Top 5 Easy Things to Do in Quarantine to Avoid Chronic Pain

There is alot of pain going around. People suffering from a severe illness. Family members grieving over lost ones. Financial pain. One area in your life that you can have some control over is your body. Taking care of your musculoskeletal system will keep you from experiencing pain, racking up medical bills later on in life and keep you in a functional state. If you want to be able to pick up your kid and not worry about your back going out, take a jog without knee pain, or get rid of that pesky neck tension that you keep attributing to stress, your joints and muscles will need some attention like you give other aspects of your life. Here are 5 things you can do to improve your muscular and joint health through these turbulent times:

1) Take a deep breath (and not for the reason you think) - Many people start to have rib mobility issues as they get older which can have a big impact on shoulder and neck health. When you stop exercising and become more sedentary, you don’t get as much expansion of the ribs and you know the saying, if you don’t use it you lose it. Try taking 10 deep breaths a day in a row with focus on your ribs expanding (I know people like belly breathing, but that’s another discussion). Each breath should be deeper than the last one. You can actually get some oxygen to the brain and keep your rib cage loose.

Alternate Exercise: Want to take it to the next level, try using some shoulder movement to assist your rib cage with Deep Breathing with Shoulders

2) Become more stable - As much as you want those 6-pack abs, the beaches are closed so what’s the point? Instead, focus on core stability. Keeping your core stable is the best way to avoid back strains and promote proper muscle activation (see #3 about Glutes) and posture.

Try Core Stabilization for Beginners before moving on to Advanced Pelvic Stabilization with Rotation

3) Don’t go GLUTEn free (sorry for the horrible play on words) - Isolating and tightening each glute muscle is key to keeping your back relaxed. The glute muscles are possibly the most inhibited muscles in the body due to various reasons (excessive sitting, improper exercising technique, etc.) Keep them on at all costs by activating them during walks, when sitting down (or standing back up) and even activating them while lying down while watching Netflix.

Alternate Exercise: Bridging and Advanced Bridging Progression

4) Build your arch - Tight calves and improper gait patterns can lead to flat feet (which takes a toll on the whole body). Try building your arch muscles in the foot and lengthen your calf muscles to improve the area of the body that takes the most impact with standing and walking. These joints accept all the force and translate that force up the body, but don’t get nearly the attention they deserve. Without good feet and ankles, you don’t stand (pun intended) a chance.

Try the Calf Stretch with Arch everyday for a better translation of force during walking which leads me to….

5) Go for a walk (and not for the reason you think) - Yes, walking can get you fresh air and a reprieve from the cabin fever everyone is experiencing. It can also maintain the hip flexibility that allows you to take long strides. If you are sitting or lying down more, chances are your hamstring and hip flexors are tightening up.

Alternate Exercise: Forward and side lunges in place (Not a fan of walking lunges because of the lack of control and stability)

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine and Co-owner of LA Orthopedic and Pediatric Physical Therapy in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter and Instagram @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com. For pediatric patients, please email us at info@laoppt.com.

Note: JAM Sports and Spine Physical Therapy and LA Orthopedic and Pediatric Physical Therapy are proud providers of TeleHealth Physical Therapy

Growing Pains: Something to Ignore?

I remember as a kid, anytime I felt pain it was brushed off as “growing pains” . I was led me to believe that it was normal and that it would go away. No biggy. This process continued to happen as the pain got worse entering adulthood. It was the start of postural problems in my youth that became my adult problems. But what if we started to treat a child’s complaint of pain as something real, possibly stopping the progression of problems into adulthood? Maybe we would save our kids from a lifetime of problems that plague most of us adults. In order to answer this question, we need to start by looking at the root of the problem.

As technology progresses, so do our postural problems. Kids hunkering down over an IPhone or a tablet will speed up the problems of rounded shoulders, sway back, abdominal weakness and so on. Even more than that, the lack of physical play and increased stationary time will indeed exacerbate that exponentially.

A common misconception is that children are injury proof. They sprain something, they will be completely healed in a few days unlike adults where it takes a toll. Doesn’t matter what they do, they will be fine. It is adulthood when the problems begin. The problem is, if that were true, you wouldn’t be seeing the imbalances in children that are commonly seen in adults. But we are. As a child moves into adolescenece his/her body is forming. Just like their brains, we need to nurture their muscoloskeletal system to form the correct way.

So you ask, what do I do as a parent?

As a practical measure, we need to start putting a limit on stationary play and increase physical play. Limiting the time on the couch and increasing the time children swinging from the monkey bars and using their full set of muscles is the best bang for your buck for a child’s musculoskeletal system. Taking it one step further, is taking our children more seriously. When your child complains of foot pain, headaches, or back pain, take notes. Do they get abdominal muscle cramping on one side of the body when they run . Do they seem to want to lay down more than they want to be up and about? Knee or foot pain with walking? Chances are, its a small imbalance that can be nipped in the bud. Finally, children should be having annual postural exams by a pediatric physical therapist, just as they see their Pediatricians for their annual check up.

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

Where Meditation and Physical Therapy Collide: Mindfulness and the Path To Retraining your Body

This might sound elementary, and it is. Doesn't mean most people are proficient in it. What I'm talking about is the cliche of having "body awareness". I first realized the power of this tool during a general yoga class. At the end of the class, we went through a meditation exercise of doing a body scan, focusing on each part of the body separately and essentially taking inventory. Later on in my years practicing as a physical therapist, I started to realize that the patients with any meditation experience, seemed to have a better grasp on inhibiting and isolating muscles, an integral part in retraining the body for better alignment. Having a better awareness between the brain and muscles or "neuromuscular" connection allows us to selectively activate muscles, giving us the ability to strengthen our weaknesses and inhibit our overactive muscles.

Here are 3 ways to improve your body awareness:

1) When working out, notice which muscles you are using instead of just getting through the motion. It might surprise you that you might not actually  be using the intended muscles for that exercise. 

2) When laying down at night, notice any aches and pains you have in a resting position and if you can change those sensations by changing positions

3) Notice your default positions in sitting, standing, and lying down. Do you like to stand with more weight on one leg than the other? Do you seem to lie with one side of your back lifted off the bed? Do you like to cross your legs in sitting always in one direction?

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

How To Reach Down Without Throwing Out Your Back

The tides are turning. Little by little we are getting away from restricting movement and activities after injury and on towards facilitating the ability to perform those movements with good mechanics. Every bone and muscle in your body has its function. As soon as we tell people to stop doing this activity or avoid this movement, those joints become dusty and shelved. Chain reactions  can move throughout the body with compensations based off avoidance due to different movement patterns. 

One of the most common and feared movement is bending. Most people sustain bulging discs and throw their "back out" from this seemingly harmless movement. Well the truth is, the movement is harmless. What is harmful is the position we are in when we reach down. If you are one of the fearful people who use a golf lean or squat down to pick something up, there is good news. With proper flexibility and some body awareness, you could be reaching down in no time!

Give this a try: When bending forward, put your hands on the most prominent part of your pelvic bone in the front. Are they even? Is one more prominent than the other? When you reach down, does one bone get even more displaced. This can be due to pelvic instability, hip mobility or poor movement patterns. By reducing the asymmetry and bending over with an even pelvis and mobile hips, our backs have nothing to worry about!

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

Take A Deep Breath

You had a long stressful day and you let out a sigh, a reflexive deep breath, almost gulping in some air. Take a listen what your body is telling you, to take a deep breath. Because of prolonged sitting, hunched over postures, and increasing levels of obesity, we are not breathing as well as we should be. Whether it is a big gut obstructing depression of the diaphragm that allows air to flow in, a tight rib cage due to a tight upper back that hunches us over or tight muscles between our ribs, it is getting harder and harder to take a nice deep breath that fills our lungs with air.

But don't despair. Just as with any part of our bodies, this is something we can train. The diaphragm and the intercostal muscles are both just that, muscles. We can stretch the inner intercoastal muscles, mobilize our upper backs (thoracic spine) and strengthen the expiration muscles so we don't find ourselves gasping for air throughout the day.

Don't Get it, Try this:

Take a very deep breath, letting both our abdominals (diaphragmatic breathing)and rib cage expand (not elevate). Feel tightness or restricted in how deep of a breath you can get? Now use a foam roller or lacrosse ball to loosen your upper back. Now try taking that deep breath again. Any difference? if so, a tight upper back can be your problem. Continue to mobilize your upper back while practicing your combination or rib cage expansion and diaphragmatic breathing to strengthen your inspiratory muscles. Don't sigh or fret, just take a breath.

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

How a Tight Shoulder Leads to Back pain

He was sitting at the table as the casserole was being passed to him from his right. He tried bringing his hand over to the right to take the dish and experienced some discomfort in his shoulder. Instead, he leaned his body to the right to grab the dish and continued dinner. You see whats wrong here? Instead of having adequate flexibility in his right shoulder, he used his trunk and spine to help him out. These are the types of moves that get us in trouble, especially if the problem is one sided.

Having adequate flexibility is underrated. Most people feel that it is "good" to stretch and not necessary. Having adequate range of motion keeps us from compensating and using a neighboring joint from helping out which can lead to a strain in the short term and missalignment in the long term.

Don't Get it, Try this:

Put both hands out in front of you  and elbows tucked into your side as if somebody is about to pass you a newborn. Keeping your elbows tucked in, start to veer your hands away from each other. Does one  hand go farther than the other? Do you start to lean to one side? If so, the side that doesn't go as far or the leaning side can be indicative of shoulder tightness.

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

The Best Way to Prevent Shin Splints

You have been training for the marathon for 3 months now. You are at a good pace and working towards your 10th mile in your program when you start to feel pain in the front of your leg. Have you hit your ceiling? Or do you just have shin splints?

Shin splints are a common problem with runners and fast walkers. Shin splints can be due to a variety of dysfunctions including too much leg rotation, insufficient ankle joint mobility or misdiagnosed altogether and actually be radiating pain from your back. The most common reason for shin splints are over-powering and tight calf muscles (back of the leg) versus weak shin muscles or dorsiflexors (front-side of the leg). So how does this wildly imbalanced leg musculature occur? Runners and power lifters have already deciphered the problem without even knowing it. Have you ever seen a lifter where shoes that lift up their heel? Have you noticed the trend towards forefoot running? These ideas have been put into practice for different mechanisms but have the same root: your calf muscles. Let me explain:

In a runner who is going for speed, using a forefoot strike is meant to increase forward momentum. But it benefits the runner's performance in another way. By avoid heel strike, the runner also avoids the pull of tight calf muscles which can slow you down through extra energy expenditure. Landing on the heel forces you to lift your foot up using the front shin muscles against those tight calf muscles. In this scenario, the runner has created a tug of war at the ankle which makes running harder and inefficient. (This is not to say one should avoid heel strike strategy as running should be individualized).

Now lifters with their specialized lifting shoes have the same dilemma. As one squats, they come to a point where they have to deal with the tight calf. By lifting their heel with these specialized shoes, they have created a way to get around the issue and delay the onset of calf tightness.

So practically, how do we start addressing the imbalance and create a healthier ankle environment? The usual answer is calf stretching. But taking a step back even before the calves get tight, we can change something even easier and more fundamental. With running, we like to talk about heel strike versus forefoot (and don't forget midfoot) strike. What about forefoot versus heel strike in walking? Or even better, forefoot versus heel weightbearing. By shifting our weight back to the heels, we start to engage the front leg muscles and give our calf muscles a little break. By decreasing the demand on the calf muscles, we keep them from overworking and tightening up and subsequently buold some strength on the opposite side of the leg creating a more balanced system.

Note: Before implementing any new strategies, a physical therapist should be consulted to see if it is right for you.

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

The Best Way To Warm up: Targeted Muscular Warm ups

Conventional wisdom says stretch. More recent research says dynamic warm ups are the way to go. What is the right answer? Well, as always, it depends. Dynamic warm ups are great to get the muscles warmed up and joints lubricated in a way that is supposed to be functional towards the sport or activity you are about to participate in. Stretching before actvity can be good if they are not held for a prolonged amount of time. One ingredient that is missing is Targeted Muscular Warmups (TMW). I first saw this on the Lakers sideline when Judy Seto (Lakers Physical Therapist) was doing a targeted shoulder resisted external rotation for Dwight Howard's shoulder. By asking this specific shoulder stabilizer to turn on, you can guarantee that specific muscle will be more active during the activity, which in Dwight's case guaranteed more shoulder stability during the game. Let's give an example of targeted muscle warm ups:

Take a jogger. To jog at a slow or medium pace, you rely on hip stabilizers to accept the shock absorption with each step. This is in contrast to running where you rely more on hip flexors and hamstrings for propulsion. To target hip stabilizers to make sure they are warmed up, you might want to target the gluteus medius and minimus versus doing a warm up that targets the hamstrings and hip flexors. Starting to get the jist?

When applying targeted muscular warmup to your pre-workout/game routine, make sure you keep in mind 3 things:

1) Do not work the muscle to fatigue. Even doing one set of light-to-medium repetitions of an exercise is enough of a neuro-muscular wake up call for that muscle to get it revved up.

2) This is not a substitute for a total dynamic warm up and light stretching and should be performed first before any other part of your previous routine.

3) Know where the muscle is that you want to wake up. Performing an exercise that is "supposed to" activate that muscle, does not guarantee it will. 

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

A Shifting Core

Know which muscles comprise the "core"? Neither do I. Because the definition of "core" seems to change with the seasons. Are they your "abs"? If you have a defined rectus abdominus muscle (read: six-pack), do you have a strong core? Which abdominals should you target to have a strong core and avoid back pain and injury? I'm here today to demystify the concept of "core" and give some practical tips to not just look good during beach season, but feel good.

Most people see a six-pack and assume that the person has a nice stable core. Nothing could be further from the truth. There are 3 planes of movement that we need: 1) Transverse plane (think twisting), 2) Sagittal (bending forward and backward) and 3) Frontal plane (reaching to the side). The Rectus Abdominus only gets half of one plane, the sagittal plane. The rectus abdominus attaches from your sternum to your pelvis and helps with getting you up out of bed, scaling a wall, cutting wood with an axe, etc. But what about the other two planes of movement? That is where the Obliques and transverse abdominus come into play.

The obliques (plural because you have two sets of obliques on each side: the external and internal) are a strong rotational muscle as well as sidebender. When they are weak they will usually defer to your back (rotational and sidebending muscles as well) for help. Excessively over worked back muscles lead to strain and worse. The Transverse Abdominus is another muscle that acts a stabilizer of the spine and synches your waist like a corsett.

Your hips are a hugely overlooked core muscle that creates the foundation for the spine. You can have the strongest abs, but without the hips, your abdominals have nothing strong to work off of. They are also your big powerful movers that are used in every rotational sport including baseball, boxing, golf, hockey and the list goes on.

A strong "core" is like an orchestra, comprised of different musicians playing together for one purpose. You do need a strong Rectus Abdominus for the sagital plane, but also strong Obliques for the transverse and frontal plane and Transverse abdominus for that cherry on top, corsett-like stability. Having strong hip muscles, while not conventionally grouped as core muscles are just as important as any abdominal. Without the combination of hip power and abdominal stability, you can look good with your shirt off, but you lack a truly strong "Core".

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

The 5 Best Things For Your Child's Physical Well Being

With all the newest technologies and gadgets that are meant to entertain us and make our lives easier, here are a few things you might want to make sure your kid is doing everyday:

1) Let them RUN - When you run, you increase your stride length. That means you open your hips to a degree that is not done with walking. Tight hips are one of the top reasons adults have pain and poor posture. Don't let them sit at the TV or iPad (see #4) for hours and lose mobility that they will need to keep a healthy flexibility in their bodies as they grow up. 

2) Go Barefoot - Running barefoot was a big craze for good reason. It builds strength in the intrinsic muscles in the feet. Having weak feet and ankles means back and knee pain in early adulthood and balance problems as you get old.  The best time to build that strength is when you are a child, when you haven't developed any bad walking habits or foot abnormalities (e.g. fallen arch, turned out foot, etc.)

3) Backless chairs - This takes us back to another early craze, sitting on Swiss balls. Having backs on chairs further increased the damage excessive sitting does on the body. If you have something to lean back on, most likely you will depend on it. Most people that sit on chairs with backs tend to slump in them, causing kyphosis or curvature of the spine as well as weakened abdominals. Teach your kids to have good posture early (or limit the amount of prolonged sitting out of school altogether) and prevent poor posture.

4) Power down the iPad - There is a reason that some of the top CEOs in the country don't let their own children play with smart phones and iPads. While their is a big need to have our children become more tech savy than we were, this doesn't mean they can neglect some of the more fundamental skills that children need for healthy neuromuscular growth. Sports and play develop a child's gross motor skills and coordination. Get your kids outside and back to the basics to build a healthy neuromuscular system. They can learn technology in school. 

5a) Get them checked out (Part 1)- Many orthopedic dysfunctions that cause us pain when we are adults start to develop when we are kids. Currently, the main things pediatricians check with your children are for congenital hip abnormalities (See Ortolani's Test)and  a rib hump (See Adams Test) to check for spinal curvature or "scoliosis". If your child has a rib hump when bending over, chances are he or she already has advanced scoliosis and might need to wear a brace or even have surgery. Most of the time, children develop small postural abnormalities that these tests won't pick up. So basically, we are waiting for things to get really bad before we do something about it. All it takes is a simple exam (find a good orthopedic physical therapist that has experience with children) to detect some of these small asymmetries of the body and keep them from snow balling into bigger problems in adulthood. 

5b) Get them checked out (Part 2) - If you child has ever had any injury that you noticed them limping or moving gingerly, don't just "let it heal". Many orthopedic dysfunctions I find in clinic with adults, stem from injuries that never fully "healed" with childhood and adolescent injuries. Most of the time, these injuries are written off because the pain goes away. What we do know is the body has an amazing capability of self preservation. If there is something wrong, your body will usually break out its arsenal of compensations to avoid having to feel pain. So while you might think the body is just healing itself, it is actually starting to form new and pathological movement patterns that only get more ingrained as time goes on. 

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com.

The Therapeutic Benefits of Boxing

You would think after getting hit in the head all day, you would get a strong order of neck pain with a side of concussion constantly. But boxers usually have relatively healthy necks (considering). What can we learn from a boxer's routine that will give us, the average joe, a shot at the title (that is of World's Cervical Champion - I know, very cheesy).

Here are the three things that training like a boxer will do for your neck:

1) Strength

Ever notice the exercises boxers do for their necks? I've never seen the average gym goer attach weights to their head and bust out sets of cervical sidebends. That's because bulging neck muscles aren't the best beach look. 

2) Upper back flexibility

All the punching and reaching boxers do actually keep the thoracic spine (read upper back) flexible, the most notorious problem for people with neck pain. If you have neck pain, it is almost guaranteed you have bad posture which includes a tight upper back.

3) General hip and spinal flexibility

Watch a boxer train. Slips, dips, side stepping, shuffling.  A great combination of rarely used movements that will keep your hips open, spine happy and pain away.

4) Hip strength

You might be wondering the role of strong hip muscles play in a good neck. If you are a holistic viewer of medicine, it is a no-brainer. If not, let me give you the house metaphor. Your neck is the roof and your hips and pelvis are your foundation. If you have a weak foundation, doesn't matter how the rest of the house is built. Its a sink hole waiting to happen. Boxers generate their power, much like golfers and baseball players from their hip muscles. Your glutes initiate the rotational movements you need for most sports and help give you power. For my last pun of the day: strong glutes will help you pack a strong punch and keep your foundation strong.

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

3-D Running

The classic "running"  we do is uni-dimensional. That's fancy for boring. Running the same way, at the same speed and the same terrain will only lead you to the same injuries and the same physical gains. To mix it up and get the best bang for your physiological and therapeutic buck, try 3-D running.  Here's how:

Three dimensions: Incline, speed and direction

1. Change inclines

When we go up a hill or stairs we are more likely to engage our legs and hips because we have to increase ankle activity as our hip flexors. We end up also using more hip  range of motion as our knees have to go higher (think marching). Going uphill will also increase the force production of our Glutes and hamstrings to make it up the incline. 

2. Change speeds

When you change speeds you effectively change your stride. Sprinting includes longer strides while slow jogging has a shortened stride. You have the benefit of activating both type I (slow twitch) and type II (fast twitch) muscle fibers as well as work both aerobic and anaerobic systems.

3. Change directions

When we jog or run, we only get the front and back benefits. Doing side-stepping and working our lateral muscles will also increase our hip flexibility as well as improve our hip strength that we need to limit knee problems and back pain.

One last change that you might want to consider: foot strike.

Foot strikes

I'm asked a lot about landing on toes vs. heels when we run and my answer is always...it depends. Factoring out any pain or orthopedic conditions, landing on the balls of our feet or heels can both benefit us. When we land on the balls of our feet it improves our forward momentum and therefore increases our speed. Landing on are heals can be beneficial as well although if you just "land" on your heel versus follow through, you are sending a jolt through your knee into the hip and even into the back.

After trying your new and improved program, you should start to notice soreness in different areas of your body, improvedflexibility and over-all efficiency by using multiple muscle groups, muscle fibers (fast twitch vs. slow twitch) and ranges of motion to gain flexibility,  increase muscular endurance and strength, burn the most calories and limit the wear and tear on our bodies.

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

The Dangers of Shoe Lifts

A very common complaint, especially after surgery and injury, is "one leg is shorter than the other". Though out of the many times I've heard this, only once did someone actually have a true leg length discrepancy or a "shorter leg". So what is happening that one might feel this way? What is causing this phenomenon that makes us jump to buy a lift in our shoes which can wreak havoc on our hips and spine, change our gait patterns and overall cause musculo-skeletal dysfunction later on in life?  

I think to understand this, we have to understand the role of the inflammatory process (which can include pain and swelling) after an injury or surgery. Most notably after a hip surgery (due to close proximity and muscular attachments to the pelvis), but also after knee and ankle surgeries, people experience post-surgical pain and swelling. This is the bodies response to heal the joint and muscles. Pain and swelling, in the musculokeletal scheme of things are the greatest cause of muscular inhibition. Knee buckling and not being able to reach up into a cupboard because of shoulder pain are just two examples of pain shutting your muscles down in a sense. It can make us think we are weak when it is just a temporary muscular shutdown, waiting to be awakened after pain and swelling subsides.

Now when we have a leg injury or surgery, not only are our muscles inhibited, but our gait and standing pattern changes. How does that happen? I can answer that question with another question. Would you feel comfortable standing on a weak leg? Probably not. What tends to happen is actually a subconscious response by your body to avoid the painful leg. This causes a chain reaction to put most of the weight onto the "good leg". Now another question. If you weigh 180 pounds and each leg was able to handle 90 of those said pounds and suddenly only ONE of your legs now has to take 150 of those lbs, do you think your body will adjust to accommodate this new balance of weight?

Now the "domino effect" begins. With most of your weight on one leg, your pelvic complex will start to shift towards to the leg that is handling most of your weight. If you can't picture this, put your hands on your hips. Does one side stick out more than the other?  This weight shift of the hips and pelvis is not just horizontal, but can go vertical as well. It can migrate upwards towards the ribs. Once the domino effect ends, you are left with a pelvis that is higher on one side than the other. When the pelvis goes up, it pulls everything along with it, effectively making the leg seem shorter. 

Now when wearing a shoe lift to "lengthen" the leg, you are not helping the problem, but actually making things more complicated by pushing the already high pelvis even higher! Imagine the domino effect that now starts in the spine. When your pelvis goes up, it takes up space. Space designated for that side of the spine. So when the pelvis goes up one one side, the spine gets pushed towards the other side. Now the journey towards scoliosis begins...

Don't Get It, Try This:

Stand in front of a mirror, preferably shirtless to get a good visual of what you are about to check. Now put your hands on the very top of your pelvis (what most people might call the hips but are mistaken) right underneath the bottom of your ribs. Now look in the mirror at the level of one hand versus the other. Is one higher? If so, shoe lifts could be the furthest thing you need right now.

Note: The above explanation is not the only reason you can have a perceived lower leg. I will discuss the phenomenon of hip drop in relationship to leg length in a future article.

 

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

Am I having a Migraine?

To know the treatment for a headache or migraine one needs to know the source first. There are many variations of a headache including neck, tension   andmigraine headache. I will leave out tension headaches and discuss in another article relating to TMJ. To figure out the type of headache we first must ask ourselves a few questions: where is it located? What is its behavior? What eases the symptoms? What makes it worse?

True migraines are of vascular nature. They are usually on one side of the head including the eye. They can get worse with light and noise. They are not eased with certain positions or pressures. Sometimes they can be triggered by adverse reactions to food, drink, or stress.

In comparison, headaches stemming from the neck are of a mechanical nature. Positioning and pressures can help. Anything that would relax the neck such as a hot shower might ease the headache. This type of headache is usually caused by irritation of a nerve in the neck called the Greater Occipital nerve. Pain or headache symptoms start in the back of the neck and over the head and and above the eye (they call this manifestation the "Rams Horn" presentation for obvious reasons). Treatment for this type of headache would differ than that of a true migraine in that you are not treating the vascular components, but of the compression of that nerve. In order to take pressure off that nerve you would need to relax the muscles (hence why a hot shower would help), realign the upper cervical vertebrae with stretching and hands on manual therapy including light massage and vertebral mobilization.

Try this: next time you get a migraine try one of three things to rule out a neck a headache 1) take a hot shower or put a heating pad on your neck 2) put pressure in the back of your neck right below your skull and hold that light pressure for 5 to 10 seconds 3) put both your hands underneath your skull and gently start to lift up. If none of these help, the neck might not be your problem.

Note: infrequently, headaches can represent more serious problems. Some risk factors for more serious underlying pathology includes if you've had a recent traumatic blow to the head, a history of cancer, AVM, history of drug abuse, history of high blood pressure as well as a long time smoker. Consult your physician if they are frequent, abnormal and severe in intensity.

Working Out Versus Rehabbing: whats the difference?

Here are my favorite responses to telling a patient they have a weakness:  "But I walk everyday" or   "I go to the gym, so I don't think strength is the problem". I really love: "But I'm so flexible" as they reach down to the floor, as if touching your toes in standing is the only test of flexibility known to man. In fact, that just tells you that you have flexibility of just a few muscles in the back of the leg and spine. What about the rest of the 600 muscles in the body? Do they have good length? Are they strong and stable and in proper posture? Does walking target every muscle in the leg in various ranges of motion? I wish it were so. Everyone who walks would be pain free (at least in the lower body and back) and I would be out of a job. Wait, maybe I take back that wish...

I read a great article in Sports Illustrated by Jamie Lisanti featuring the director of rehabilitation for the Atanta Hawks, Mike Roncarati. His treatment philosophy sums it up. " During conditioning, Roncarati says, a player concentrates on physiological output, such as lifting more weight, jumping higher or sprinting faster. But a rehab session is more focused on internal movements, such as body position and muscle activation." He describes these sessions as "body vitamins" that "help prevent injuries" and increase the physical health wellness of their musculoskeletal systems. He separates training from being in the training room. Most active people get a good dose of working out, but most people  aren't able to address the weaknesses and imbalances of their body.

So which is better? Should I spend my exercise time isolating the muscles that need to be addressed or do I go for speed, strength, power and endurance and do multi-joint/full body work outs? The answer is, as it always is, it depends. When you sign up for the gym, you will always be asked if you want personal training sessions. The first question they ask is "what is your goal?" Do you want to decrease pain, increase strength, lose weight, increase your flexibility or improve athletic performance?  Anyone wanting to get out of pain will most likely need to address their strength deficits, flexibility imbalances (remember you can touch your toes but still be considered tight somewhere else), posture and in some cases losing weight can help. If you are a division I college athlete trying to get drafted into the pros, I might endeavor to say that your priorities are different. But to stay healthy, adding a little rehab can add a lot of time to your career. 

Here's a tip: When deciding how to formulate your workout routine, consider this: Multi-joint exercises which can include squatting, push ups, rows, and lunges can build strength and endurance depending on intensity, rest between sets and amount of repetitions. Isolation exercises are ones that work out only one joint and are usually pin point on targeting weaknesses. Discussing your weaknesses and muscle imbalances with your physical therapist can help you figure out which isolation exercises and or/stretches you can combine with a fitness program that focuses on "physiological output" which can keep you in overall good, physical health and still meet your personal goals. 

Untested Theory #2: Recurring ankle inversion: Lax ligaments, proprioceptive deficits or decreased weightbearing ability?

Dealing with the most common sprained ligament, the Anterior Talofibular Ligament, which occurs mostly with inversion injuries, would be beneficial to understand the reason for common occurrences of this injury once originally sprained. In school, I have been taught that the ligament loses some of its tensile strength and therefore the importance of building up the Peroneal musculature that can perform the same action of limiting excessive ankle inversion during sport and play. The other reason I was taught, was the loss of proprioception of the ankle joint. Proprioception is the ability to sense the joint position in space. While my contention is basically a spin off of the original reasons for reoccuring ankle sprains, I believe the clinical difference when it comes to treatment and return to play criteria can be more helpful. 

When someone generally gets injured, the layman will start to notice a "limp" or what clinicians call a gait abnormality. The body naturally has compensatory techniques to relieve its own discomfort and pain. When we sleep at night, we will position ourselves in the least tense position in order to fall asleep. For example, if someone has a tight upper trapezius on one side of the neck (due to underlying vertebral position or general joint pathology), they will generally bend their head to that side to put the muscle on slack. While this might be bad in the long run by creating more shortness in the muscle, in the short term it means decreased tension in the neck in order to sleep.

When walking, the same principle applies. If someone injures their ankle, they might be in pain for a short period of time. During that time, the body will adjust to lessen the pain by decreasing the amount of weightbearing into the ankle joint by either: 1) decreasing total weightbearing in that leg and thereby increasing more load into the opposite leg 2) decreasing the amount of weightbearing time on that leg by shortening the stride 3) positioning the leg in a way to adjust the forces to transfer more load into a neighboring or joint.

After injuring the ankle, one might position the leg into more hip abduction (kind of a tripod stance or gait) decreasing ankle inversion torque forces and positioning into more eversion and pronation. This can have deleterious consequences and snowball effects for other joints of that extremity in the future, but we will save that for another discussion ( maybe "The Effect of Inversion Sprains on Gait as it relates to the _____). One might also start to increase the weightbearing on the contralateral leg and lessening the amount of weight on the effected leg. This, in my opinion, can be  a big factor in reinjuring the ankle once again. As the leg gets used to less weightbearing on that leg (unless addressed early on after the acute stage of the injury by reestablishing normal gait patterns and equal weightbearing), the individual will get accustomed to this new gait pattern that can now be, unfortunately, translated into sports. When participating in sports, we can see how this might affect the landing from a jump. When you are not used to absorbing normal forces during average activities such as walking, how much more so would you have trouble absorbing the force when its double or triple that amount? Let me give you this scenario: John Smith, a high school basketball player injures his right ankle. After "limping" for a few weeks, he states that his ankle has "healed" and he is ready to get back on the court. He starts practicing and his coach sees that he can jump and run pain-free so he puts him back in the lineup. John is fine for most of the game. Any negative effects of the injury are negligible and he looks like he came out of this injury unscathed. Until he jumps up for a rebound and is contested from the left side. He has to adjust in midair and lands with most of his weight on his right leg. His ankle has been unused to this type of weightbearing the past few weeks. It immediately goes into excessive inversion again and he is out for another few weeks with what is called a "re-aggravation" of his original injury. But here's the thing. It never fully "healed". It felt like it did with his new compensatory gait pattern, but proper weightbearing and normalized gait mechanics were never established. He should have never been cleared to play even though the eye test seemed like he was 100%.

Most of the rehabilitation treatment we use for inversion sprains actually attack this problem. Performing single leg activities and challenging the ankle with uneven surfaces during balance exercises help the ankle get used to increased weightbearing. Most of this is to challenge the treatment thoery of strengthening the peroneals and improving proprioception. A nice addition would be a patient educational focus of equalizing weightbearing during gait and stairs as well as handling single leg forces with sport specific training with and without perturbations to simulate game day situations. 

Proposed Return to Play Criteria after Ankle Inversion Sprains:

1) even weightbearing in quiet stance using clinical observational expertise (if you feel comfortable making that determination)

2)  perform single leg squats equal to in repetition, quality and knee/hip flexion angle of supposed healthy contralateral leg

3) jumping and landing on single leg with and without perturbations to hip and trunk with the ability to land with minimal sway of the trunk or hip and especially no loss of balance (compare to healthy contralateral leg to determine normal for individual)

4) no subjective complaints of imbalance or pain with any of the above activities

The Apparel Issue: Maximize The Way Your Wardrobe Keeps You Healthy

In most of my articles, I tend to focus on the internal: the vast network of muscles, nerves, joints, and fascia and the interplay between them. We try to show the connection between injuries and the compensations your body makes to try and correct the localized problem,leading to an alignment pathology. What is just as important is the external or your environment. This can consist of many subcategories, but i will deal with one in this issue: clothes, shoes, and accessories. They might create your sense of fashion in the positive, but they can be a health related downfall as well. 

Here are some fashion pitfalls to avoid and  keep your body in a healthy state:

Tight Pants:  

You ever hear of the term "If you don't use it, you lose it"? This applies to your flexibility as well. if you don't have a normal-sized stride, your hips will adapt and tighten. Take small steps because your pants have no give and you will lose that ability all together. And if you have read any of my articles, you know my golden rule of body mechanics: if one joint is not working properly, the neighboring joint takes the brunt of it. That means your back and your knees are expected to do more than they should which causes anything from chronic lumbar strains to early onset arthritis of the knee.

Note: Try wearing pants with substantial give such as Spandex or Vinyl when working out. Or you can go "old school" and just wear sweat pants or shorts. 

Arch Supports and Shoes:

When i'm asked about shoes, it always seems like a frantic barrage of questions: What brand should I wear? Running shoes or cross trainers? Minimalist or well supported shoes? PLEASE HELP ME! Well my answer is, as always, "it depends"? What kind of arches do you have? If you are flat footed, you need arch supports. If you have high arches, flat soles are fine unless you have plantar fascitis (but that's a whole other issue we will discuss in another article). Brands are based off of preference. Don't fall into the peer pressure pitfall of buying the same shoes as an ultra marathoner if the only time you run is to the bathroom in the middle of the night after eating Mexican food for dinner. 

Note: Many running stores have gait pressure plate machines that analyze the pressures you put when walking or running and can help you pick out something more specialized to your foot. Or you can find your local Podiatrist or physical therapist (I know a good one!) and get the most uniquely tailored shoe advice in town. 

Bras

Ok men, for this one you could look away unless you are interested in "The Bro" or "The Manssiere" (Google Seinfeld if i've lost you). Most women I see with upper back pain contribute this to the extra weight in their chests. While I don't believe this is the only reason for their pain, wearing the right bra can make a big difference. Certain manufacturers have made bras that are bio-mechanically suited to redistribute the weight off your chest and into the straps of the bra. For men (if you have decided to brave this topic and keep on reading), try a compression undershirt for the same effects.

Remember, just as your muscles and joints can be manipulated, so can your environment. Being more conscious and aware of what is causing your pain can actually be the solution to your problems. By making small adjustments in your daily wardrobe, you can make a big difference!

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

Why Am I Such a Klutz?

A self proclaimed klutz walked into a bar... You are waiting for the punch line, but it can be indicative of a more serious sign than just plain old clumsiness. Constantly bumping your right elbow into a bookcase or tripping over the threshold with your left foot might seem innocuous (as long as you catch yourself before hitting the floor). What starts off in youth as being labeled an "uncoordinated" person can translate into something more troubling into adulthood. Loss of coordination can range from a neurological issue or can be a musculoskeletal imbalance. Whatever the cause, there may be a fix. Here are a few examples of ways to shed the label of "klutz" and become a more coordinated and balanced individual:

1) Tripping - lack of ankle or hip mobility can be the source of constant near or actual falls.  Quick Fix: Is it hard to raise your toes up when standing (you can lean against the wall to keep your balance)? Start stretching your calves a few times a day to increase the length of you leg muscles so your feet can raise up higher and clear the floor more easily instead of bumping your toes.

2) Bumping into objects - Always felt your alignment was off? Is one shoulder higher than the other? Turns out you might be bent over to the side as the resultant of some spinal curvature. Quick Fix: Go back to the Donna Summers era (no leotard needed) and try stretching to the side each way. (Lat Stretch YouTube Video) Is one side tighter than the other? Perform the the tight side as a stretch multiple times a day. Are both sides pretty even? Let you hips sway side to side (without moving your feet). Do your hips go to both sides pretty evenly? Try the pelvic shift stretch (Lateral Pelvic Shift Stretch) to the tight side.

3) Dropping things - Ever been embarrassed for dropping your drink and spilling wine over the hosts carpet at a party? If this is a sole occurrence and the result of little too much Cabernet, then you might be safe. If this has happened multiple times even on sober occasions, you might have a pinched or irritated nerve in your neck. The muscles in your hand are controlled from the lower nerves in your cervical spine, right before the neck becomes the upper back. If those nerves are compressed or irritated you might start losing discriminatory sensation, dexterity and strength of your hand which can lead to dropping light objects that normally wouldn't break a sweat. Not Such a Quick Fix: Have neck pain that radiates into the arm? Does your arm ever "fall asleep"? See a board certified physical therapist for thorough testing to rule out nerve compression in the neck. 

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

Tummy Time for Adults

In today's busy world, we sometimes neglect the important things in life. One of the most obvious items of neglect is our bodies. We lift heavy objects with no regard to the spine. We sit all day with no reverence of the hips and how important keeping them mobile and flexible. Just the prolonged sedentary positions we keep ourselves in alone can have such devastating effects (see  "The Health Hazards of Sitting" by Bonnie Berkowitz and Patterson Clark). One of the most common bad postures we stay in is "flexion". For the purposes of this article, "flexion" is a bending position of the joint.  Here are some day-to-day examples of the over-excess of flexion we can unknowingly find ourselves in:

1) Sitting at a desk - for those of us with desk jobs, not only are we keeping our hips flexed for prolonged periods of time, most of us tend to slouch a little and keep the low back in a flexed position. This puts stress on our discs or "spine cushions" of the spine, leading to disc protrusions and herniations. 

2) Lounging in the Lazy-Boy - putting your feet up and relaxing in that dreamy chair can have hellish effects on your spine and pelvis. While most people tend to find relief of back pain in these chairs, it is nothing but a short term relief. Actually, keeping your legs elevated will rotate the pelvis and shorten the hamstrings. Keeping our hamstrings shortened for prolonged periods will now leave us with tight hamstrings, the enemy of a healthy back.

3) Sit-ups - Getting ready for the summer? Want to get beach-ready abs? Crunches  will get you there, but at the cost of your thoracic. Most crunches target the upper abdominals and can lead to thoracic kyphosis or in plain terms, a hunchback. 

Now how do we maintain extension or an upright posture or reverse the flexion-induced damage we have spend most of our lives in?  Let's take a cue from the development of a baby. Lying on our stomach can help promote an upright posture. Just as a baby can only tolerate this short periods of time, so too us adults should not be in this position for too long, especially in the geriatric population. Before starting this, you should check with your physical therapist on ways to limit compression on the neck as well as stretching your hip flexors to avoid too much lordotic pressure on the low back. If lying on the stomach is not right for you, discuss other "extension" avenues including certain postures in yoga or certain swimming strokes. 

Dr. Joshua Mazalian, DPT, OCS, CSCS is the owner of JAM Sports and Spine in Los Angeles and specializes in sports and orthopedic physical therapy. You can reach him on Twitter @jamsportsPT and Facebook as well as email at info@jamsportsandspine.com

Untested Theory #1: Glutes as a spinal mover or neuromuscular inhibitor?

If I were to create a drinking game based off the amount of times you hear the word "glutes" in any rehabilitation setting, the game would be an instant classic. Replacing "core" as the buzzword in the physical therapy world, they are the powerful standing muscles, hip movers and lumbar synergists that seem to do it all. You have bad knees, strengthen the glutes. Gait is off, we need to work on glut contraction. Pain anywhere in the body, let's fire up them glutes. Research has strongly shown the correlation between knee stability and glut firing (google the work of Chis Powers). Most gait analysts can point out the compensatory movements of the lumbopelvic region with weak and unused glutes. 

I would like to put forth another use for the glutes: a spinal rotator. In open chain, Glut max will extend and externally rotate the hip. In closed chain, based off the attachment to the sacrum (and therefore the spine), especially with single leg weightbearing, I propose we can use the gluteus maximus as a spinal contralateral rotator. I believe this is important in how we treat acute injuries. When a patient has a reactive paraspinal group of muscles, asking a patient to perform rotation spinal movements to derotate the spine to neutral might be asking too much. By using the glute to assist in that rotation, we are not just pulling the spine into neutral, we are inhibiting the so called "spasm" (as most doctors like to put it - i prefer hypertonic muscle group) of the paraspinals which assists the patient out of the acute stage and on its way back to lumbar health. 

Conventional wisdom says that glut activation causes parapspinal neuromuscular inhibition from its overactive state and decreases strain on the back. Is it because both muscle groups are synergists that extend the body and that making sure they both do their jobs equally, keep each other from doing too much and away from "spasm"? Or does uniltaeral glut activation rotate the spine back to neutral which decreases the misalignment of the spine which would be another cause for spasm. Anyway you put it, the glutes are in style and are here to stay.

Give it a try:

Have unilateral muscle spasm/hypertonicity/bulkiness in the paraspinals? In single leg stance on the same leg, perform a max glut contraction while palpating the affected paraspinals and feel if it starts to calm down as well as any spinal rotation

Note: Comments and feedback are welcome as this is mainly based off of biomechanical theory and self anecdotal evidence. 

Second note: If you performed the drinking game for every time I wrote glutes in this article, I imagine many physical therapists will be calling in sick tomorrow. Enjoy!