 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
Hovers
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. Cheers, Dr. Ravi Patel, PT, DPT, CSCS
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Ok, so now that you’ve stepped up to the bar and have set yourself in a good position by following the “3 B’s” (if you don’t know what I’m talking about, see Part 1 of this series), it’s time to safely pick some weight off the floor. There are a number of different nuances you can get into when teaching someone how to deadlift, but for this sake of this post we are going to break the lift into two main parts: First Pull and Second Pull. 1. First Pull: This is where you lift the bar from the ground to your knees. During this part of the lift you should be keeping your spine in a neutral position by having your hips and shoulders rise at the same time until the bar reaches your knees. If you let your hips rise faster than your shoulders then you’ll end up rounding your lumbar spine, and if you let your shoulders rise faster than your hips then you’ll end up over-extending your lumbar spine. Both of those approaches increase the shear forces at your vertebra, which our spines are not designed to handle. 2. Second Pull: Once you get the weight past your knees you are entering the second pull of the deadlift. At this point in the movement your main focus needs to be “bringing your hips to the bar”, meaning your shoulders continue to move upwards as your hips move forward towards the barbell. So the big takeaway here is that, when you initially starting lifting the weight off the floor, you need to keep your hips and shoulders moving in the same direction, at the same rate, until you get to knee height, and at that point you start to shoot your hips forward as your shoulders continue to rise. Sounds simple enough; right? Well, there are techniques you need to also remember in order to not just perform the lift correctly, but to also keep your back out of harm’s ways.
So there you have it. By utilizing appropriate muscle activation, spinal position, breathing mechanics, and biomechanics, you’ll be able to successfully deadlift with less pain and more weight. At Athletes’ Potential we work daily with barbell and strength athletes, so if you’re struggling with pain while you deadlift and live in the Atlanta area, give us a call or fill out the contact request form below! Thanks for reading,
Dr. Jake, PT, DPT, CSCS Back pain is such a common complaint that we treat, but what if I told you that back pain can be caused by pelvic floor dysfunction? First, it is important to remember that pain does not equal damage. Second, it is not unusual to experience pain in a different area from where the dysfunction lies. This could be referred from another area or a secondary effect to moving in a weird way due to the dysfunctional area. Cause and effect in this case is very similar to asking “Which came first, the chicken or the egg?”. What we can state confidently, is that your back and your pelvic floor go hand-in-hand. Studies show that folks with low back pain have decreased pelvic floor function compared to those without back pain. Could this be pelvic floor inhibition due to the back pain? Can weakness or over-tension or control issues of the pelvic floor be causing the back pain? For many, the pelvic floor is very nebulous. What is it anyway? Where is it? What does it look like? Do only women have them? Males do have pelvic floors, but the anatomy is different. For this post, we will referring specifically to the female pelvic floor. But guys- you too can have pelvic floor dysfunction! This image below is a great look at the female pelvic floor and it’s close relationship to the other pelvic and lumbar spine architecture.  The pelvic floor helps to support the weight of your organs, helps with toileting and sexual function, and influences posture and control through pressure within the core. Weakness, over-tension, spasm or damage to the pelvic floor will change the support of the sacroiliac (SI) joint and the forces that we create through the lumbar spine. If you have addressed your lumbar spine without much change in symptoms, go a different route! Keep in mind, there are other signs of pelvic floor dysfunction, other than leaking urine or back pain. They include painful sex, frequent constipation, the feeling of heaviness in the vagina with jumping/running/bearing down etc. Addressing the Pelvic Floor There are 3 areas to cover that address your pelvic floor in a functional way -- position, breathing and bracing. All of these can be applied to any athlete in any setting. Position- Keeping the ribcage stacked over the pelvis is an important position to maintain, regardless of activity. This sets the canister (“core”) up for optimal function- meaning the diaphragm, pelvic floor, abs and back muscles can work harmoniously to lift the most weight, support the spine and minimize pressure on the pelvic floor. Breathing- Diaphragmatic breathing is essential for pelvic floor function and decreasing pain around the low back. The pelvic floor mirrors the movement of the diaphragm, so it is a simple way to relax a tight pelvic floor. Also, two major muscles that run from the ribs to the pelvis also have connections to the diaphragm. So deep breaths can work as a gentle mobilization!  Bracing- How do you prepare for heavy loads or challenging positions? If you simply hold your breath and go, you are missing an opportunity to create more tension! Or if you are holding your breath for a position that should not require that much power, you are increasing the workload on your pelvic floor and back for no reason. For example, preparing to lift a couch versus preparing to lift a pencil. Put simply, if you are lifting something heavy, holding your breath is fair game. IF you do it correctly. If you experience symptoms- low back pain, leaking, heaviness- then do not hold your breath until you seek help for how to correctly brace. Knock the weight down or the mileage down to a place that you do not have symptoms and work there until your tolerance improves. If you notice you are holding your breath with lifting a small object, such as your purse, then let’s talk breathing. Breathing out on exertion for a task like this will help the pelvic floor contract reflexively and can keep symptoms at bay. Try it out! Big picture: Back pain does NOT equal back injury. It is very likely that back pain can be decreased and function improved with addressing the pelvic floor as it work with the low back muscles. Check out these simple ways to check your position, breathing and bracing. Often times, pain is a product of HOW you are moving. If you take a crack at it yourself but just can’t seem to find improvement, reach out to us at Athletes’ Potential. We work with people like you every day to get them back to high functioning lives without pain and with a better understanding of how to move their body. Thanks for reading! Dr. Jackie, PT, DPT  “The aim of CrossFit is to forge a broad, general and inclusive fitness supported by measurable, observable and repeatable results. The program prepares trainees for any physical contingency—not only for the unknown, but for the unknowable, too. Our specialty is not specializing.” The quote above was taken directly from CrossFit.com. It describes CrossFit’s mission, and it is undeniable that CrossFit accomplishes its mission of preparing trainees for multiple arenas of physical contingencies. The point of this article is not to argue nor neglect the many benefits associated with CrossFit training. However, even with CrossFit’s ability to program and prepare you for the many physical challenges that life may throw your way, when it comes to building a functionally strong and healthy back, there is one crucial area where CrossFit falls short: multiplanar movement. Before we talk about how CrossFit doesn't deliver multiplanar movement, first let's look at how our spine moves throughout the day. Whether we are going to the grocery store, playing softball, or hitting a round of golf, our backs do not move in one dimension. To perform movement efficiently and effectively, our spine must be able to move through a combination of movements in three different planes: frontal, sagittal, and transverse.
 In order to fully bulletproof our backs and prevent back pain from occurring, not only must we be able to move through these three planes of movement, but we must be able to strongly control our spine throughout each motion and this is where CrossFit falls short. The world of CrossFit lives in the sagittal plane. Squats, deadlifts, snatches, burpees, kettlebell swings, muscle-ups, toes-to-bar, double-unders, Fran, Murph, Gracie, and Annie. What do all of these have in common? In all these movements and exercises your back is predominantly bending forwards and backwards, meaning in all these movements your back is moving in the sagittal plane only. There are very few movements in CrossFit that require you to challenge your back rotationally or laterally and as you’ll see below, that’s a problem. Holding your child at your side, swinging a bat/club/racket, getting in and out of your car, serving a volleyball, opening a door, and kicking a ball. What do all of these activities have in common? These are all movements commonly found in sports and in daily routines and they all challenge your back rotationally and laterally. Not only are these multiplanar movements incredibly common, but because CrossFit doesn’t address frontal or transverse plane movements, if you aren’t doing any type of accessory training, you’re going to be weak in two-thirds of the required movement patterns, and you’re going to be at a greater chance of developing back pain. So does this mean that Crossfit is terrible and you should stop doing all those squats, deadlifts, and other aforementioned CrossFit workouts? Absolutely not. Sagittal plane movement is crucial to our everyday lives (i.e., bending over to pick something off the floor, getting up from a chair, etc.), it just isn’t the complete picture. You’re leaving your back vulnerable to injury if you aren’t working on getting strong in the other two planes of movement. The solution to this problem is simple though, you just have to take the time make sure you’re putting in the work. To get an idea of how to start training in the frontal and transverse planes, try adding in some of our favorite transverse and frontal plane strengthening exercises either before or after your next WOD. Perform 3-4 sets of each exercise to form fatigue. Chop and Lift (multiplanar)  Pallof Press with shoulder flexion (transverse plane) Single-Arm Farmers Carry (frontal plane) At Athletes’ Potential not only do we help CrossFit athletes with low back pain all the time, but we are CrossFit athletes ourselves. We take immense pride in thoroughly understanding your sport, what it’s strengths are, and where there may be some deficits. If you’re a CrossFit athlete living in Atlanta, and you’re struggling with back pain, we’d love to help you. Give us a call at 470-355-2106 or fill out the contact request form and we’ll contact you. Thanks for reading, -Dr. Jake, PT, DPT, CSCS   That’s a funny cartoon, but back pain is no joke. Chronic low back pain is the leading cause of disability in the world. Throughout our lives, 80% of us will experience low back pain. So why do some recover completely while others have chronic, sometimes debilitating, back pain? As movement specialists, we (physical therapists) often want to explain the why of pain with muscles, joints, and movement patterns. Sure, we can work on asymmetries in movement and perceived muscle weakness but for chronic pain this is only a small piece of the puzzle. Back pain can be particularly frustrating for a few reasons. For one, imaging does not directly correlate to pain nor does it change conservative treatment strategies. Also, improvement from back pain often has ups and downs, sometimes with no indication of what causes it. What NOT to do if you have back pain Going straight to the orthopedic for back pain can start a cascade of chronic back pain. Lumbar spine imaging should not be the first line of care for back pain. I see it too often- either the imaging shows something that seems “scarier” than the pain that the patient feels OR the pain is quite intense but the image shows nothing out of the ordinary. The latter tends to be the most frustrating. If there is nothing torn, bulging, ripped, degenerating (insert any other terrible descriptor here), then why the heck does my back hurt SO BADLY? Our nervous system is extraordinary because it has the ability to adapt and change with our stimuli- inside and out. This becomes a problem when it adapts in a way that we call “central sensitization.” Essentially, the central nervous system (brain and spinal cord) becomes extra sensitive to stimuli. So something that should cause little pain, or none at all, sends serious threat signals to the brain which leads to pain. The best analogy commonly used is the house alarm. If a burglar breaks the window in my house, I expect the alarm to sound. However, if a tree branch scrapes the window, I do not expect the alarm to sound. But with central sensitization, the alarm does go off. And this alarm is PAIN. Check out this cool video about chronic pain. It only takes a few minutes: Explain Pain Is it a false alarm? Based on the healing rates for tissues in the body, we know that after a few years into back pain, the pain is not stemming from actual tissue damage. If there continues to be pain similar to the original onset, it is likely that there are some central nervous system changes. When working through this with patients, it always starts with education so that they understand I am acknowledging that they feel the pain but also that they understand pain DOES NOT equal damage. To progress towards improved function and a pain-free active lifestyle, we focus on repetition of basic movements that may or may not be painful. The idea is to train the neurological system that simple bending over should not be threatening or painful. That being said, sometimes it is painful! In that case, I set the following rules: if the pain is low level and constant we are ok to work in that range, and if pain begins to escalate throughout the movement we will take a break. But as you build resilience and confidence through the movement range, you will experience less pain and the central nervous system will lessen the threat associated with that movement. TAKE AWAYS:
At Athletes’ Potential, we treat a lot of back pain. A story that we hear often is that people have bounced between providers, tried more severe/invasive treatments, long term use of pain meds or anti-inflammatory drugs, etc., but still have pain! We specialize in helping people maintain a pain-free, high-level, and active lifestyle. Whether this looks like running marathons, lifting heavy weights or playing with your kids, we can help you get there. If this sounds like your past and the future you want, give us a call. We would love to help! Thanks for reading, Dr. Jackie, PT, DPT, CSCS We recently had a patient come in who had been dealing with low back pain for over a year. He was super active, training 5-6 days per week, but hurt his back one day simply standing up from a chair. He had seen his family practitioner periodically for steroid injections, which would provide some relief for a couple months but then end up right back to square one. Frustrated with his lingering back pain, he gave us a call and after a thorough evaluation, some manual techniques, and exercise programming, he left our office with decreased pain and improved mobility. We see patients like this all the time here at Athletes’ Potential… which makes total sense. Back pain can happen with some with some of the most innocuous movements, and in many cases, without warning. In fact, On average 80% of Americans will experience low back pain at some point in their lives and more than a quarter of the population currently deals with low back pain on any given day. Not only have most people had some form of back pain, but it many cases it is the result of poor movement patterns that have been abused for years causing the root of their problem to be both incredibly complex and multifactorial. Great news though! Whether you hurt your back trying to hit a new deadlift PR or simply bending over to put your kid in their car seat, there’s a profession out there, armed with years of training and knowledge, designed perfectly to help with your low back pain: Doctors of Physical Therapy. Here are some of the reasons why you should see a doctor of physical therapy the next time you’re experiencing back pain. Advanced Education: Physical therapists go through seven rigorous years of both academic and clinical training in order to become Doctors of Physical Therapy. We have spent seven years in school studying human anatomy and physiology, kinesiology, biomechanics, and tissue histology. In other words, we know how the body moves, how it heals, and how to optimally restore its strength and mobility in order to get you to your goals. Multiple Treatment Options: As I mentioned earlier back pain can be pretty complex, requiring multiple different treatment options to not only alleviate your symptoms, but correct the underlying problem that caused the issue in the first place. Unlike other healthcare professionals, doctors of physical therapy have the ability to choose from multiple different tools in their toolbox. Whether this means using corrective exercises, dry needling, joint manipulations (cracking your back), soft tissue mobilizations, taping, or wrapping, a physical therapist has the ability to customize the most appropriate treatment program for you. Patient Empowerment: More than anything else, a physical therapist's ability to educate you the patient is invaluable to your recovery. There are 168 hours in a week, at most you’ll see a physical therapist 3 times per week for an hour...that still leaves 165 hours where you’re on your own. Compliance is crucial. For true long-term changes to happen versus short-term reductions in symptoms, you have to know what you should and should not being doing, and physical therapists are second-to-none in making sure that is exactly what happens. Additionally, after you’ve had back pain once, there is a 90% chance you’ll have back pain again at some point in the future. Think of it this way, after you roll your ankle once, you’ll more than likely roll your ankle again at some point. Don’t panic though, the education and coaching you’ll receive from your physical therapist will allow you to know exactly what to do in order alleviate most future back pain exacerbations in a few days instead of weeks, months, or even years. In review, you’re not alone in your back pain. In fact, it’s more likely than not that you’ll experience some form of back pain in your life. However, this doesn’t take away the fact that back pain can hinder your daily activities and keep you from what you enjoy most. Physical therapists are highly trained musculoskeletal experts that not only help patients alleviate their low back pain, but keep it away by empowering them to take their healthcare into their own hands.
If you’ve living in Atlanta, and you’re struggling with back pain, we’d love to help you. Give us a call at 470-355-2106, or fill out the contact request form and we’ll contact you. Thanks for reading, -Dr. Jake, PT, DPT, CSCS One of my patients woke up the other day with pain that started on one side of her lower back and radiated down her hip, hamstring and into the side of calf. She told me this while I was making pancakes on Saturday morning for our kids. My wife is my number one patient so I’m writing this blog post for her. I know that many of you suffer from some degree of pain radiating down a leg as well. My goal with this blog post is to teach you a few simple strategies to ease these symptoms. Let’s start by defining sciatica. It’s actually an umbrella term describing pain that radiates along the course of the sciatic nerve. The sciatic nerve is a huge nerve that starts in the lower back. It comes together and courses down the hip, through the hamstring and then branches into two other nerves at the height of the knee. If you’ve ever sat on something hard like a wallet for too long on one side, you may have experienced some short term sciatica. What sciatica is and what causes sciatica are two separate things. Sciatica itself is the pain/irritation you feel down the leg. The cause of sciatica can be a number of different things. First, it could be coming from your lower back. This could be due to a bad disc herniation, poor movement at the small joints in the lower back, lack of mobility in the hip and even prolonged positional pressure like sitting on a plane to Australia. Because of the many varying causes for sciatica, my goal is to give you a number of different self-management options. We’ll cover three different areas where you could improve and ease much of the sciatica that you do experience. These areas are:
Step 1: Easing sciatica issues by getting out of positions that cause increased symptoms This seems blatantly obvious to most people. The reality is that many people stay in pain producing positions for extended periods of time. For instance, let’s take a traditional office-based job. Sciatica can be irritated with prolonged sitting, especially in a very flexed position. This puts the lower back into a flexed or rounded position. Because of this forward flexed position, the discs (think shock absorbers) of the lower back had additional stress placed on them throughout the day. Take a look at the picture below. This shows the amount of pressure on the discs of the lower back in different positions. You can see that sitting in a forward flexed position increases the amount of pressure on the discs by 85% compared to standing. Even sitting in a good position increases the pressure by 40%.  What this shows us is your best option is to stand more, if possible. Even better, stand up and walk around more. Walking is like spraying WD-40 on the joints of the lower back and hips. Getting a standing desk is a good option for most people. They are becoming much more common in workplaces and even in schools. Stand Up Kids is a great reference for some of the other health benefits to getting a stand up desk. If you are stuck sitting at a desk and you notice your back feels better when you stand, a lumbar roll may be a good option for you. These are firm rolls that are placed at the height of the lower back. They block the user into a more upright sitting position and deter much of the slouching that we see when people sit at a desk all day. You can also make yourself one of these pretty easily. Just get a gym towel, roll it up tight and duct tape around the roll. That’s it. It may not look as cool but it works. Step 2: Easing sciatica issues by adding in self-mobility work to muscles in the lower back and hips Let’s go over two areas you can start working on daily to help ease pain down the leg. For all of these areas our dosage is this: perform them twice a day, two minutes each technique per side. For all three techniques it should take you about 8-10 minutes with transitioning from one exercise to the next. The first muscle is the quadratus lumborum. We’ll just call this muscle the QL because the actual muscle name sounds like a Harry Potter spell. The QL is a muscle that is one either side of the lower back and connects from the rib to the lower back to the pelvis. This muscle can refer pain down into the back of the hip region and is notorious for being irritated in people who sit all day or lack strength in their trunk. The second muscle is actual a group of muscles. We call it the lateral hip complex but it includes fibers from the gluteus maximus, gluteus minimus, gluteus medius and deep rotators like the piriformis. These muscles, in particular the piriformis get blamed for much of the sciatica people experience. We’ll catch a little bit of all of these muscles with this one technique. Step 3: Working on improving control of the lower back and hips This step is often the one that people skip over. This is especially true if someone gets pain relief with some of the mobility techniques or a passive treatment like dry needling or massage. Controlling your own body is massively important. I love the saying, “Strength is never a weakness,” and it’s true in this case. Here are two techniques to get some control back in the right areas. The first thing we want to do is account for a huge area of dysfunction in almost every patient I see. That area is breathing! I know, you’re obviously breathing if you’re alive and reading this article. Just because you’re breathing doesn’t mean that you haven’t started doing it in a compensated way. We take an astounding 20,000 breaths per day. Many of us who have had issues with sciatica or lower back pain tend to breath in a dysfunctional pattern. The main dysfunctional pattern I see in my patients is chest breathing. These are the individuals that just raise their rib cage and shoulders every time they breath. What they neglect to use is the diaphragm to initiate the breath movement. This can happen for a number of reasons but for the purpose of this article let’s just leave it as something we want to try to correct. Below is a breathing exercise you can start using to correct this problem. Try and get 5-8 minutes of this breathing drill in per day. You can break it up into 1-2 minute bouts or get the whole 5-8 minutes in at once if you want. The last exercise you can add in is to help develop some control in extension between your lower back and hips. This is an exercise called the banded bird dog and it requires a significant amount of stability/control. It also connects the hip with the shoulder on the opposite side. This is very important because we function so much in rotational patterns. Think about throwing a ball. If you’re throwing with your right arm then your plan leg is your left leg. This diagonal control is very important for the lower back and controlling torque through the spine. Getting strong in this pattern is one of the best ways to create long term function and decrease the likelihood of sciatica issues. Try and do 3 sets to form fatigue with as much rest in between sets as you need. Form fatigue is when you can’t perform a perfect repetition anymore. If you’re like me you probably read the highlighted bullet points and then you’ll read this last paragraph (I call it efficient reading!). Let’s go ahead and summarize everything and make sure we’re clear on what to do. First, get out of positions that cause sciatica. Move to a standing desk if possible and if not get up and move around as much as you can. Next, start working on mobility to areas that can be problematic for sciatica. This includes the QL and the lateral hip. Last, start getting some control back in your hips and lower back. Control and strength in these areas will be a huge benefit to you in any physical activity you chose to do. Give this stuff a try for a week or two. If you feel like you’re not making progress or are ready to get some one on one help, we can help. We help people just like you get back to running, golf, tennis, CrossFit and cycling without sciatic pain. Check out our testimonials pain to see what others have to say about the work we do. Stop avoiding activities because of pain, get some help and get back out there. - Dr. Danny, PT, DPT, OCS, CSCS
Let me start out by making this clear. I have a Doctor of Physical Therapy (DPT) degree I do not have a Doctor of Medicine (MD). If you have a rash and a fever I’m honestly useless to you. If you tweak your lower back picking something up, I’m your man! Much like our friend Stu from the Hangover, there can be a bit of confusion about what different medical professionals actually do. Yes a Dentist is a Doctor but not a Doctor of Medicine. For the context of this post when I refer to a MD, I mean a General Practitioner or Family Practice Physician. This is typically who most insurance companies mandate you see before you can go see a specialist like an Orthopedic Surgeon. MD’s that function in the capacity fill a huge and vital role. They have to know a little bit about a ton of medical problems. They may see one patient with the flu and the next one could have a sprained ankle. They have to be able to decide what to do with that patient or if they would be better off to refer them to a different medical specialist. One of my duties in my last jobs in the Army was actually to serve as a clinical instructor for MDs going through a Family Practice residency. They would spend a few weeks with me learning about musculoskeletal evaluation and treatment. They were always so excited to actually learn how to treat people, not just diagnose them. They especially loved the mobility techniques and dry needling I would teach them because they would get results fast. The one thing they couldn’t change however is the amount of time they would get with their patients. On average an MD will get to spend 8-10 minutes with a patient. That’s not a lot of time to establish trust, listen to what the patient has to say, do a thorough exam and then actually treat that person if it’s needed. Many states and insurance companies want patients to see an MD first. One of the reasons for this is the very unlikely chance that your musculoskeletal pain could be caused by something internal. This could be pathology such as cancer, internal organ pain or a number of other systemic diseases. This is where red flag questions become an important part of evaluating someone. Red flag questions are asked to help rule out pain that is not coming from muscle, joint or bone problems. Also, any good medical professional, no matter what their degree should be able to tell when something just doesn’t seem right. I’ve caught cancer on two occasions, Lyme disease once, gallbladder disease once and muscular dystrophy once. That’s 5 people out of the thousands of people I have seen over the past few years. Here is an example list of red flag questions typically asked when someone has lower back pain. If you answer no to these questions you can feel pretty confident that your pain is coming from muscle, joint or bone related issues.
So, when you hurt your back you have two options. Option one, go and see your MD, have them spend 8-10 minutes with you and ask you the above set of red flag questions. Most likely they will give you some tylenol and a referral to see a physical therapist. Or you can pick option two and go see a physical therapist. Spend 60 minutes with that individual, answer the same set of red flag questions and then start working on fixing your back. -Dr. Danny, PT, DPT “Mobility programming is like pizza, even when it’s bad, it’s still pretty good! “ -Danny Matta (yes I just quoted myself) Here’s a scenario that never happens. A CrossFit athlete leaves his 9-5 job where he just sat at a desk for 8 hours. He drives to his local box and is giddy with shear joy and anticipation over what the mobility work might be for this day’s WOD. He wonders to himself if his coaches will have him work on his hip capsules or maybe he if he’s lucky the sliding surfaces of his latissimus dorsi and serratus anterior. This is obviously a fabricated scenario because the truth is most people don’t get excited about mobility work. Even though you or your athlete’s might not like it too much, it’s kind of like having to eat your vegetables when you were a kid. You know it’s good for you and you still have a hard time accepting it (unless the vegetables were covered in cheese, then they were acceptable.) Sometimes the toughest part of programming is where to fit mobility work into a WOD. If your athletes are busy people like I am, they may get one golden hour at the gym between 3-5x per week. We want to use our time as efficiently as possible. Programming for a group of people with different mobility problems can be a bit tricky. Here are two strategies you can use to make it more effective. We’ll use this simple programming below to show different areas you can add mobility work in to your WOD. By the way, this programming is not for competitors, this is an example of programming for a novice to intermediate CrossFit athlete. WOD Dynamic Warm Up: some type approx. 8-10 minutes Back Squat: Strength Block work up to 3 sets of 5 reps (Rest 2 minutes between sets) Annie: 50-40-30-20-10 Double Unders and Sit Ups, cut off time of 12 minutes. Cooldown: 3 rounds 200 M run forward, 200 M run backward 5 hand release push ups 65-75% effort on the run. Focus on keeping the forearm perpendicular with the ground during hand release push ups. * The most basic mobility goal should be to focus on improving fundamental positions that are being challenged in that day’s WOD. * If our athlete’s are squatting, we want to improve the bottom position of the squat. If our athlete’s are pulling from the ground, we want to improve the position in the start of a pull and so on and so forth. If you wanted to improve the position of one of the movements above, which would you, pick? My answer to that question would be the squat. It’s the one movement we are dedicating the most time to in the WOD and is a fundamental archetype shape. So if we wanted to improve this movement we have a few options, but here are two that we use most often. 1. Exaggerate reality By this we mean, program a mobility drill that exaggerates the squat position. This could either be a drill that drivers your knees out further than you normal do squatting, forces you into a deeper bottom position than normal or driving your knees further forward to improve the ankle range. Don’t try and get too complex here, do something that looks like a variation of the squat but exaggerates it in some way. Here are a few videos of ideas that you could add in for this WOD’s programming. 2. Mobilize the muscles that were the primary force producers If we take the programming from above, we could say that the quads and hip flexors are going to be the two muscle groups that are most likely to be sore over the next few days. In this second strategy, we focus on trying to help the athlete’s have less soreness by doing some fascial techniques right after the cool down. You can really set your athletes up for success this way, especially the newer athletes that might be sore for a few days after a WOD like this. Here are a couple techniques you could add in after the WOD to get the quads and hip flexors feeling better. Fast-forward to minute 3 if you just want the specific techniques.
Now that we have some ideas of what we might want to work on, when should you add your mobility work to this WOD? If you’re really strapped for time and want to be super efficient I would recommend doing the mobility work during the built in rest periods of the squat block. If you have a built in two minute rest period, throw a band around a hip and open it up for a minute on each side before doing your next set. This is one of our favorite ways to save time and improve a movement position in the process. By the time you get to your last couple of sets, your hips should be nice and mobile to hit that new 5RM PR. If you can’t add it in between sets for some reason, the next best option is to make it part of the warm up in some way. Maybe add a kettle bell to the rocking sumo technique(show nabove in the first video) and get that heart rate up while improving the bottom position of the squat. Programming for a group can be hard but if you follow these two strategies it will help get your mobility work organized. You’re never going to be able to pick one mobility technique that’s the best mob for every person in your 5 PM class. Everyone is a bit different, so focus on improving positions used in the WOD and fascial techniques for muscles that are most likely to be sore. This will help everyone get something useful out of their mobility programming. If you have any mobility programming questions leave us a comment or hit us up on Facebook. We’re more than happy to help you get on the right track! -Dr. Danny, PT, DPT  Do you sit frequently? If the answer is yes, you need to work on you psoas. The psoas, technically psoas major, is a hip flexor that starts at our back and inserts into our thigh bone(femur). When we sit for prolonged periods of time, this muscle gets brutally short. It's very rare to work with a CrossFit athlete in Atlanta or around the country for that matter that doesn't have problems with this muscle group. We can use some common strength and conditioning equipment to help get into our psoas and reset our pelvic position. Give it a try guys and don't forget to test your squat before and after you mobilize. It's time to take your psoas back! Dr. Danny, PT, DPT |
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