Lower back and hip pain - Professor Shirley Sahrmann

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I was privileged to be able to hear Professor Shirley Sahrmann speak in Manchester on Sunday 6^th November 2011. For those who don't know her, she is a highly regarded expert on muscle and movement imbalances. Her book, Diagnosis and Treatment of Movement Impairment Syndromes, is an absolute must read for any therapist working with the body, regardless of modality.

Prof. Sahrmann is based at Washington University, USA, so to catch her on a flying visit to the UK was an opportunity not to be missed.

So what was I there to learn? The official title of the course was Differentiation and Effective Management of Lumbar Spine and Hip Pain using the Movement System Syndromes Approach. A bit of a mouthful I think you'll agree.

Issues covered:

• Kinesiology of the lumbar spine, pelvis and hip.
• The concept of relative flexibility and it's presentation in the lumbar spine and hip
• Current knowledge of the structural variations in the hip including cam and pincer.
• Movement systems syndromes of the lumbar spine and hip joint, and contributing factors.
• Clinical and research evidence of the interactions between the lumbar spine and hip.
• Practical application of the movement system syndromes including screening and clinical reasoning.
• Rehab exercises to correct movement faults.

The objectives of the day were to enhance our treatment strategy when a client presents with back and hip pain, learn how to effectively manage those conditions and have a more systematical way to examine those clients.

What have I learnt?
There were some big issues that have resounded with me since the course last weekend.

• All Systems in the body involve Movement, be it muscle fibres contracting to produce movement via the joints and bones, gases being exchanged in the respiratory system and the circulatory system transporting those gases and nutrients to where they are needed. Any abnormality in any one of the systems affects the others, and all structures in the body. Something works less efficiently, becomes dysfunctional and pain is felt. 

• Repeated Movements and Prolonged Postures cause deviations at joints, making them less efficient, dysfunctional and in some cases painful. The tissue changes that occur with Repeated Movements and Prolonged Postures includes neuromuscular changes. The progression of dysfunction and its associated degenerative changes is not only affected by physiological factors, but also biomechanical interactions and through an individuals lifestyle and personal movement patterns - the way that everyday activities are performed is the critical issue.

• The body will always chose to move along the path of least resistance. With the resulting tissue changes from Repeated Movements and Prolonged Postures, relative flexibility or weakness can develop. For example, long distance runners typically have strong and dominant hamstrings, rectus femoris (one of your quadriceps) and tensor fascia lata (involved in hip flexion, medial rotation and abduction) - bending the hip, turning it in, and pushing it out whereas weakness tends to develop in the iliopsoas (hip flexors) and gluteus maximus (external hip rotation and hip extension). The joint movements can then become disrupted from the optimal, and in this case, where the hamstrings are dominant and gluteus maximus weak, the end result can be a hamstring strain. Sahrmann attributes this to the joint movement being altered because the muscles which should be working to control the precise, pain free movement of hip extension, are not doing so. I'll write more about this soon because it really is fascinating, and definitely a topic for all runners to know more about.

• You get what you train. Quite simply, if you train a muscle to be strong, it will hypertrophy and develop more fibres, and hence be stronger. But, and this is the important point, following on from the previous point about the path of least resistance, those muscles not trained (or not as much) will be comparatively weaker.  Why is this important? Well, if you have strong quadriceps (thigh muscles) but weaker abdominals (stomach muscles) your pelvis will be pulled down at the front and this can lead to lower back pain because of an increased lumbar curve.

• The presence of a muscle doesn't not mean it is being used appropriately. Sahrmann calls this "missing in action"- meaning that although there is physically a muscle being "worn" does not automatically mean it's working the way is should. This also contributes to the path of least resistance in movement.

• The final message which is still ringing in my ears is this, You will continue to do what is familiar, not necessarily what is right.  It's worth reading that again to really get it in your head.

Having a good therapist (and Sahrmann is a very, very good one) test muscles for movement impairments and weaknesses is essential. It is the first step to correcting any imbalances you may have. You have, of course, got to want to make the change, as different ways of moving will need to become habit. They have to become part of your daily activities. Comfortingly, this is one message which we at Global Therapies already advise our clients. We show clients where they have movement patterns or imbalances which are sub-optimal, and then educate them on how to modify movements and strengthen specific areas to improve symptoms.

I have to say that I'm quite overwhelmed by the amount of knowledge passed on by Prof. Sahrmann. She is quite incredible, and to see her working with a client, demonstrating the tests she carries out was truly humbling. I'll be ordering her second book, there's a whole lot more for us to learn yet.

When should I change my running shoes?

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I was pondering this one the other day.
With so many people constantly pounding the streets/fells/treadmills, there is a massive market for running shoes. However, they are rather expensive, so when you have a pair of shoes you naturally want them to last for as long as feasably possible. Once their running days are over, you may use them as a pair of slippers, a trophy or something to keep handy in order to throw at next doors cat.

The question is when is a good time to buy a new pair? How long can I continue wearing these bashed up old shoes- they feel comfortable, so therefore they can't be too bad, right?

It has been said by some people, (and a lot of shoe companies, who stand to make a fair old whack from it), that you should have a general rotation of 3 pairs of shoes, an old pair, which are beginning to wear out, a middling pair which have been broken in, and a pretty much brand new pair, which you are in the process of breaking in. The advantage of this is you don't continually trash one pair into the ground, gradually destroying any semblance of support it might once have had and then buy a brand new pair of trainers which have a level of support/cushioning etc. which you then have to get used to all over again. Instead, you have a constant rotation of old and new shoes so that you never have a massive step from one type of shoe to another.

This is really good if
a) you always use the same shoes and
b) you have a lot of money

I don't think I've ever actually bought the same shoes time and again, mainly because I never used to run enough to wear out a pair before some snazzy new thing came out that I wanted to try- and by the time I wore them out, again, there was some brand new "tech" that was innovative, and again, I'd buy those shoes.

Notice that I have just been talking about "cushioning" and "support". A lot of Barefoot runners will be sitting there sneering saying, well, my shoes don't have any cushioning OR support. That all comes from my foot and the way in which I run.
Well. inov8 X-talons are pretty close to minimalist shoes, and when they look like this....
its about time to replace them.



Lets have a closer look at those shoes.

I asked the runner to stand evenly with both feet shoulder width apart. Obviously the left foot is a bit worse than the right- the grip isn't being utilised fully, and the inov8 symbol certainly isnt pointing straight up and down the shoe. You might also notice all the wrinkles (in the shoe, not the legs), where long term, some might say excessive use has slowly deformed the shoe into its current state.
I'm not saying this runner shouldn't use Inov8s because they don't correct his gait issues, I'm simply drawing attention to the fact that even "barefoot" or "low profile" shoes, also have a life span and need to be replaced and that isn't necessarily to do with when the grip wears out.

Take a quick look at a non-destroyed pair of inov8s look- (they've been worn, but not worn out)

Take note of the way an inov8 shoe looks from the back when it isn't completely destroyed. The foot symbol on the back of the shoe points straight up. The grips are all touching the floor. It is a stable platform on which your foot sits. The platform is flexible and your foot controls it in an intuitive way- which makes it more like barefoot running than "shod" running, however, as you run in them, be aware that if you have bad biomechanics, you will wear the shoe out faster.

Have a look at your shoes and ask yourself if they are still providing a decent platform for your feet. Yes, new shoes are expensive, but so is a knee/ankle op when things go wrong and you get an overuse injury from bad biomechanics... and if you say- ah well- I can wait for the op on the NHS, think about the long months during which you won't be able to run because you've screwed up your knee. Surely thats worth looking at how good/bad your shoes are, and forking out for a replacement if necessary.

Desk Jockeys

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By this I mean a desk-bound employee pushing papers and typing at keyboards all day long. Low exercise levels (just on the job, we're not saying you're lazy), restricted movements and repeated actions, none of which are all that good for your posture.

So what does poor posture mean for our bodies? Well, muscles can become weak and elongated, short and overly tense, switch off completely because others have taken over their role or just generally dysfunctional. You might experience muscular pain, joint stiffness, headaches, a sense of not being quite right, or suffer from RSI (repetitive strain injury). Whatever the cause, poor posture isn't good for muscles, tendons, ligaments and joints, and the effect is felt all over your body.

Here's how it goes....you come to work, just like you do every day. Switch on the computer, check your in-tray, in-box, action list, make a coffee and settle in to the day's work. I know. I've been there. You do the same things over and over again, day in day out. Your chair stays in the same position. Your phone is probably a little out of reach because otherwise it gets in the way of the keyboard (go on, check how far away it is). Papers are piled up on either side of you. The filing piles up. If you're lucky (or perhaps unlucky) to have a paperless job then you just come in, sit down and keep your arms in the same position for what, 2-3 hours at a go? Longer? Basically, apart from the coffee breaks, a quick wander around the office and lunch (that is if you take lunch away from your desk), you're sat at your desk with your body fixed pretty much in one position.

Is that good for you? No. We've posted elsewhere (Fascia. Fascianating) about how fascia is kind of like plastic, needs to be able to glide freely and how it becomes stuck and bound together with inaction.

Now consider your desk set up and seating position. In the position you're in, with limited movements, think about what your shoulders are doing. Really take a few moments to notice how they are positioned. Now your neck. What's happening there? And what about your pelvis?

Lets look at each of those in turn.

Shoulders: most likely they'll be rounded forwards, hunched over. In general, this means the muscles on the front of your chest are short and tight (predominantly the pecs but also muscles in your neck and obviously shoulders) and those at the back will be weak and long (upper trapezius, rhomboids – in between your shoulder blades). Because your shoulders are forwards there could be a tendency for your mid back curve to be increased, putting pressure on your spine.

Neck/head: the ideal position for your head is with your ears directly above your shoulders. I'm betting your head is forwards meaning the chin is forwards and muscles at the back of your neck are long and weak, or maybe not firing effectively.

The average head weighs about 10lbs. For every inch your head is forwards your muscles have to cope with an additional 10lbs of weight – so for a 2 inch head forward position your head is effectively weighing the equivalent of 30lb – 3 times the weight that it should be!! Now imagine the strain that your muscles are trying to cope with, there's no wonder after years of sitting at a desk that a stooped forwards position leads to muscular pain, headaches and dysfunction. When your head is positioned correctly gravity distributes the weight downwards and your muscles don't have to work anywhere near as hard. This is because gravity is working in a good way, rather than pulling your head forwards and downwards.

Pelvis: are you slouching, in which case your pelvis will be tipped backwards (posterior tilt). Don't just think about what you're doing right now but about how you sit day in day out. Because you are now aware of it you probably sat upright a little more, this is perfectly normal, but what we're after is for you to think about how you usually sit. Good posture need not be sitting bolt upright, just keeping your spine in a neutral position is good. Going back to slouching, which I think it's fair to say from experience, after way too many years in an office myself, that the majority of people do slouch. What's happening to your muscles? Well, for a start, just sitting for long periods leads to short hip flexors – the muscles that bring your leg up in front of you. When you think about it it is common sense – your legs are bent in a sitting position so the muscles which bend your legs will be held in a shortened position, even if they're not contracting. Your glutes are inactive, they forget what their job is. Because your pelvis is tucked under your hamstrings (the muscles on the back of your thighs) also shorten. Even if you stand up and sit down a couple of times, its not your hamstrings or glutes that are really working, its the quads- which, as we mentioned, are already shortened. 

One thing I haven't mentioned so far is whether or not you sit with your legs crossed. I did, for quite some time, before working out (during training to be a massage therapist) that this wasn't such a good idea. It's led to me having one weak hip flexor (the psoas muscle) on the left and one which is too tense on the right – the leg that crossed. The good news is that with some strengthening work on the weak muscle I can rebalance this out fairly easily – oh, and I now keep both my feet flat on the floor when desk-bound!

It's common with head forward posture for the gravity shift to cause your upper back to curve backwards and your the hips to tilt – one thing is compensating for the other (we've said elsewhere that everything is linked and connected), and you end up out of shape, quite literally, feeling a little wonky and perhaps not being 100% comfortable but not really knowing what is not quite right.

The risk to your health because of poor posture are not only muscular aches and pains, but headaches, compression of the spine, dysfunctional muscles and postural imbalances. These can lead to all sorts of other health issues which you won't instantly connect with poor posture, such as breathing disorders.

How can you make things better? Find out if your employer will carry out a desk assessment, most places do these days because it's a serious health and safety consideration for them. Get one booked in. Your screen needs to be positioned so that you look straight at it without your chin dipping (ideally your chin should be parallel to the ground) – this will help you keep your ears positioned over your shoulders and the gravitational forces from your head going straight down. Shoulders should be positioned directly over your hips and spine in a neutral position. Your chair needs to be the correct height and if needed use a foot rest. Your telephone should be within easy reach and if you're on the phone a fair bit get your employer to invest in a headset – hands free calling significantly reduces neck and shoulder strain. Consider moving your mouse to the opposite hand for a few hours every few days – you'll get used to it quicker than you think.

To start with this will all feel a little weird. It's bound to because you've been sitting incorrectly for some time now. But please persist. Any imbalances which have worked there way into your body over months, maybe years, will take a decent amount of time to work their way out.

My final comment refers back to where this all began - restricted movements. You can change your job but for most it isn't a practical solution. So we have to make do with what we have. What you can do is to get up and move. Do as cats do every time they move or get up – Stretch! 

Most important is to move and keep your body fluid. I highly recommend a book called “Stretching” by Bob Anderson – he provides a simple easy to follow guide to stretches for various sports and daily activities, and I note the latest edition has a section on Computer Stretches!