenting to me complaining of back pain the movement they were most likely performing when they felt their pain was DEADLIFTS.

Why is this the case?

There can be a million different reasons why you are experiencing back pain with deadlifts. I don't have all day and would probably get carpal tunnel from trying to delve into all of them so we'll just examine a few reasons why.

1. You are not using the right muscles: a deadlift is a functional hip extension movement that involves the posterior chain (hamstrings, glutes and lumbar erector spinae plus latissimus dorsi). The glutes and hamstrings are the primary hip extensors and if they are not activating correctly - the load will shift to the muscles of the lower back. I always tell people they should be sore in their glutes & hammies after deadlifts, if not, they aren't using the right muscles.

2. You aren't engaging your lats: your lats assist with maintaining lumbar extension and shoulder extension. Activating your lats before and during the lift will help keep your back in a good position and also keep the bar close to the body.

3. The bar is too far away from your body: the bar path in a deadlift should be a straight line off the floor. The further away the bar is from your body, the "heavier" it is. Keep the bar against the legs for the duration of the lift.

4. You are rounding your back: you need to maintain a flat thoracic spine during a deadlift. When the weight gets too heavy, we have a tendancy to round the upper back. If you find yourself rounding your back, drop the weight.

5. Your hamstrings are too tight: your hamstrings attach to the bottom of your pelvis and if they are too tight, will pull your pelvis into posterior rotation (butt wink) which is an effective position to be deadlifting in. Also, tight muscles are WEAK muscles.

6. Fatigue: workouts with multiple rounds/reps that have deadlifts and other hip extension movements (think kettlebell swings, running, etc). Once you get tired, you probably are no longer thinking about which muscles should switch on a what point. You just want to get the bloody workout over with already! If you have a tendancy to get back pain with these types of workouts, think about reducing the rounds/reps/weight and focus on your technique. Your back will thank you for it.

Try getting your coach to video you while you are doing your deadlift (Coach's Eye) and watch it frame by frame to see where you may be going wrong. The deadlift should  be a basic movement to perform but it is often done poorly. Get the foundation/technique correct before loading excessive weight on the bar.