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Body Parts

Front Squats

Stability, Mobility, And Better Posture

The squat has been described as the king of all exercises.  The large amount of muscle recruited during squatting makes it a very metabolically demanding exercise.  In athletics, the capacity to perform a full squat with proper torso, hip, and knee position has been correlated with greater durability–fewer injuries.  The overhead squat test is one of the patterns assessed in the Functional Movement Screen and is used in physical therapy and athletic training.  Squatting with the load placed on the front of the body is an excellent way to enhance mobility, stability, and strength.  Compared to leg presses, seated leg curls, and knee extension, front squatting creates much more carry over to activities of daily living and athletics.  The problem is most people do not know how to get started with front squats.

When you squat with the load across the front of the body instead of on the upper part of the back, the stress on the spine is reduced.  You can “cheat” a back loaded squat by leaning forward, but you cannot lean forward with a front squat.  Leaning forward on the front squat causes the load to fall from your shoulders or hands.  Front squatting creates a greater core stability demand and reduces shear force on the lower back.  Full depth front squatting will improve your posture and restore mobility in the hips, shoulders, and thoracic spine.

Front squatting is an exercise that is more equivalent to daily tasks and athletics.  Lifts in real life rarely place the load across your shoulders.  When you lift the grandchild, carry the groceries, or hoist the wheelbarrow, the load is in front of the body.  During athletics, the opponent is in front of you, and you must stay upright and tall to dominate the activity.

Front Squat 101
Before loading the squat, practice bodyweight squats to a depth target.  I like to use a 12 inch box or a Dynamax ball (12 inches in diameter).  You should be able to perform a body weight squat to a thigh below parallel position with a stable spine before attempting a loaded front squat.  When you perform a loaded front squat, initiate motion from the hips by sitting down and back.  Push the knees out and descend so the thighs travel to below a parallel to the floor position.  Keep the chest up and torso tall as you push back up.  Finish at the top by contracting the gluteal muscles and keeping the front of the rib cage down.

Choose A Proper Implement
While the barbell offers the greatest loading capacity, many individuals do not possess the shoulder mobility to hold the bar on the shoulders.  The Goblet Squat position with a kettlebell or dumbbell works just as well.  A sandbag hugged close to the body in the high Zercher position or bear hug hold has a high degree of athletic carry over.  Avoid the Smith machine variation.  You end up leaning on the machine and this eliminates much of the core stability demands and exposes the spine to greater shear force.

Michael S. O’Hara, P.T., OCS, CSCS

Chicken Run

Viscosupplementation For Your Painful Knees

When the knees start aching, activity levels fall, fitness recedes, weight is gained, and cardiovascular problems follow.  The baby boomers are reaching the time of life when knee joint breakdown begins.  Many patients have knees that show arthritic changes on imaging tests, but they are too young for a knee replacement.  While we know losing weight and improving leg strength and mobility will help decrease knee symptoms, many people have so much knee pain they cannot move enough to exercise.  One of the medical treatments that can help these patients is viscosupplementation.

Viscosupplementation is an intra-articular knee injection of hyaluronic acid administered by a physician.  Hyaluronic acid is a natural substance found in the synovial fluid of our joints.   Its function is to act as a joint lubricant and shock absorber.  Patients with knee arthritis have less hyaluronic acid in their joint.  The idea is that by adding some hyaluronic acid to the knee, the pain will decrease and the body will be stimulated to produce more of its own hyaluronic acid.

chicken 200
The FDA approved viscosupplementation injections as a treatment for knee arthritis in 1997.  These medications are derived from chicken combs and are now available from several pharmaceutical companies.  They are given in a series of three to five injections over a number or weeks and can be repeated every six months.

Viscosupplementation works best on patients with mild to moderate knee arthritis.  It is a treatment and not a cure for the arthritis in your knee.  The injections do not produce an immediate relief of knee pain.   It usually takes three or four weeks and several injections before patients report a decrease in knee pain.  Manufacturers claim six month’s of pain relief.  Clinically, the patients I talk to report three to six months of pain control.

The big benefit of viscosupplementation is that it can reduce knee pain and permit the physical therapy or fitness client the opportunity to begin exercising and work on the fitness goals that reduce stress on the knees.  The three to six month window of pain free knees is enough time to improve strength, restore functional mobility, and decrease bodyweight.  For people with knee arthritis, reducing loading and improving strength is the best life long method of managing knee arthritis.

Michael S. O’Hara, P.T., OCS, CSCS

Heads Up

The Downside Of Upside Down Exercise

H_HoudiniExercise activities that place the head below the heart have become more popular in fitness programs.  In almost every gym you see decline bench pressing, incline sit ups, glute-hamstring developer exercises, and more recently, hand stand push ups as a regular part of many exercise programs.  While these activities may have some value, you might want to reconsider training in an inverted position for some other reasons.

Esophageal Reflux
When you invert your torso, the contents of your stomach can more readily travel back up into your esophagus.  Head below your belly with a hiatal hernia, a little extra mesenteric fat, and some strong contractions from the abdominal muscles, and you have the perfect environment for gastroesophageal reflux disease (GERD).  Millions of Americans (14%-20% depending on the study) take medications to manage the symptoms of GERD—heartburn, chest pain, persistent cough, difficulty swallowing, hoarseness.  Prilosec and Nexium are the biggest moneymakers the pharmaceutical industry ever created.  Many Americans (10%-15%) have GERD, but are unaware of the problem because the tissue damage has not reached symptomatic levels.  Erosive esophagitis or Barrett’s esophagus is a clinical finding of cellular change in the esophagus and a precursor for esophageal cancer.  Esophageal cancer is one of the more deadly types of cancer.

Glaucoma or Retinal Disease  
The head down position raises pressure inside the eyeball.  As little as 30 degrees of decline has been shown to increase intraocular pressures.  It is estimated that 2.2 million Americans have glaucoma, but only half of these know they have the problem.  Individuals with glaucoma already have elevated intraocular pressures and should avoid these positions.  The back of the eye (retina) is susceptible to changes in vascular pressures, so if you have any retina issues, avoid the head down position.

High Blood Pressure / Hypertension
Your heart, lungs, and arteries are conditioned to pump blood with your body in an upright position.  Many vascular alterations occur when we flip into a heads down position.  When you assume the head below your heart position, the arterial pressures inside the skull increase.  Elevated cranial blood pressures can lead to headache and much more severe problems such a stroke.  One in three Americans are walking around with high blood pressure.  Add in an exercise induced elevated heart rate and some less than pliable carotid arteries and you have the ideal environment for a big bad brain event.  If you have hypertension, I would not go about using any inverted positions in the gym.

Bottom Line
Apart from going blind, having a stroke, and developing an incurable cancer, you should be fine.

Michael S. O’Hara, P.T., OCS, CSCS

Bench Dips

Poor choices in exercise selection are often the cause of injury and pain.  Most gym members are unaware of the damage that is created until it is too late.  The joint stress produced by activities that manipulate body position in an effort to isolate a certain muscle very often create significant articular irritation.  If your fitness goals are to stay strong and injury free for an entire lifetime, I suggest you avoid certain exercise activities.

A staple of Self and Shape magazine, this exercise probably will make your triceps muscle work hard if you possess enough shoulder mobility to drop down and bend the elbow 90 degrees.  Unfortunately, bench dips also produce excessive stress on your neck and shoulders.  During a bench dip, your neck is forced forward and the shoulder girdle is pushed into extreme positions of extension and internal rotation.  Most of us have poor neck and shoulder posture and this activity feeds into the forward head–rounded shoulder posture that is epidemic in today’s computer based world.  The movement of the shoulder joint during a bench dip pushes the humeral head forward and makes the long bicep tendon take a severe twist over the front of the humerus.  This position stretches the anterior capsule of the glenohumeral joint making you more susceptible to shoulder subluxation or dislocation.  Biceps tendonitis, tendonosis, and complete ruptures are one of the more common injuries we see every day in physical therapy.  At the top of this exercise (elbows extended), the shoulder is loaded in a manner that compresses the subacromial space, making you more prone to impinge on the superior rotator cuff tendons.

Women typically have less stable shoulder joints and more sensitive necks, yet they seem to gravitate to this drill.  MRI imaging tests of non-symptomatic shoulders reveal that many of us are unaware that we are walking around with rotator cuff tears and bone spurs in our shoulders.  An exercise that places the shoulder into a stressful position may be all that is needed to make that tear or spur start waking you up at night.  For athletic performance purposes, the bench dip movement is worthless as it is not similar to any movement pattern you ever perform on the field of play.

The gym is full of exercises to train triceps that are safer than bench dips.  Try getting better at push ups, and remember that you cannot preferentially “burn fat off” the back of your arm with direct triceps training.  If you speak with any of the strength and conditioning coaches that make their living getting athletes ready to perform at optimal levels, none of them use the bench dip.

Michael S. O’Hara, P.T., OCS, CSCS

The Lunge No One Loves

The simple drop lunge is an exercise that will improve your hip mobility, enhance athletic performance, and reduce the chances of injury to the knees and lower back.  The drop lunge trains a movement pattern you have to perform in nearly every sport.  To play tennis, basketball, or even bowling, you must be able to efficiently cross the one leg back and behind the other leg.

The reason most people do not utilize the drop lunge is that it requires consistent practice, a degree of single leg balance, and lots of hip mobility to achieve any level of proficiency.  It is not a muscle isolation, bodybuilding type exercise, so you will not find it highlighted in Mega Muscle magazine.  The more you struggle with the drop lunge, the more you need to include this essential movement pattern in your training program.

In physical therapy, we use the drop lunge with most of our lower extremity patients.   In programming for fitness clients, I use the drop lunge as a movement preparation drill and rarely add extra resistance.  The drop lunge can be loaded with a medicine ball, barbell, or with a pair of dumbbells.

Drop Lunges
Stand with the feet at shoulder width.  Step with the right leg behind the left leg and drop into a squat position.   How far you lunge across with the right leg will depend on the length of your legs and your mobility.  The heels will be off the ground and you will have to come up onto the balls of your feet.  Keep the torso tall and the abdominal muscles braced.   Return to the starting position.   Perform the next repetition with the left leg reaching behind the right.  Alternate legs and perform five on each side.   If you find one side is more proficient than the other, perform extra repetitions on the limited side in an effort to train away the movement asymmetry.

Common Mistakes:
Keeping the front knee too straight and failing to perform a full lunge,  losing your balance,  allowing the torso to fall forward,  looking down at the floor.

Michael S. O’Hara, P.T., OCS, CSCS

The Incredible Shrinking Man

The How, Why, And What To Do About Getting Shorter

Starting at about age 40, we begin losing height at a rate of four tenths of an inch every decade.  The trip from 40 to 80 years of age can easily take two and a half inches off of your height.  Some of the loss occurs as part of the normal aging process, and some because of disease and deconditioning.  The reasons we get shorter are well understood, and the good news is that we can do something about many of the causes.

Thinning Discs
One third of our spinal height is made up of the intervertebral discs.  The disks are made up of the same type of tissue as your nose.  The capacity of the discs to deform and bounce back to their starting shape permits one vertebrae to move on the other vertebrae.  The discs have a fluid filled center that helps attenuate force in multiple directions, similar to a shock absorber.  As we age, the discs between the vertebrae tend to become thinner.  If the distance between the top of your sacrum and the base of your skull is 33 inches, you have a potential 11 inches of disc height you can lose to father time.  Sitting increases the load on the tallest discs and a lifetime of prolonged sitting can accelerate your shrinkage.

Strength and Spinal Changes
Strength deficits in the postural muscles of the neck, posterior shoulders and upper back permit the head and thoracic spine to fall forward.  Extreme changes can create the hyperkyphotic spine or Dowagers Hump in the upper back.  Poor core stabilizer control will cause the pelvis to fall forward and the lumbar spine to collapse.  Obesity accelerates these alterations in spinal posture, as the weak muscles must support greater loads.  The muscles are the guy wires that hold the spine tall.  Lose tension on those wires and the tower starts to twist, bend, and get shorter.

Compression Fractures
The body of each spinal vertebrae resembles a cylindrical can with a webbing of reinforcing bone on the inside of the can.  As we age, osteoporosis can take a toll on the bone density of the vertebral body.  A compression fracture of the vertebral body is similar to standing a soda can on end and crumpling the can.  A crushed vertebrae is much shorter, thereby reducing overall spinal height.  Many people suffer small spinal compression fractures and are unaware of the damage until they undergo an imaging test.

The Fight For Height
So what can you do to maintain your elevation?  Keep your body strong and your weight under control.  Pay particular attention to the muscles on the posterior aspect of the body.  These muscles must fight the war against gravity every day.  They keep your spine tall and prevent the postural collapse that is all too common in the elderly.  Sit less and stand more.  The compressive forces of prolonged sitting on your spine are just one of the many bad things that sitting does to your body.  Exercise caution in regards to activities that compress your spine.  I would not recommend a sixty year old take up motocross or begin an exercise program that consists of deadlifts and Olympic lifting.  Be proactive about getting your bone density assessed, especially if you are a woman who went through menopause at an early age.  Have your vitamin D level checked, and if necessary, start supplementing on a consistent basis.  If you are diagnosed with osteopenia/osteoporosis, work closely with your physician on  medical treatment.

Michael S. O’Hara, P.T., O.C.S., C.S.C.S.

Toddler Fitness

Why Squatting Properly Makes Everything Better

A healthy squat pattern keeps your lumbar spine happy.  The ability to squat with strong, flexible hamstrings and gluteals keeps you lifting and carrying safely and efficiently.  If you are unable to squat, then every time you move toward the floor, you use your lumbar spine instead of the bigger and more powerful hips.  Just like the tread on a tire, you only have so many cycles of flexion in the lumbar spine.  Once you use those cycles up, the back problems begin.

If you enjoy water skiing, snow skiing, volleyball, or other lower extremity intensive recreational activities, you need a full, solid squat pattern.   If you are unable to efficiently decelerate force across all of the lower extremity joints, you are far more susceptible to injury.  The Functional Movement Screen Overhead Squat Test has become one of the best predictors we have for future injury.  Athletes that score poorly in this test get hurt more often and the injuries are more severe.

For those primarily interested in training for aesthetics, a set of loaded squats will do far more for your lower extremities than nearly any other exercise.  The metabolic boosting response from a set of twenty full depth squats is unbeatable.  Try three sets of twenty kettlebell goblet squats and let me know how you feel.

The squat exercise can be done anywhere and it requires no fancy equipment.  It is not overly complex and can be progressed with different types of exterior loading.   It builds better communication between the feet, legs, and torso than any seated machine based training and has far greater carry over to real life.

Unfortunately, due to deconditioning, injury, or a lifetime of sitting, many of us have lost any degree of squat capacity.  The good news is that regaining this pattern of motion is easy.  Listed below are some methods of retraining your squat.

Start At the Bottom
Babies learn to squat from the floor up.  As adults, we reverse this and try to relearn from the top down.  Lets go back to the baby method.  Try sitting on box or bench about sixteen to eighteen inches high.  Slide the hips to the edge and bring the feet back so the knees are bent.  Place the feet as wide as your shoulders.  Lean forward and push the knees apart as you stand up.  Do not push up with your arms on the bench or legs.

Push the Knees Apart
Many of us have sleepy gluteals (butt muscles) and are unable to push the knees apart effectively.  The knees collapse inward into a damaging valgus position.  Try placing a resistance band around the knees and push out on the band as you rise off the box.  This will reinforce activation of the gluteus medius muscles and improve your performance.

Keep a Long Lumbar Spine
If you slouch forward when you squat, try holding a stick overhead as you rise up off the bench.  Grip the stick like you mean it and pull the shoulder blades tight across the upper back.  This will help activate the muscles surrounding your spine and pelvis that have become disassociated from their isometric stabilization duties during a squat.

Load From the Front
When loading the squat pattern, I believe it is far more beneficial to load from the front.  Front loading will make the pattern stronger and it is far safer.  The sheer force on the lumbar spine is less in a front loaded squat than a back loaded squat.  Front loading does a better job of improving squat mobility, core strength, and functional carry over.

Michael S. O’Hara, P.T., OCS, CSCS

Sooner Is Always Better

Recent Research On Early Physical Therapy Intervention For Lower Back Pain

Physical Therapists play a key role in the management of lower back pain.  The lower back pain patient often must travel a long and irregular road on the way to a physical therapist for care.  Patients often have multiple doctor visits, imaging tests, various medications, epidural injections, and worst of all– rest.  So when is the best time for a lower back pain patient to see the physial therapist?  A recent research study has answered that question.

Scheduled to be published in the journal Spine, this study* of over 32,000 patients has concluded “Early physical therapy following a new primary care consultation was associated with a reduced risk of subsequent health care compared with delayed physical therapy”.  Early physical therapy was defined as less than fourteen days.  Early physical therapy lowered costs, reduced the number of visits to the physician and decreased the use of injections, diagnostic imaging tests, and surgery.

Industry and business has figured this out.  Computer chip maker Intel has a program that gets their injured employees with back pain to the physical therapist in 48 hours.  Since utilizing this program, the cost of care has dropped by 30%.  The number of lost workdays has fallen from 52 to 21 days and patient satisfaction with the program is better.  Since 2006, Starbucks has been using a program that gets their employees with back pain to the physical therapist in twenty-four hours.  They have achieved lower costs, earlier return to work, and greater satisfaction from the patients.

In 2009, I spent three days with WorkSmart Solutions in two different industrial plants in Rockton, Illinois.  The physical therapist from WorkSmart visited the plant three days a week and consulted with the employees on any problems with pain.  They provided treatment as needed and assisted with work site ergonomics and activity modification.  The Human Resource departments in both plants remarked on the reduction in administrative hassle and the lowering of work compensation claims for lower back and neck pain.  The employees raved about the care for from the physical therapist and the ease of access to ongoing help.

The earlier we can intervene with physical therapy treatment the more likely we are to prevent the deconditioning that occurs with rest, the development of hypersensitive pathways, and fear of activity.  Lower back pain is a mechanical injury that requires the management of all mechanical forces in the patient’s life.  Education on proper posture, body mechanics, and fitness activities as well as modification of the work site are all part of comprehensive physical therapy intervention.

*Spine, Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary car referral of patients with low back pain to physical therapy: Impact on future health care utilization and costs.

Michael S. O’Hara, P.T., O.C.S., C.S.C.S.


Multi Directional Power Training

Surge 180

We have recently added a new training tool to our physical therapy clinics.  The Surge 180 is a simple and incredibly effective training device for rehab patients.  The patient stands on the platform, grasps the handle, and works against resistance provided by three pistons.  The physical therapist can use the Surge 180 to improve many different areas of performance.

Safe and Effective Power Training
Most physical therapy patients are severely underpowered.  Not only do they need to get stronger, they must also get better at creating force quickly.   The patient can accelerate against the handle of the Surge 180, and because the overall mass is so small, there is no damaging inertia to overcome.  The mass of a weight stack, barbell, or dumbbell creates so much inertia that when you attempt to move the load quickly it creates damaging joint stress.

In life and athletics, our bodies move in all directions.  The Surge 180 handle moves forward–backward, right–left, diagonally, and into rotational movement patterns.  The handle excursion is big enough to accommodate patients of all heights.

It Demands You Stand
Rehabilitation is all about getting better at functioning in standing positions.  Patients need to learn how to efficiently transfer forces from the ground up through their body.  On the Surge 180 platform, the patient can be positioned in-line, split, straddle, or single leg stance.  Connecting the shoulder to the opposite side hip, through an active core is the essence of rehabilitation training.

Core Coordination
The coordinated performance of the team of muscles that control the hips, pelvis, and spine is more important than simple strength.  Standing, walking, climbing stairs, and carrying all require the synchronous transfer of forces from right to left and back again.  The resistance provided by the Surge 180 creates the neural feedback to fire those reciprocal motor patterns.

Michael S. O’Hara, P.T., OCS, CSCS

Suspended Push Up Animation

Atomic Push Ups Are A Fitness Blast

Your muscles work as a team to carry you through the day.  They never function alone, so training them with isolation exercise will produce less than optimal results.  The muscles over the front of the body are linked together through interwoven layers of fascia to form what Thomas Myers, in his book Anatomy Trains calls the “superficial front line”.  The shoulder girdle is slung onto the body in a basket weave pattern of muscles.  One of the best exercise activities to activate this team of muscles is the Atomic Push Up.

The guys and gals at TRX named this exercise because of the metabolic response it produces.  Although the TRX company popularized the Atomic Push Up, you can use any type of suspension trainer that has foot straps.  This exercise helps build a better connection between your shoulders and hips.  It will strengthen the push pattern and activate the frequently neglected hip flexors.  Unlike a bench press type drill, the Atomic Push Up requires core control and the active participation of your legs.  Atomic Push Ups require a great deal of neural control as you must coordinate muscles from the hands to the feet to properly perform this drill.  The Atomic Push Up is not a bodybuilding type exercise that will “sculpt your outer pectorals” but it will help you move better.

Atomic Push Up Performance
Attach the suspension trainer overhead with the foot straps eight inches off the floor.  Sit on the floor and place the feet in the straps.  Roll over and assume a push up position with the feet suspended off the floor in the straps.  The top of the suspension trainer should be directly over your feet.  Descend toward the floor, and as you push back up, pull the knees up toward your chest.  Use a steady cadence of lower down–push up–knees in–knees out.  Beginners should aim for sets of five repetitions.  Stop before the performance of the drill deteriorates.  Common faults are sagging in the middle, lack of depth during the push up, and poor head position.  For men, twenty repetitions of Atomic Push Ups is a worthy fitness goal.  For women, eight is great.

You generally do not see Atomic Push Ups performed in commercial gyms because suspension trainers are rare and this exercise is difficult.  Beginners may wish to place a mat under the torso and head in case of a sudden face plant.  You can use a pair of parallellettes if you find weight bearing on your hands is difficult.  Moving the body forward so the suspension strap is pulling you backward makes the exercise more challenging.

Michael S. O’Hara, P.T., O.C.S., C.S.C.S.