The Canoe

Think about this situation and what you might do differently.

John loves to go fishing in his canoe. He’s got a great canoe. Lately when he launches his canoe it rubs on a few jagged rocks coming on and off the water. At first he didn’t see the wear, now he can see the worn surface and torn fiberglass. When he pushes on the worn area he feels the weakness in the structure. John kept on the same routine day after day. Finally the side wall gave and water would leak through, slowly sinking his canoe. Even with a little leak he could stay out 2 hours. When the leak got bigger could barely do any fishing before there was too much water.

At what point does the damage become more difficult to repair?
What if John just started launching his canoe away from the jagged rocks?

More importantly what if you were the canoe?
Would you think differently about how to care for your own injury?

Let’s flip the story:

John works building cabinets. He’s a great craftsman. Lately he’s had to bend awkwardly to pull some materials from behind a saw they’d recently moved. At first he didn’t notice his back, now he feels a pull along his spine. He feels tenderness when he presses on his low back. John kept on the same routine day after day. Finally during one awkward bend he felt a stronger pain that wouldn’t go away. Despite the pain he could get through about 2 hours work. When the pain worsened he needed help operating the machinery and could barely work.

Caring for your own health can be as simple and as logical as caring for anything you hold dear.

Strength is essential: part 1

Strength is an essential part of staying healthy. Having a better understand of how your body becomes and stays strong can help you stay healthy. In the first part on our series on strength we’ll look at how your body adapts to become stronger.

Strong Enough

Our physiology demands that we conserve energy and resources. It takes significant resources creating and maintaining excessive amounts of muscle tissue so we will only become strong enough to handle our regular exertions. If we don’t regularly lift 50 lbs then there is no reason to keep the extra muscle tissue for heavier lifting around. Eventually it shrinks away. If once or twice a month you lift heavy things your body will react and lay down new muscle but within a week if that stress isn’t applied again that new muscle will shrink away to conserve energy and resources. Over the many years of your life your body has fine tuned itself to only ever be strong enough for what you do week to week. There’s no prediction or anticipation that you’re planning on moving next month and will be lifting many 50lb boxes.


Intensity Matters

Yes, walking is exercise. Walking will not make you stronger. Being able to take 1000 steps without needing to stop is low intensity. Low intensity will not spark new muscle growth. If doing 10 lunges is difficult and makes your legs burn with fatigue it will spark new muscle growth. To your muscles those lunges are 100 times harder than walking so it should make sense for them to adapt.

Imagine walking was the extent of your regular exercise for your legs. It doesn’t really prepare you well for climbing stairs, bending towards the floor or lifting from the car trunk. Then for several weeks you did lunges on a regular schedule. Now they have become the new strength expectation for your legs. You have become far stronger and better prepared for more challenging tasks since lunges are already fairly intense.


What’s the frequency?Pretty young girl fitness workout

Remember that those adaptations are not permanent. Your body is always ready to reclaim resources (like new muscle fibers). So if you do one round of lunges and take a week off chances are you’ve lost some of those new fibers. The general rule is 48 hours between stresses. Less than that and you run the risk of over training. 72 hours (or every third day) is very acceptable and you’ll clearly see improvement. It just won’t happen as quickly. 4 or 5 days between exercise sessions and you’ll certainly maintain any new strength you’ve gained but improvement will be very slow. Stretch it out to a week or more and you’ll potentially lose any gains you’ve already made.

Keep in mind this applies to a specific muscle not exercise in general. If you’re lunging to strengthen legs one day but then working planks for your abs the next day that isn’t going to negatively affect your leg recovery and strengthening.


Change your story

You can’t get through your week without being faced with a strength challenge. It often leaves you wondering why you’re not as strong as you used to be. Change your story. Stop assuming that low intensity exercise like walking your dog or cleaning up around the house will keep your strong. Appreciate that your body will only ever become as strong as the challenge it faces. This doesn’t have to mean 2 hours a day in a gym lifting heavy. But it does mean regular efforts above your typical day.

A simplified balance

Talk to a nutritionist and their most simplified approach to weight loss is that if the calories you use up exceed the calories you take in you’ll lose weight. Flip that equation and you’ll gain weight. Often you can simplify injuries to this level as well. Every activity places a certain level of demand on your body and everyone has a certain physical capacity. If the demands exceed the capacity you’ll eventually hurt yourself. If you flip that equation you may enjoy an injury free existence.


Demands greater than Capacity = Injury

Understand demands and capacity

Your body is constantly adapting to the demands consistently placed on it and will be expertly prepared for those demands. If your life consists of getting up, driving to work, sitting all day and then watching tv for the night your body will only remain strong enough to roughly keep your body upright while standing or sitting. If you only expose yourself to small physical demands you’ll only maintain a small capacity. If you always take the elevator you’ll always get tired climbing stairs.

Infrequent activities do not last

You stress your body, maybe you do 10 lunges. Your muscles and connective tissues are stretched and strained. The repair process takes 24 to 48 hours and your body adds some extra muscle and connective tissue fibers in case you need them for the next time you do 10 lunges. After a couple of days if you don’t do any more lunges those fibers may not be maintained and are re-absorbed and their materials used elsewhere. 2 weeks later you do 10 lunges and they’re no easier.

Organized demands

You do 10 lunges. 2 days later you do 10 more lunges. Every 2 days you take the new tissue your body has added and stress them. In turn your body adds more tissue and you stress that tissue. Suddenly you have greater muscle strength and connective tissue that can better resist that stress and strain of 10 lunges 2 weeks later you do 20 lunges and they feel as easy as 10. More importantly when you decide to move a few heavy boxes in the basement you’re less likely to injure yourself thanks to this new capacity.


10-15 minutes of smart physical activity done every other day is a great starting point to reduce your risk.


The blunt truth

You need to give your body a capacity beyond the demands you may place on it. If you’re facing a physical demand that you know is greater than your capacity; expect injuries. Maybe not the first time but you’re poking a sleeping bear. You don’t need to hit the gym and squat 300lbs. You need to be good at movement, you need to be practiced at lifting, pushing and pulling things that weight as much as things you interact with regularly. This could mean a shovel full of snow, a basket full of laundry a couple 2 by 8 boards or a heavy bag far in the back your car trunk. If you’re not preparing for the demands, prepare to call my office.

Joint Alignment

In my experience most patients are inherently aware of this concept before they ever set foot in my office. There is also a very large contingent of doctors and therapists who don’t appreciate or understand the importance of joint alignment.

The feeling of misalignment

At some point in your life (maybe your day) your knee, shoulder, wrist, elbow, ankle, hip, back, neck etc. has suddenly become limited in their normal motion. You feel resistance, locking, pain or pressure right in the joint preventing you from moving further. Maybe you try to check your blind spot and you feel like something in your neck blocks you. You try to squat down and stiffness quickly develops in your knee to prevent you from completing that movement.

Many times (by many health professionals) this gets chalked up muscular tightness. You can’t turn your neck because the muscle is tight or is in spasm. You can’t complete a squat because your quads are tight. This might explain mild cases where you can feel a stretch develop and slowly work through that tightness. You typically don’t feel that pain at the joint.

Altered Joint mechanicsPosterior Knee joint

This can be a complicated topic and is often missed during assessments. Your knee joint makes for an excellent example with a lot of research behind the concept. It’s construction leaves it to act much like a door hinge, pivoting primarily around just one axis with some extra cushioning inside. If the top and bottom of the joint line up well the movement is typically free of crunching or creeking and at the end of bending or straightening there are two cartilage surfaces still in contact with one another. If the door hinges are installed correctly there’s good contact between the metal pieces and they slide well over one another.

Quite commonly misalignment will develop at the knee joint where the shin bone is turned outwards compared to the thigh bone. This is commonly seen in Helfet’s test when the tibial tuberosity (center-line of the shin bone) is too far lateral compared to the center of the knee cap. Because of this subtle twist the cartilage surfaces don’t align perfectly and so towards the end of straightening or bending those cartilage surfaces slide off one another forcing your to stop your movement. Those cushions between bones are being repeatedly pinched. Now one half of the door hinge is slightly angled. It creeks as it opens since now only parts of the hinge are touching with far greater pressure.

Normal reactions to joint pain

Joints have powerful control over their surrounding muscles. They contain nerves that are highly sensitive to any compression or stretching of it’s tissues or cartilage. Joint misalignment compresses and tensions those tissues causing signalling to muscles in the area to relax or tighten to try and improve the joint position. This is where many assessments start and finish. “You can’t squat fully and your quads have become tight, they must be preventing you from squatting fully. Let’s do some stretches.” Too often the underlying issue is missed. Correct the knee alignment and the signalling to other muscles fades. Quads get back to a normal length and tension without unnecessary work.

Long terms changes

Quite often misalignment develops without traumatic injury. A long day at costco, vigorous hike or a hard leg day can often be enough. This will leave people assuming their joint is unaffected despite their pain because there was no trauma. So they deal with the issue for weeks or months. They stretch, they exercises, they deal with the pain. That joint has been signalling surrounding muscles to fire harder or stop firing for days or weeks. The tissues of the joint have been bearing higher than normal tension and the cartilage has been repeatedly rubbed hard in certain places. Why do you think it’s so common to develop arthritis in just one knee even if you’ve never had a significant knee injury?


No pain, no gain.

This is a very slippery slope that I strongly hope you’re not sliding. I especially hope your personal trainer or therapist isn’t pushing you down that hill. You really only have two options when thinking about pain. You either have pain or you don’t have pain.

I have pain. So therefore no pain, no gain.

Let’s say that lifting your arm in the air gives you shoulder pain. A very unique feeling that you could easily identify and would probably avoid certain activities to prevent. For now think of that as Pain. It is the signaling from valuable tissue in your shoulder that its very integrity is compromised. There is an injury and the way you just moved worsened it. You should stop. So how in this scenario could more Pain be of any value? Listen to your body.

Sometimes things aren’t that simple. Sometimes Pain doesn’t develop for a few hours or a even a day. That same shoulder Pain arrives 3 hours after you’ve unloaded the dishwasher and did laundry. The cumulative effect of those activities compromised the integrity of that very important tissue in your shoulder and now it’s signalling your brain with Pain. This really isn’t different, that injured tissue is compromised either by 1 movement or many movements and could be felt immediately or delayed.

Your rehabilitation should follow this concept. Movement does some amazing things. Even the slightly pull on tissue stimulates the production of connection tissue, new cell production and repair of existing tissue. Pain isn’t a requirement. Being able to perform movement that doesn’t create immediate or delayed pain should be a very simple definition of rehabilitation.

I don’t have pain. So therefore no pain, no gain.

Congratulations you’re pain free. Now you’re probably thinking about performance improvements. What is pain telling you about your performance? Let’s get back to tissue integrity. If you’re feeling genuine Pain, you’ve managed to compromise the integrity of a tissue. This doesn’t mean appropriate stress through microtrauma. This means damage. Injury. Sure it will likely heal over a few days and maybe even trick you into thinking that’s how ‘good’ sore feels. It’s not. Performing a movement that causes pain means you’ve exceeded the integrity of a tissue either by applying too much load or stretch. Maybe the movement was too fast, heavy, awkward, unpracticed, inappropriate (i.e. the continental lift) or you’ve progressed too quickly. That part could have many answers. Pain has one answer: stop, reassess your approach to learning/improving that movement and begin a new approach after you’ve healed.

Maybe you’re reading this and thinking if people stopped training a movement every time they approached pain their training would suffer. I completely agree. Wolfe’s law. Tissues respond to stress. Efficient training means getting tissue very close to the point of failure without crossing that line. I’m talking about to the person who feels their hamstring grab on deadlifts, whispers to themselves “no pain no gain” and bangs out 2 more sets. The person who progresses their squat weight too quickly and needs five days to recover before they can train again. If you’re training hard you will occasionally become injured and feel Pain. If you do re-read the previous section of this article then try not to make the same mistakes.


[almost] Nothing is absolute. If you’re “into pain” or want to feel pain to better relate to others in pain my advice may not apply. There are treatment techniques that can be pretty painful. Shockwave treatment comes to mind. I do numerous muscle/tissue releases and adjustments that can at times be painful. Brief fleeting moments of pain applied by a qualified practitioner are an exception.

The vast majority of people out there aren’t qualified to make those exceptions so in your own rehab and training listen to immediate or delayed pain, assess the cause and work to keep moving without pain.

Why tight hamstrings matter part 2

In Part 1 we looked at the function and physiology of tight muscles and how progressive lengthening and strengthening can improve your rehabilitation and performance. Part two of this series looks at the bio-mechanical implications of tight hamstrings.

The mighty Hip Hinge

This action is arguably the most important movement for a healthy low back but also for force production through your hips. To simplify: hinging at the hip is what should happen when you bend forward at the waist. In an ideal movement your torso maintains a neutral (picture 2) posture while almost all of the forward bend occurs around your hip axes. A poorly performed forward bent shows limited change in the hip angle with excessive bending through the low back. hip-hinge


Poor movement or posture in this forward bend excessively loads your spine and intervertebral discs. It also destroys any mechanical advantage meaning our muscles have to fire harder when we bend forward and return to standing. Think through how many times in the run of a day would you bend forward and return to standing. Imagine you work in a plant or factory where you spend the majority of your day leaning forward over an assembly line or work table. How long before this excessive loading starts to wear on the joints and tissues of your back.

Back to hamstrings. They are one of the strongest limiters for this hip hinge. In a proper hip hinge you take your hamstrings through considerable lengthening. If you lack flexbility in your hamstrings you will quick stop pivoting about your hips because your hamstrings have pulled tight. If your haven’t reached the end of your required movement then you will likely bend through your spine to make up the difference.

Spine stability while running

Imagine yourself on a bosu ball, a balance board, a floating wharf on a pond. Every time the platform tilts forward you adjust your posture. Wobbling side to side makes you constantly lean side to side to stay upright. Your spine is undergoing the exact same balancing act as you run. Every foot strike tilts your pelvis side to side and the muscles around your spine work hard to keep your spine and torso balanced above.
So here is the important question, does your back hurt after you run. If yes is your answer maybe it’s time to think about spine stability while you run.

The sideways hip drop

Since your spine and pelvis operate in 3 dimensions let’s simplify things and just worry about side to side movements. What is unique about running versus walking or even standing is that you’re jumping from one leg to the other. When you walk you have near constant support on both feet, especially during that all important foot strike where forces going through your body are the greatest (*somewhere around 1.5 – 2x your body weight). During running one foot hits the ground while the opposite leg is no longer supporting that side of your pelvis. So what happens? You have one force driving upwards through the support leg and 1/2 of your body weight driving downwards on the unsupported side. That’s somewhere in the realm of 2-2.5x your body weight forcing your pelvis to tilt in the time it takes your foot to fully hit on the ground, milliseconds. In that same time your spine has to quickly react, help absorb that force and keep your torso upright. You’ll repeat this process about 4000 times in a 5K run.


Making the correction

Having the strength to absorb that force is paramount. That strength comes from a group of muscles called your hip abduction complex which includes well known muscles like your glutes (maximus, medius and their youngest sibling minimus) and other less common muscles like piriformis, superior and inferior gemellus. These muscles help lift your leg to the side if your not standing on that leg otherwise it helps keep your pelvis level. What are some effective exercises? I have three favorites for lateral hip strength and all you need is a resistance band.

1. Side lying leg lifts: Lying flat on your side with your legs stretched straight lift your leg 12-18 inches in the air and slowly bring your feet back together. Really focus on keeping your pelvis anchored by not allowing it to roll backwards or to hike towards your ribs. Wrap a light resistance band around your thighs to add resistance. You should be able to comfortably perform 5-10 repetitions. As you improve you can add 2-3 more sets of 5-10 repetitions with a 30 second break.

2. Side lying clams: It’s the exact same set up as exercise #1 but now you bend your legs about half way. Instead of lifting your whole leg pinch your heels together and just lift your knee. This exercise will really make your pelvis roll backwards so work hard to anchor your pelvis so all of the movement happens down in your hip joint not up in your back. Use the same sets and reps as #1.

3. Sideways band walks: Take a resistance band and tie it in a loop around your feet so there’s a little tension if your feet are shoulder width apart. Making sure to lift your feet with every step. Lift your left foot and step sideways to a wide stance. Then lift your right foot and slowly return to shoulder width stance. You should feel the resistance from the band with each step. If you have space repeat those wide steps 3-5 times to the left and then back 3-5 times to the right. Keep a light bend in your knees and proper back posture.


The forward tilt

The next dimension we want to check in on is front to back motion for your spine. The most common in this case in what is called the anterior tilt of your pelvis. It is normal to have a slight (about 10 degrees) anterior pelvic tilt. That angle allows for a normal inward curve in your lumbar spine and sets up the muscles of your pelvis and low back for the best possible strength. It’s a very common issue for runners, especially as they fatigue, to start exaggerating that anterior tilt. Now instead of having a slight inward curve of your spine it’s significant. That wharf on the pond is slanted well forward and you’re leaning back hard to keep from falling in. That alone can be exhausting and painful for your low back.

Sadly, that’s just the start. That change in pelvic and spine angle takes away from the stability provided by your abs (aka core) so you’re forced to rely on your hip flexors and long low back muscles to stabilize that poorly positioned spine. To make matters worse that altered pelvic angle makes it more to effectively use your glutes to properly absorb the force of every foot strike. Instead those forces are transmitted straight to your low back where joints and muscles a fraction the size of your hip joints and muscles are expected to absorb the same forces.side-on-runner


Making the correction

This can be as much about comfort and habit as it is about strength. Maybe it feels normal to increase the tilt of your pelvis so it may not be a strength issue as much as a matter of practicing good posture. Watch a couple episodes of Family Matters and carefully watch Steve Urkel, he takes posterior pelvic tilt to a very high level. If watching him helps you can work on sitting, standing and eventually walking with slightly “Urkelled” hips. You never need to take this to the extreme but just a light push in that direction. If watching some classic 90s television doesn’t solve it here is a simple drill to help you feel the pelvic position.

Sit on a fairly hard chair or bench where you can plant your feet firmly on the ground. Focus and feel exactly what part of your bum is hitting the seat. On a hard seat your should feel that pressure land right on your sit bones (ischial tuberosities to be exact). Practice tilting your pelvis forward and backwards trying to feel the pressure on your sit bones move forward and backward. Now try to isolate just moving the pressure backwards without slouching your torso. Feel exactly what you’re contract/pushing to make that movement happen. Once you’re successful there move on to standing with bent knees and try to recreate the same pelvic tilt. Progress this to walking while tilting and finally practice this technique while running.

Do you plank? This is another great way to test your pelvic control. A lot of people with low back pain feel planks working their low back rather than their stomach. This is typically because their ‘strong’ position comes from hyper-extending their low back while stabilizing with their hip flexors and low back muscles (as we talked through above) rather than their abs (aka core). To correct this position drop to your knees while staying in the plank position on your forearms. This should make it simpler to start moving your pelvis towards that Urkel position and removing the pressure from your low back. With practice you’ll be able to hold a kneeling plank with tension in your stomach and minimal pressure through your low back. The next step is key. To make this exercise more challenging dig your toes into the ground while in your kneeling plank and slowly lift your knees 1 inch off the ground. This should really ramp up the tension in your stomach while allowing you to maintain good pelvic position. Work to build your endurance in this position by holding as long as you can (up to 60 seconds) without losing posture or feeling that strain return to your low back. It’s more effective to perform the exercise for a shorter period and rest than to push through back technique or pain.

Why tight hamstrings matter Part 1

Understanding muscle physiology and biomechanics can make a world of difference to a person training but also to their recovery when injured. These concepts apply to any muscles but with the prevalence of hamstring strains being one of the highest this might hit home with more people. Since they’re fairly large ideas we’ll start with my favorite concept the length tension relationship.

Length Tension curve

This should ring a bell with anyone who has studied exercise physiology. The concept explain how and why a muscle can produce different amounts of force as it progresses from long to short and short to long. Your fingers can be a great example of how the many small fibers of any muscle interact; a key foundation of the concept. Interlock your fingers (like the photos below) and imaging thousands of tiny hooks on the fingers of one hand that will connect with thousands of hooks on the other hand. The greater the area of contact between fingers then greater the number of hooks that connect and give you the greatest strength. This follows a simple pattern: as you slide your fingers together the area of contact increases to a peak (middle image) then slowly decreases as your fingers overlap too far and slide behind your hand (third image). The curve below shows how that area of contact directly affects that muscle’s strength. I’ve added dotted lines to show the area of overlap, notice how that area of overlap directly relates to the strength curve below.


So now apply that concept to your hamstrings but this time we’ll run the concept in reverse order, short to long. Imagine lying flat on your back and think about the length of your hamstrings. In that position they are pretty short. Probably close to that fully shortened position from the pictures above (on the right). Now imagine one leg being lifted straight in the air until your foot is directly above your hips. As your leg moved from the floor to straight up in the air it passed from near fully shortened (too much muscle fiber overlap), through mid length (optimal overlap and max strength) to near full length (minimal fiber overlap and weakness). The key is that you are not equally strong at all lengths. You have the best strength and lowest likelihood of injury in that middle 50% of the movement.


So here is the real magic. Hopefully this turns a light bulb on. Let’s get back to tight hamstrings. If yours are tight you have probably realized that you can’t actually lift your foot all the way above your hips. If you could you’d have a fairly large range of that motion where you are acceptably strong (highlighted in green). Instead, inflexible one, you have a very narrow window (shown on the right image in green) where you are usefully strong surrounded by two equally large ranges where you are weak and susceptible to injury.

Improving your length and strength

When you get right down to performance or recovery you want a larger range of motion through which you have useful strength. Adding length to a muscle through rigorous stretching will give you greater range but all you’ve really done is spaced out those hooks. You’ll also introduced new ranges of motion that your nervous system hasn’t experienced so you can expect to be fairly uncoordinated. Proper improvements come from slowly increasing the length of a muscle while performing strengthening exercises that progressively challenge that new range of motion. This will encourage your muscle to build more hooks and train your nervous system to control this new found range.

There's nothing wrong with your…

A phrase used regularly by many health professionals and generally rejected by patients with a problem. There’s nothing wrong with your back, neck, shoulder, knee etc. Chances are if you’re in their office you know that something is wrong. My advice on this one after hearing countless patients tell me their own “There’s nothing wrong” stories or similar “It’s in your head” tales is to keep in mind who is telling you that there is nothing wrong.

Everyone will examine you through their own professional lens. Here’s an example: let’s say you have low back pain and your family doctor has sent you to specialists for opinions and treatment options.

First it’s off to a surgeon, they examine you and determine your back pain doesn’t warrant surgery. Your back pain doesn’t require removing bone, cutting tissue or reshaping cartilage so from a surgeon’s perspective there’s nothing wrong with your back.

So now it’s on for some x-rays. The radiologist looks at your x-rays and she doesn’t see any fractures, dislocations or deformities so as far as she can report there is nothing wrong with your back.

You talk to a urologist they check your urine and bladder, the nephrologist looks at your kidneys and the enterologist checks on your digestive tract. None of them see your low back pain because through their respective professional lenses. Your back pain doesn’t show up because it doesn’t fit into their expertise or expectations.

If you’ve been through this I have an important translation for you: “There’s nothing wrong” really means “I can’t find your problem” or “I can’t treat your problem”.

Understanding this very important translation should help you realize that you are ultimately responsible for your own health and you may need to take the extra step to find the right health practitioner who can find and treat your problem.