It is not uncommon for a patient to come into the clinic and say they were told by a medical provider that they have unstable hips (generally referencing their pelvis). This is often followed by a laundry list of movements they “should not do”, possibly ever, to avoid making their pain worse. These patients often report frequent visits to have their body worked on and “put back together” in order to go through life without constant pain or joints “going out.”
Sometimes these patients haven’t seen any medical providers at all, but describe their pain as if something is unstable, slipping, shifting, etc. Perhaps they googled it and this is the best way they could find to verbalize the sensations they felt.
What this shows is a widespread assumption that our back/pelvis/hips can suddenly shift and change position and are “unstable”. Look at all these strong and beautiful ligaments. The strength of these is so great, could bad posture or lifting something in a “bad” way really cause that much movement?
Research shows that we are unable to accurately palpate (feel with our hands) if a joint position is “out of place” or moving in an “unstable” way. The linked systematic study found that “current clinical methods utilizing palpation for diagnosing SIJ pathology have been found to be unreliable and invalid in the literature and may have limited clinical utility.” Through research, we know that the SIJ can move on average about 2 degrees or 3-4 mm. That is such a small amount, I challenge the notion that we can actually feel that with our hands- through skin and fat and muscles.
So why do some people believe that our hips and pelvis are all willy-nilly and unstable?
As humans, we relate to stories. However, pain is not something that is easily understandable for everyone and may not have a concrete explanation- particularly when one has been in pain for years and it affects their daily life. Humans want a WHY. An easier explanation is that your SI joint is painful because of instability and movement at the joint. This seems relatable to folks because it might FEEL just like that- like it’s moving too much.
While explaining pain in this way can be helpful in some respects, the problem is that it snow balls into the “things I can’t do” list because if my pelvis is unstable, then I probably shouldn’t workout and DEFINITELY shouldn’t run. But one thing that we DO have research supporting is exercise to decrease chronic pain and improve quality of life.
So if you have pain, don’t panic! Go MOVE. If you need guidance for where to start, find providers that will encourage you to be active and strategically help you return to the activities you love. (Pro tip: This rarely entails the word “never." As in “you should never lift weights or “you should never run."). Let us know if we can help you!
Thanks for reading,
Dr. Jackie, PT, DPT, OCS, CSCS
I recently attended a continuing education course called Functional Range Conditioning (FRC). It was one that has been on my list for quite some time and it was awesome to finally check it out.
In this blog post, I’m going to expand upon some of the principles and techniques I learned and how you can start to implement this in your daily movement practice.
First, let’s define a few words. What is flexibility? What is mobility? Are they the same thing? We hear these words used interchangeably. However, they are in fact different.
The foundation of the FRC system is based on the acquisition and maintenance of functional mobility and articular health. It is very dependent on your passive and active range of motions.
Basically, the goal is to make your AROM and PROM the same. PROM is the prerequisite which will allow you to improve your AROM.
FRC utilizes a concept called “bioflow.” While I don’t get too caught up in systems or their coined terms, I’m cool with this one. It basically talks about tissue continuity (gross tissue --> cellular --> intracelluar) calling it STUFF. Stuff being cells, fibers, and ground substance. Composition of these components dictate the type and physical properties of a certain tissue whether it's bone, fascia, ligament, tendon, muscle, capsule etc. Cell signaling and progressive adaptation is how these cells change into these different structures. Think about an ACL graft that is harvested from a patellar tendon – do you think it stays a tendon over time or evolves to becoming a ligament just like the initial ACL? Yeah, science is pretty cool.
I could geek out on this stuff all day, but let’s move on to the application of improving your mobility – there’s a few techniques used to start working on making your passive movement more active.
Insert Controlled Articular Rotations (CARS) - Active, rotational movements at the outer limits of articular motion. There’s 3 levels for CARS which are related to isolated blocking, external resistance and amount of irradation. Irradation simply put is the amount of tension you create throughout your body – in nerdy science terms this is also called Maximum Voluntary Contraction (MVC) often expressed in percentages.
The best example of irradation is to give someone a hand shake. First, squeeze using your hand, then hand and forearm, then hand, forearm and shoulder, etc. Your grip gets stronger and stronger the more musculature you recruit. The more irradation, the more force you exert. You can use this to dial in higher levels of recruitment while doing your CARS or other FRC techniques. “Force is the language of cells” – one of my favorite quotes at the course.
CARS can be implemented different ways whether that is by focusing specifically on a certain joint or you can take part in the morning CARS routine to give all your synovial joints in your body some love each day.
The next step to continue to work on improving your joint integrity and control is via PAILS and RAILS. PAILS and RAILS are isometric contraction efforts (sometimes combined with stretching) used to communicate with both the connective tissue & neurological systems.
2-3 minutes of stretching to build stretch tolerance, then:
This is a great video by Joe Gambino from Par Four Performance going over the Hip 90/90 PAILS/RAILS.
I see PAIL/RAILS as a way to safely acquire and create control into these newly stretched positions without movement. Basically isometric holds to own a position with increased stretch tolerance.
The next and my most favorite part of the course and system is the End-Range Control techniques. End range is where we see a lot of injuries and tissues breaking down. Why? Well, from a physics standpoint, we’re just not able to produce as much force at these end ranges due to length-tension relationships. Another big factor is because we rarely go there. And when we do, we typically aren’t ready for it and are pushed there by accident – which is why we need to train these end ranges. It allows us to build better tissue resilience and reduce the risk of injury. Here’s how we break down end-range control:
End-Range Control: PALS/RALS
Passive Range Holds
Passive Range Lift-Offs
End-Range Rotational Training
My suggestion is don’t get too caught up on the wording of these different techniques, but understand the conceptual framework and you’ll be able to implement this immediately. We all know that we have certain aspects of our joints where our active and passive is not the same. If you’re wanting to improve your squat or overhead position, or if you just want to build up resiliency in different tissues, then give your joints some love with some of these different techniques.
Dr. Ravi Patel, PT, DPT, CSCS
Breathing. Seemingly, the most innate skillset you have as a human being. So innate that it’s used as a benchmark for being a healthy newborn and your first time taking in a breath happens within 10 seconds of entering the world. Fast forward to adulthood and you’re breathing an average of 12 to 20 times per minute without a single thought. With all that practice, we must be pretty good at it; right? Not exactly. Stress, lifestyle choices, and mechanics all play a huge role in how we breathe, and all breath is not created equal.
Just like any skill, practice makes perfect, and I routinely see the opposite. I constantly see people who can only breathe into their chest, who don’t know how to take appropriate deep breaths, and who have no control over their diaphragm. This is a problem for many reasons and let me tell you why.
First and foremost, deep breathing has profound effects on your autonomic nervous system. Your autonomic nervous system includes your sympathetic and parasympathetic nervous systems which control your fight-or-flight responses and your rest-and-digest responses, respectively. In the world we live in, it’s easy to feel the weight of stress - stress from your job, driving in traffic, relationships, finances, etc. Here’s the crazy part though: our brain can’t decipher between the stress of being chased by a bear and the stress of being behind for an important work deadline. To the brain, stress is stress and breathing short, shallow breaths is one of the main ways our brain interprets stress.
All this to say that shallow breathing is both a cause of increased stress and a symptom of increased stress responses, creating a vicious negative feedback loop leading people to live in a chronically stressed state of mind. No bueno. Not only are there serious cardiac, mental, and metabolic diseases linked to chronic stress, but chronic stress can also put you at a higher risk of injury AND slow down your rate of recovery from current injuries.
Here’s the good news though: Something as simple as taking longer, deeper breaths using your diaphragm has been demonstrated time and time again to not only prevent the effects of chronic stress, but also significantly decrease non-specific mechanical low back pain. But don’t take my word for it:
Training your diaphragm is relatively easy. Below I’ve listed my three favorite drills to do so. While doing these drills, I’ll often have my patients perform something called an “apnea breathing” pattern, which is designed to slow down your breathing, increase your parasympathetic nervous system, and decrease your levels of chronic stress.
In review, taking deep, long breaths could be an effective treatment option for you if you’re dealing with low back pain and, at a minimum, will help your live a healthier life. However, diaphragmatic breathing is just a piece of the ever elusive puzzle.
If you’re dealing with low back pain, reach out with any questions. We design and implement programs to help people just like you, whether you’re someone who doesn’t know where to start or has had an unsuccessful rehab experience. It is our goal for the people we work with to get out of pain and return to their sport or activity performing better than they did before.
Thanks for reading,
Dr. Jake, PT, DPT, CSCS
Dr. Danny and Dr. Jackie's views on performance improvement, injury prevention and sometimes other random thoughts.