Exercise and Mood

ACL injuries – what are they and how do I stop them from happening?

Anterior snapping hip pain: A hip flexor issue

Audible snapping noise or snapping sensation in the hip is normal, however audible snapping with PAIN is NOT.

There are just about many reasons why you may be experiencing snapping hip pain particularly located in the front of the hip. A common cause can be attributed to iliopsoas syndrome.

Iliopsoas syndrome is a clinical term that refers to dysfunction of the hip flexor muscles iliacus and psoas, collectively known as iliopsoas. They are located in the front of the hip and function to flex the hip, in other words lift your knee up during a marching action.

Injury to the muscles, its tendons (tendonitis or tendinopathy) or inflammation of the surrounding structures such as the bursa (bursitis) commonly results in pain and weakness along intermittent audible snapping whenever the joint is in motion. This may explain why some of the simple tasks such as running up the stairs, bending down to reach the bottom shelf or sitting and standing from a chair is all of the sudden daunting.

Causes

Hip flexor pain is largely an overuse problem.

While injuries to the hip or its surrounding structures can pose a risk for developing iliopsoas syndrome, it may not also be associated with an injury.

Those at risk include runners, jumpers or sports that require a lot of kicking. Also at risk are those who participate in strength training and weight lifting exercises that require a lot of bending and squatting.

The psoas muscles (minor and major) start in L1-L5 segments of your lower back and travels down to meet the iliacus muscle before they blend in to insert in the front of the hip. This arrangement allows the muscles to perform their prime duties as flexors of the hip (raising your thigh, kicking).

The hip joint is a ball and socket joint – which means the hip joint is a very mobile joint having the freedom to move into front, side, rotate, kick back etc. Therefore, the hip flexors act as supporting muscles of almost every action that occurs at the hip joint.

Additionally, the muscular attachment in the lower back means that the psoas part of the hip flexor plays an important role in supporting your lower back when we are sitting, standing or lying down.

Therefore, cause of anterior hip pain stemming from hip flexor dysfunction can be linked with possible pathology of other surrounding structures. Most commonly those with lower back pain tend to present with iliopsoas dysfunction.

Symptoms

Individuals with iliopsoas syndrome will often present with the following symptoms.

• Onset of symptoms
  • Onset of symptoms develop gradually overtime, this can be over a period of weeks to months depending on the frequency of aggravated activity. Symptoms usually begin with an intermittent pattern before settling to noticeable and persistent pain. At this stage, simple everyday movements involving the hips like standing up from a couch or crouching down to reach down the bottom self in the supermarket can be noticeably painful.
• Location of pain:
  • Pain is usually localised in the front of the hip joint, where the hip flexors attach. In some cases, groin pain is also a common a compliant
  • Lower back pain or lower back stiffness is often attributed to the hip flexor dysfunction
• Aggravated activities
  • Hip flexors are versatile muscles that are activated during hip and lower back movements. Hence why almost all tasks the involve the two region of the body can result in hip flexor pain. These can be walking, running, sitting to standing, stair walking, kicking etc.

Quick tests:

Thomas test is a quick test that allows you check the flexibility of your hip flexors.

1. Sit at the very edge of a table
2. Lift one knee up to your chest and hold
3. Lie down flat on the table & relax

– Assess both sides 

To check:

• If your thigh on the opposite side is not in contact with the table but lifts up, your iliopsoas muscle is likely tight.
• If your lower leg kicks out in front instead of resting down in a 90 degree angle, your quadriceps are likely tight

Stretch vs Strengthen?

To stretch or to strengthen? – is an important question raised when dealing with iliopsoas pain.

• If you noticed hip flexors tightness on the Thomas Test – stretching and myofascial release with a massage ball or a foam roller would be an appropriate method to improve tissue flexibility. 

• • Iliopsoas stretch

• • Foam roller

Lower Back Pain with Deadlifting

Deadlifting is one of the most very versatile exercises in the gym. There are about 11 variations of the exercise, whether you are doing it with dumbbells, kettle bells, barbells or traps bars. The variations and the technical complexity of the exercise can be extremely intimidating for some, especially for those who are combating lower back pain.

While there are multiple factors to consider when determining that causes of lower back pain, the technique and the execution of the exercise is by far the most common cause. Therefore, this blog will focus on the common mistakes you are likely making in the weights room resulting in your persisting lower back pain.

What are the benefits of deadlifts?

Deadlifting is one of the most respected exercises in the gym, often referred to the king or queen of all compound exercises. This means that at one shot of movement you are activating almost every key muscle in your body.
Including your heart – Yes, the heart!

Before we elaborate of the musculoskeletal system, here a little interesting information on why the heart. For starters, the heart is a muscle. Its prime function is to supply nutrients and oxygenated blood throughout the body for effective organ functioning. To do so effectively it regulates the blood pressure and heart rate. So yes – to simply put it deadlifts when done correctly as advised by a health practitioner can have tremendous health benefits on reducing heart rate, blood pressure and improves overall conditioning of the cardiovascular system.

As sides that, from a musculoskeletal stand point there are strategic strength, power, and coordination and aesthetic that are achieved. In the era of computers and laptops and sedentary jobs – Working at a desk for 7-8 hours a day, we become more dominant in using the muscles in the front of our body (the anterior chain) and the muscles in the back (posterior chain) tend to be inactive and weak.

For this reason, the deadlift is particularly regarded as the single most beneficial exercise one can do that targets the entire body at one go, perhaps with more emphasis on the posterior chain.

What muscles are used?

As seen in this picture on a ‘conventional variation’ of a deadlift almost every muscle is highlighted – from the gripping the bar with the hands to gripping the ground with the feet.

• core muscles
• gluteus
• hamstrings
• adductors
• quadriceps 

Technique faults to consider

1. Poor core stabilization

Core-stabilisation is the foundation fundamental to almost any given exercises in the gym, let alone a deadlift.
When you are told to ‘brace’ your core – it’s not the sucking in of your belly or holding your breath. It about activating or ‘tightening’ up the key of your ‘core’ to contain the pressure (intra-abdominal pressure) from within. This is absolutely crucial in creating stability and preventing overloading for your spine, especially when lifting heavy. 

For the simplicity of this blog, information around intra-abdominal pressure is kept brief and explained using the ‘soda can’ analogy.

What exactly is ‘core’? 

What many people don’t know is that core is more than just abdominal muscles. The core aka the corset of our mid-section includes the deeper and the outer muscles.

• DEEP CORE

The deeper core, regarded as the main ‘core subsystem’ as seen in this picture essentially involves four muscles
strategically designed for maintaining pressure (intra-abdominal pressure) in our mid-section.

• OUTER CORE

The outer core muscles as shown are stronger and bigger muscles covering most of the surface area of our mid-section. When activated, they support the the deeper core muscles in maintaining the intra-abdominal pressure. They include:

• Erector spinae
• External oblique
• Rectus abdominis
• Latissimus dorsi

How to brace your ‘core’

• Sit or stand tall with your hands resting against your abdomen.
• Take a deep breath in as though you are storing the air in the base of your lungs.
  As you do this must feel your abdomen ballooning out.
• Now, tighten your abdominal muscles firmly, as would before you cough.
• Then gradually released your breath whilst keeping your abdominals tight.
  As you do this you will feel pressure building inside your abdomen. 
• Repeat this cycle until you get comfortable with the bracing.

2. Incorrect set up, initiation, lift and descend 

INCORRECT SET UP 

Most people approach the barbell with a squat stance. This means the hips drop too low in line with the knees and the bar is too far. This causes you to stretch your arms forward to reach the bar which prevents the optimal latissimus recruitment needed to secure the bar for the lift.

Tips:

1. Approach the barbell and stand with your feet shoulder width apart.

2. The barbell should be directly in line with your midfoot.

3. Feet can be pointing straight or slightly off centre positioned out.

4. Your knees should be tracking in the same direction as your feet.

5. Bend down to reach the bar and position your hands just outside your knees using an overhand grip. The bar should be close to your shins.

6. From a side view: your hips should be positioned between your shoulder blades and your knees.

7. The barbell should be directly underneath your arm pits. 

INCORRECT INITIATION

Head up and chest up, hyperextended back or head up, chest collapsed and rounded back are the two most common lifting mistakes seen when deadlifting. This means there is inefficient requirement of larger muscle groups in the lower extremities to be the ‘main drivers’ of the lift, instead heavy amounts of load is places on the spine and its surrounding soft-tissues (ligaments, muscles, fascia).  Therefore, the risk of lower back injury is significantly greater and depending on the weights used and the training intensity, injuries can range from simple overly fatigued muscles to significant soft-tissue strain or in worst cases a herniated disc injury. 

Tips:

8. From side view: align your torso with shoulders and hip

9. Activate the latissimus by squeeze your armpits down and slightly pinching your shoulders blades back

10. Before you lift, think about the lift. Rather than pulling the weight up with your upper body, think of bracing or stiffening your upper body and then pushing the ground away from your body with your feet and straightening your knees and your hips (similar to how you push the weight plate away during a leg press)

THE LIFT & DESCEND 

Tips:

11.  With your posture now set and body braced, push the ground away with your feet to straighten your knees and hips to stand up tall. From the time you initiate the lift until the barbell touches down to the ground, it should travel in a vertical line.

12. When standing tall, avoid hyperextending with your back. Make sure your body remains in the braced position ready to lower the bar down.

13. Push your bottom back, this will allow you to realign your arm pits with the barbell to steady your decline and allow the barbell to travel in a vertical line to the floor.   

To consider:

While these are a few key principles to consider before you execute a perfect ‘conventional deadlift’, there is really no ONE size fits all . Technique to setting up and lifting should be strictly individualized based on your height, flexibility, lifting experience and goals.

So before you consider this all intimidating exercise, whether you are a novice, or someone who is getting back to action after an injury, follow these simple steps:

• Start slow and start low on weights.
• Have a gym partner spotting you, an extra pair of eyes to watch your technique will always help
• Or simply use a mirror – and practice, practice and practice.

It all comes down to efficiency, using the correct muscles to their best activation range as much as possible. So that when you reach close to the fatigue point it’s the major muscles such as the glutes, hamstrings fatiguing not the smaller less robust lower back muscles.

What are muscle knots or myofascial trigger points?

“My neck feels so tight and knotted up”, “can you give my shoulder a rub, there are so many knots in them”, etc.

We have heard people referring to these terms time to time in our daily life, but we have hardly ever put real interest in finding out what the real meaning behind it. So, what are muscle knots? What causes them? But most importantly, what can we do to treat and get rid of them?

What are muscle knots?

Muscle knots are jargon term for a more scientific term of trigger points. A trigger point is a hyperirritable spot and a hard, palpable nodule in a taut band of the skeletal muscle that can be either extremely painful with external pressure or compression onto it such as palpation (they are usually called active trigger points), or not very painful at all even with palpation (these are usually called latent trigger points). Myofascial trigger points can lead to pain, weakness, muscle dysfunction, and sometimes loss of range of motion secondary to muscle tightness.

Often these trigger points can lead to a common condition known as myofascial pain syndrome. It can be an acute condition resulted from a certain overuse injury/event, or chronic condition which resulted from years of repetitive work. It does not only involve the primary muscle, but also its surrounding connective tissue known as fascia (fascia is a thin connective tissue casing and holding all the soft tissues together – imagine that when we process a piece of meat, there is a thin white film on top of the meat that we normally try to remove). Trigger points also cause the muscle to be more sensitive to pain with sensitization of the nerve tissue.

Fig 1. Multiple trigger points in the trapezius under cellular view

Most common types of myofascial trigger points:

1. Primary or central trigger points are those that cause severe pain locally at the pressure with irradiation according to referred pain map. Usually are based around the centre of a muscle belly – and it is almost always the active trigger points.
2. Secondary or satellite trigger points arise in response to existing central trigger points in surrounding muscles. They usually spontaneously withdraw when the central trigger point is healed. Can be present in the form of a cluster – and most of the satellite trigger points are latent ones, but they can eventually become active if it is provoked/aggravated.

Etiology/causes of myofascial trigger points:

Muscle knots or trigger points are formed from various reasons, but most common causes are overuse or trauma. However, our bodies are very complex and they can also be formed due to psychological stressors. Muscle knots or trigger points can also be formed from enough stress in the soft tissues with sustained abnormal/bad postures or repetitive activities, and they can begin to elicit pain.

Causes of trigger points:

• Aging
• Injury sustained by a fall, stress, or birth trauma
• Lack of exercise – commonly in sedentary persons between 27.5-55 years, of which 45% of men
• Bad posture – swayback posture, telephone posture, cross-legged sitting
• Muscle overuse and respective microtrauma – weightlifting
• Chronic stress condition – anxiety, depression, psychological stress trauma
• Vitamin deficiencies – vitamin C, D, B; folic acid; and iron
• Sleep disturbance
• Joint problems and hypermobility

Myofascial trigger point referred pain:

Active trigger points and muscle knots do not only respond to pressure or palpation. They can also be inducing muscle stiffness that spreads its painful ache out and around a central myofascial trigger point. When this happens, these muscle knots can spread and refer/radiate pain towards all corresponding areas. In 1983, two experts in myofascial pain syndrome and its referred pain, Janet G. Travell and David G. Simons, have carried out a thorough research and produced a map of referred pain pattern for various common myofascial trigger points and they called it “Myofascial pain and Dysfunction – The Trigger Point Manual”. Today, specialist clinicians such as chiropractor, osteopath or physiotherapist like us still refer to the textbook in our practice time to time.

Fig 1. Example of infraspinatus’ myofascial trigger point referred pain

Signs and symptoms of trigger points or muscle knots:

• General sore spots, sensitive to pressure, primarily in muscles.
• Affected limbs may feel a little heavy, stiff and feeble.
• Pain mainly elicits at a localised spot that you can almost pinpoint it.
• Pain can be dull, aching, and nagging.
• There is usually no clear mechanism of injury, but flare-ups can be exacerbated in response to extremes of position, or exercise.
• Pain is usually in episodes but episodes can last a long time (for days, weeks, or months).
• The pain may move around and even to the opposite side of the body. However, it is still a very uncommon symptom, but a distinctive one of trigger points.
• Any heat modalities such as hot showers, baths and heat packs provide pain relief.
• The pain is not strongly linked to movement as a low back pain or ankle sprain would be.

What can physiotherapy help to treat myofascial trigger points?

Physiotherapist is well-trained to treat the condition with a variety of useful tools and techniques in together with their knowledge to approach the condition most effectively.

• Trigger point massage involves applying sustained pressure directly over the irritable trigger point to create a hypoxic environment for the knot, which reduces blood and oxygen supply. The main goal is to relax and free up the contracted/knotted muscle fibers at the trigger point to produce a gradual relaxation.
• Dry needling therapy is a treatment modality where your trained physiotherapist inserts a few fine needles aiming at the trigger points of the concerned muscle. This causes a cascade of chemicals to be released from the muscles, which can cause a local twitch response, which is a contraction and RELAXATION of the muscle fibres in the contracted tissue. 
• Massage, especially deep tissue massage.
• Passive stretching exercises.
• Postural advice/education that can be contributing to the eliciting of trigger points.
• Education regarding self-release methods you may apply at home to help relieving pain, muscle knots and myofascial trigger points, such as foam-rolling, massage balls, etc.