In the February issue of our newsletter, Mike O’Hara discusses ways to improve hip mobility and strength. Read Jeff Tirrell’s article on why dairy products may actually be good for you. Having back pain doesn’t mean you can’t have a fitness program.
Finding Fitness With Lower Back Pain
The number of USA emergency room visits, pain medication orders, injections, imaging studies, and surgical interventions directed at lower back pain continue to rise. I frequently meet people who report their fitness efforts have been hampered by low back pain. I have five recommendations that can help fitness clients with lower back pain have more success in the gym.
#1 Do not exercise first thing in the morning: Ergonomic experts have found that many more industrial lower back injuries happen in the morning. The theory is that the discs in the lower back imbibe or gain fluid overnight and are more likely to deform with a physical challenge. Give your lower back one or two hours of walking around time before starting an exercise session.
#2 Isometric strengthening of the spinal stabilizers: The function of your “core” muscles is to limit movement of the lumbar spine and pelvis. Stop all crunches, toes to bar, sidebends, sit ups, seated twisting, and learn how to perform bird dogs, side hovers, Pallof press, planks, and carries. Compliance with this single hint would reduce USA expenditures on lower back pain dramatically.
#3 Enhance the function of your hip flexors and gluteal muscles: Please cease all the forward spine flexion, toe touching, spine twisting activities. Greater lumbar spine range of motion is associated with more–not less, lower back pain problems. Learn how to foam roll and mobilize the hip flexors and gluteal muscles. Prolonged sitting and most popular “cardio training” deadens these muscles. Properly functioning hip flexors and gluteal muscles keep the pelvis stable and take stress off the lower back. Reawakening dormant gluteals and hip flexors is the magic that resolves long term lower back pain.
#4 Focus on single leg strength training: Ditch the front loaded hip hinges–deadlifts, cleans, snatch, and drop the loaded squats. Swear off the lower lumbar deranging leg press. Reduce spinal compression and train the legs, one at a time. Single leg training reveals the right / left side movement asymmetries that drive lower back pain. Resolving these asymmetries and sparing the spine goes a long way to abolishing back pain. You will need some guidance on exercise selection and execution- this brings me to #5.
#5 Get some help: Exercise is the most powerful medication on the planet. Nothing else comes close. Take the proper dose of appropriate training and the results will be amazing. Take the wrong dose of an inappropriate activity and the results can be devastating. This is especially true for people with a history of lower back pain. Find a qualified physical therapist to guide you through your fitness journey. One way or the other, you are going to spend time and money on your health. Proactive spending is always cheaper and more beneficial than reactive spending.
Michael S. O’Hara, PT, OCS, CSCS
The last twenty years have brought about many changes in the fitness industry as our understanding of functional anatomy and evidence based training grows. Some of these changes have been taken too far, misunderstood, or poorly applied such as stability training. When I was introduced to weights in 1998, exercise programs were built around machines which offer very little carry over to stability, core strength, and function. Machine based training fails to maximally improve balance/stability, prevent injury, or maximize performance. Enter functional fitness. This concept has been popularized by strength coaches and physical therapists such as Eric Cressey, Dan John, Mike Boyle, Grey Cook, and Fenton Fitness owner, Mike O’Hara who saw a gap in training methods and optimal coaching. Functional training includes better core stability/lumbopelvic control and more unilateral (single limb) exercises that closely mimic human movement. Unfortunately, as with many concepts in the fitness industry, this trend has been taken too far.
Many have latched onto “functional” fitness and incorporated unstable surfaces to challenge the small stabilizing musculature. This gives the illusion of strength and function, but as world renowned strength coach Mark RIppetoe says, these are simply “balance tricks”. Real life doesn’t involve unstable surfaces like wobble boards, bosu balls, physioballs, etc. This type of training highly restricts the amount of work the primary movers of the body can do, and doesn’t allow for strength adaptation to occur which should be a primary focus of any solid fitness program.
This Functional Stability series will address the best ways to improve real world function and strength while reducing injury.
Jeff Tirrell, CSCS, CSFC, Pn1
To set up for the split squat, put one foot in front of the other with the heel of the back foot off the ground. 85% of the weight should be on the front foot. An airex pad can be placed under the body for the knee to come down on when lowering to the floor. When in the bottom position of the exercise, the front knee should be in line with the toe creating a slight shin angle. Make sure to push through the front heel on the way up instead of the toe. This exercise can be made easier by holding onto a railing, or can be made harder by adding weight such as a kettlebell in a goblet hold. The split squat displays greater hamstring, external oblique, and gluteus medius muscle activity than the back squat, but less quadriceps muscle activity.
RFE Split Squat: RFE stands for “rear foot elevated”. With this variation of the split squat, set up with the back foot elevated on a bench or a padded stand created for this exercise. An airex pad can be used under the knee if necessary. Squat down, touching the knee to the floor or airex pad. When in this bottom position, the shin angle should be angled forward just as before, not straight up and down. Common errors include sitting too far back on the rear foot, touching the glute to the heel, or the back foot can tend to roll off the padded stand on the way up and move more onto the shin. Avoid this by putting more weight into the front leg and dropping the knee straight down instead of back. This exercise can be made more difficult by adding dumbbells in each hand, a kettlebell in the goblet, racked, or double racked position, or a barbell in the front or back position. Make sure to descend slowly, creating an eccentric load instead of dropping down fast.
FOB Hip Lift: FOB stands for “feet on ball”. Lay on the floor or table on your back and place the arms out to the side. Push down into the floor with the arms to stabilize the body. Keep the feet together and brace your abdominal muscles. Use the glutes and hamstrings to lift yourself up off the floor, making sure to keep everything tight at the top of the movement. Hold 3-10 seconds at the top and lower slowly and controlled. You can remove the arms from the floor and rest them on your stomach or behind your head to create more of a challenge.
One Leg FOB Hip Lift: Same setup as before except one leg will be used. The other leg will be pointed up to the ceiling as the other presses into the ball to lift the body. This creates more of a stability challenge.
FOB Leg Curl: This variation starts out just like the FOB hip lift, except at the top of the movement when the body is raised, the knees are bent and the ball is pulled in towards the body creating more work for the hamstrings. Keep the hips extended by activating the glutes and moving the hips upward, avoiding the tendency to bend at the hips. It should look like your hips move up and then return to a straight body position.
One Leg FOB Leg Curl: The hardest variation for the FOB series is the one leg curl. Use one leg instead of two, extending the other leg up to the ceiling. Make sure to still avoid bending at the hips in this variation as well.
One Leg Deadlift: When starting out with this exercise, it is best to just use bodyweight. Stand with 95% of your weight on one leg. Extend the arms and free leg out to a “T” position, bending the standing leg slightly. The extended leg should be reaching backwards as far as it can go. Think about sitting into that hip just as you would during deadlifts. As this exercise becomes easier and balance is not an issue, it can be progressed by holding a kettlebell. The kettlebell should be held in the same side as the leg extending back. Reach the kettlebell straight down by the big toe; the weight should not go in front of the toe but rather by the instep of the foot. If you have progressed pass the kettlebell, two kettlebells can be used or a barbell with weight. The primary muscles being used in this exercise are the posterior leg muscles including the glutes and hamstrings.
One Leg Squat: Stand in front of a 12-18” box (start higher, and work your way to a lower box). You will want to have 5-10# of weight to use as a counter balance (dumbbell, plate, or med ball). Standing on only one leg, slowly lower yourself to the box. As you descend, reach forward with the weight to help with balance. Control the descent until your butt taps the box and then stand back up. Work for 3-12 reps before switching legs. Over time, try to get to a lower box so that your hip is slightly below your knee at the bottom position.
Watch video of these exercises: https://youtu.be/SqFqf81UnIk
A Plea For Your Knee
In our physical therapy clinics, we treat patients with knee pain on a daily basis. It has become more common to train younger clients with a history of knee injury and ongoing knee pain. Jane Brody’s recent *article in the New York Times has some excellent advice on the care and management of knee pain problems. I have some further suggestions and clarifications.
The mass portion of the Force = Mass x Acceleration formula needs to be at an appropriate level for your knees to stay healthy. Carrying extra body fat creates an environment that invites knee wear and tear. The common knee pulverizing mistake is to perform high impact exercise activities in an effort to lose fat. If you are twenty pounds overweight, do not run, stadium step, soccer, tennis, or pickleball. Start with strength training and low impact cardio. Lose the fat first, and even then, the lower impact activity will be healthier for your knees. From the overweight client limping into the clinic I get the “I need to move around to lose weight” protest. I am sorry, but fat loss is primarily a function of dietary alteration. Exercise has very little impact on body fat levels if you do not eat properly.
Train the Way You Wish to Play
A properly planned fitness program makes your knees more durable (fewer injuries) when you participate in your favorite recreational activity. The training must be tailored to your activity goals. If your goal is to play tennis, then you must perform three dimensional deceleration / acceleration activities as part of your training program. Yoga will not prepare your knees for tennis. If you want to water ski, then you must perform strength training for your back, hips, and knees. Distance running will not prepare your knees for water skiing. If hockey is your recreational past time, you need to be strong, well conditioned and competent in all planes of motion. Long duration recliner intervals will not prepare your knees for hockey.
If your hips do not move well, your knees will pay the price. In this age of all day sitting and minimal physical activity, hip function is at an all time low. Physical therapy patients with knee pain nearly always present with glaring restrictions in hip range of motion and strength. If your knees hurt, dedicate some training time to restoring hip rotation and hip extension movement. Learn how to perform some remedial gluteal activation drills. Learn a proper hip hinge, squat and a pain free lunge pattern.
Participation in a single inappropriate activity can produce a lifetime of knee trouble. That box jump workout of the day- maybe not. The warrior, electric shock, mud hole, death run–bad idea. Trampoline with the grandchildren–what were you thinking!
Be Proactive and Seek Treatment For Knee Pain
“Training through the pain” can take a graceful athlete and turn them into a lifelong speed limper. The presence of pain changes the way your brain controls movement. Left untreated, it can permanently alter neural signals and produce movement patterns that linger long after the pain has resolved. Live with enough cycles of inefficient movement and you develop early breakdown in the knee.
Michael O’Hara, PT, OCS, CSCS
*What I Wished I’d Known About My Knees, Jane Brody, New York Times. July 3, 2017
Read the NY Times article here: https://www.nytimes.com/2017/07/03/well/live/what-i-wish-id-known-about-my-knees.html?_r=0
Keep your shoulders and spine happy and strong by following Mike O’Hara’s advice in “Pushing Up Performance”. Video explanation and performance of pushups and their variations included. Jeff Tirrell discusses the proper performance of pull ups in his article. “Movement You Should Master”. Is your mobility limited? Try massage sticks or foam rollers with the information provided in “Pain, Pressure, and Pliability”.
Train your hip adductors and bulletproof your legs by following the advice in Mike O’Hara’s article Adductors Galore. Video demonstration and explanation included. Mobilize your upper body by foam rolling. In Foam Roll T W I, Mike explains the importance of adding foam rolling to your exercise program.
Very Short Term Running Preparation
I was recently asked by a fitness client to post exercise recommendations that would prepare her for outdoor distance running. This person was two weeks away from being out on the road, running two or three miles a day. She is middle aged, has a prior history of lower back pain, and her goal was to lose fifteen pounds and “tone up”. Given such short notice, these are my recommendations.
Perform soft tissue work on a daily basis. Foam roll the legs and use a lacrosse ball on the plantar fascia. The vast majority of overuse injuries in runners happen in the lower legs and feet. Attempt to unwind the myofascial distress created by 600-700 foot impacts a mile.
Improve your reciprocal hip pattern–one hip goes back and the other goes forward. Most general fitness clients have glaring deficits on one side. Perform some split squats, posterior lunges, step ups, and or walking lunges. If you struggle with these activities, I would reconsider running as a fitness activity.
Wake up your gluteals. Every day, perform fifty or sixty bridges, hip lifts, or leg curls. You need super gluteal strength / endurance to run distances and avoid lower extremity injury. If your butt gets sore from fifty bridges, you need to do them more often.
Running is a skill and most recreational runners need some practice. Running hills will improve gait mechanics, enhance hip extension, and decrease deceleration forces. Find a fifty-yard hill. Run up the hill and walk back down. Perform five hill runs.
You are always better to run too little than to run too much. Start with very short runs– no more than half a mile. Increase your total weekly mileage by no more than five percent a week.
You can’t do this in two weeks, but this is my big recommendation to all future runners. Lose the extra weight before running. As a method of fat loss, distance running has a poor track record. It tends to elevate the hormones that make you hungry, and physiological adaptation to distance running happens fairly quickly. Extra adipose makes you far more likely to develop a running related injury. I know the guys and gals you see running miles and miles every day are lean. Please remember that lean runners are successful with running because they possess the optimal body mass to run long distances. They did not start heavy and become lean. Put a fifteen pound weight vest on that guy or gal and everything will change. Their gait will lose efficiency and become less graceful. The extra fifteen pounds of load creates the biomechanical overload that makes them much more likely to suffer an injury.
My final recommendation is that you not become disappointed if you develop pain. A runnersworld.com poll conducted in 2009 revealed that 66% of respondents reported a running related injury that year. The statistics indicate that one third of the participants at you local 10k fun run will require medical attention for a running related injury over the next year. Have the good sense to stop when the pain begins.
Michael S. O’Hara, PT, OCS, CSCS
Hamstring injuries are on the rise. In this month’s newsletter, Mike O’Hara, PT provides information on preventing hamstring injuries and includes videos of the recommended exercises. Learn what it is to be “farm boy strong” and what you can do to become a “functional farmer”.
Standing desks are great for posture and health, but many people have difficulty when they first start using them. In this issue, Mike O’Hara, PT gives exercises that can help you stand for longer periods of time. Watch the video for instruction on these exercises. In his article, “The Biomechanics We All Need To Know, Mike agrees with the advice given by Stuart McGill. Be sure to read about Fenton Fitness Member Jan Pilar and her success with her program.
Renegade Rows and SHELC
When designing programs for rehabilitation patients and fitness clients, I often pair up exercises. This practice is commonly called super-setting and it has multiple benefits:
Train efficiently—You get much more work done during your training time.
Abolish performance deficits—Most physical therapy and fitness clients need to work on glaring right vs. left movement asymmetries, postural restrictions, and stability limitations.
Lose weight—Fat loss is a primary goal of most fitness clients. Pairing exercises ramps up exercise intensity and creates the hormonal response that improves body composition.
Move better—Training neurologically related movement patterns improves motor control.
Renegade Row-SHELC Combo
The renegade row starts in the top position of a push up. Rubber hex dumbbells work the best for this exercise since they do not move on the floor. Place the dumbbells on the floor and position the hands on top of the dumbbells. Try to align the dumbbells directly under the armpits. Maintain a strong grip on the dumbbell handle during the exercise. Spread the feet at least shoulder width. Tighten the shoulder blades down the back and create total body tension. Without allowing the torso to turn, row one dumbbell up so the thumb approaches the armpit. Lower the dumbbell in a controlled manner and repeat with the other arm. Perform five repetitions on each arm.
Supine Hip Extension Leg Curls
Set the TRX straps so the bottom of the strap is at the mid-calf level of your leg. Lay supine and place the heels in the foot straps of the TRX. The feet should be directly under the overhead attachment point of the TRX. Place the arms on the floor at a 45 degree angle. Brace the abdominal muscles and keep the head down. Push the arms against the floor for stability. Lift the hips off the floor and keep them up for the duration of the set. Bend the knees so that the feet travel toward the body. Keep the hips up and extend the knees in a controlled manner. Perform ten to fifteen repetitions. Common mistakes are turning the feet outward and allowing the hips to fall toward the floor as the knees flex and extend.
The anti-flexion and anti-rotation core stabilization demand created by this pair of exercises produces some interesting next day abdominal muscle soreness. The ability to link the hips to the shoulder and produce movement is what everyone tries to accomplish with functional training. Move through three sets of the Renegade Row – SHELC combo and let me know how it goes.
View video of Mike performing these exercises here: https://youtu.be/2_fT0zShTSo
-Michael S. O’Hara, P.T., OCS, CSCS