Tuesday, December 23, 2008
Friday, December 19, 2008
I recently worked with John Howard at his Nov. 2008 San Diego FiTTE System Work Shop where he and Ernie Ferrel trained new FiTTE System practitioners. I was fortunate to give presentations on using Dartfish as a video analysis assessment tool.
Check out the above link to learn more about John's FiTTE System protocol.
Monday, December 15, 2008
Cycling and Lower Back Problems
By Richard A. Izzo, D.C., C.C.S.P.
During cycling, unlike running, it’s not just the bio-mechanics of the lower back and leg motion that is important, but the melding of human motion with machine. The biomechanics of cycling requires that the lower back and pelvis move in order for proper coordinated lower extremity motion. The anatomy of the lower back consists of muscles, tendons, ligaments, discs, and joint surfaces. For the purposes of this article we will concentrate on joints and muscles.
Soft tissue can shorten, tighten, weaken, hypertrophy, or be over stretched and strained. Muscles that have shortened can do less work. This is due to the fact that work is defined as force times distance. Thus, if the resting length of the muscle is shortened, the potential power generated is reduced. In cycling, the work is the distance per pedal stroke as measured by bike length traveled per stroke, or the power generated as measured in watts. An example of this is the cyclist whose hip flexors and quadriceps are tightened. Since there is less potential to do work (in this case, lengthen and contract a maximum distance) power is decreased, which means that it is harder to push a big gear. Since hip flexors originate in the lower back, when they tighten they can also cause lower back pain.
To analyze the normal pedal stroke lets use the analogy of a clock. From the one o’clock position to the three o’clock position the quadriceps contract with the downward pedal stroke. Force is transferred from the cranks to the wheels and you travel forward. The next important part of the pedal stroke is from 9 o’clock to 12 o’clock, where the hamstrings pull the crank on the upstroke. If one leg is not pushing or pulling the same as the other you will not have a smooth fluid pedal stroke. This loss of efficiency will affect the quality as well as quantity of motion. This creates “dead” spots in your pedal stroke, which decreases the torque you can produce.
Pelvic misalignment, short leg syndrome, tightened hamstrings, malalignment of the patella, or tightened lower back muscles can be the cause of these dead spots. Pelvic misalignment can cause a short leg syndrome. When one of your legs is shorter, the amount of force generated will not be equal. This can cause the body to compensate by recruiting other less efficient muscle groups to do the job. This added stress could cause overuse, inflammation, and over time, degenerative changes. With joint position being off, motion cannot occur normally due to the fact that more energy is necessary to do work (force times distance). The quality as well as the quantity of motion is decreased. Smooth, fluid, efficient motion, is not occurring, with the result being that your body is working harder than it should. There is a loss of energy to abnormal motion. This causes decreased performance, which comes into play when riding a century or a time trial.
Even when the symptoms of joint and muscle dysfunction are not evident, the problem may still exist, and it should be addressed and fixed before symptoms arise and degenerative changes occur. Chiropractic sports doctors check for these imbalances of the spine, soft tissue and extremities, and treat them with hands-on care, including physiotherapy, spinal adjustments, rehabilitative exercises, and stretching. A good approach for preventing injuries is to get regular checkups for musculoskeletal imbalances before symptoms occur, and follow a regular strengthening and flexibility program. Be sure that the bike you ride is properly fit to you as well as to your budget.
See you on the road.
Dr. Richard A. Izzo is a Board Certified chiropractic sports doctor with a practice in Rye Brook, NY.
During cycling, unlike running, it’s not just the bio-mechanics of the lower back and leg motion that is important, but the melding of human motion with machine. The biomechanics of cycling requires that the lower back and pelvis move in order for proper coordinated lower extremity motion. The anatomy of the lower back consists of muscles, tendons, ligaments, discs, and joint surfaces. For the purposes of this article we will concentrate on joints and muscles.
Soft tissue can shorten, tighten, weaken, hypertrophy, or be over stretched and strained. Muscles that have shortened can do less work. This is due to the fact that work is defined as force times distance. Thus, if the resting length of the muscle is shortened, the potential power generated is reduced. In cycling, the work is the distance per pedal stroke as measured by bike length traveled per stroke, or the power generated as measured in watts. An example of this is the cyclist whose hip flexors and quadriceps are tightened. Since there is less potential to do work (in this case, lengthen and contract a maximum distance) power is decreased, which means that it is harder to push a big gear. Since hip flexors originate in the lower back, when they tighten they can also cause lower back pain.
To analyze the normal pedal stroke lets use the analogy of a clock. From the one o’clock position to the three o’clock position the quadriceps contract with the downward pedal stroke. Force is transferred from the cranks to the wheels and you travel forward. The next important part of the pedal stroke is from 9 o’clock to 12 o’clock, where the hamstrings pull the crank on the upstroke. If one leg is not pushing or pulling the same as the other you will not have a smooth fluid pedal stroke. This loss of efficiency will affect the quality as well as quantity of motion. This creates “dead” spots in your pedal stroke, which decreases the torque you can produce.
Pelvic misalignment, short leg syndrome, tightened hamstrings, malalignment of the patella, or tightened lower back muscles can be the cause of these dead spots. Pelvic misalignment can cause a short leg syndrome. When one of your legs is shorter, the amount of force generated will not be equal. This can cause the body to compensate by recruiting other less efficient muscle groups to do the job. This added stress could cause overuse, inflammation, and over time, degenerative changes. With joint position being off, motion cannot occur normally due to the fact that more energy is necessary to do work (force times distance). The quality as well as the quantity of motion is decreased. Smooth, fluid, efficient motion, is not occurring, with the result being that your body is working harder than it should. There is a loss of energy to abnormal motion. This causes decreased performance, which comes into play when riding a century or a time trial.
Even when the symptoms of joint and muscle dysfunction are not evident, the problem may still exist, and it should be addressed and fixed before symptoms arise and degenerative changes occur. Chiropractic sports doctors check for these imbalances of the spine, soft tissue and extremities, and treat them with hands-on care, including physiotherapy, spinal adjustments, rehabilitative exercises, and stretching. A good approach for preventing injuries is to get regular checkups for musculoskeletal imbalances before symptoms occur, and follow a regular strengthening and flexibility program. Be sure that the bike you ride is properly fit to you as well as to your budget.
See you on the road.
Dr. Richard A. Izzo is a Board Certified chiropractic sports doctor with a practice in Rye Brook, NY.
Knee Pain and ITB Syndrome
By Carl Petersen, PT & Catherine Fussel, PT
Iliotibial Band Friction Syndrome is one of the most common causes of knee pain. Though frequently found amongst runners, it is also seen in tennis players, cyclists and occasionally in skiers, weight lifters and soccer players.
The iliotibial band (ITB) is a thickened strip of fascia, or outer casing, of a muscle that runs up the outside of the thigh. It extends from the outside of the pelvis, above the hip, to just below the knee joint into the tibial bone. Two muscles insert into the ITB where it begins at the pelvis - the tensor fascia latae muscle and the large gluteus maximus muscle. The ITB's primary function is to stabilize the knee and hip during walking and running.
During its course from the pelvis to the knee, the ITB crosses over a bony prominence on the outside of the knee known as the Lateral Femoral Epicondyle (LFE). A bursa, a fluid filled sac that reduces friction, lies between the ITB and the bone. As the knee bends or flexes past 30 degrees, the ITB slides over the LFE and the bursa. As you straighten or extend the knee, the band slides back over the bony prominence. It is this repetitive sliding back and forth that causes irritation of the ITB and the underlying bursa causing Iliotibial Band Friction Syndrome.
ITB Friction Syndrome is an overuse injury. Pain results from inflammation of the iliotibial band itself and/or the bursa. Inflammation of the periosteum, the outer covering of the bone, can also occur, causing pain as well.
MECHANISM OF INJURY
Although ITB Friction Syndrome may simply be due to training errors like too rapid an increase in running distances, it is also commonly due to faulty biomechanics. The ITB spans two joints, the hip and the knee, making it susceptible to stress from a multitude of causes. For runners, these may include leg length discrepancies, often secondary to a rotated pelvis, excessive "bow-leggedness", over-pronation (flat feet) or excessive supination.
Over-pronation of the foot causes the tibia to turn inwards, tightening the ITB and putting it on extra stretch. While excessive supination of the foot decreases the foot's ability to absorb forces during running and walking transferring increased stress to the knee.
Common training errors that may lead to ITB friction syndrome include persistent running on uneven or canted surfaces and increased knee flexion from over striding such as during downhill running. Cyclists may have their cleats positioned so that they are turned in too much or their seat height may be too high.
Mal-alignment problems of the pelvis, knee and foot need to be assessed and corrected or else, despite your best efforts, ITB Friction Syndrome can become a chronic injury. Talk to a reputable physiotherapist or sport medicine practitioner to determine if your IT Band symptoms are being exacerbated by mal-alignment.
Lastly, although this syndrome is commonly caused by over-pronation or leg length discrepancies, it is often the fact that the iliotibial band itself is tight and short. As well, the muscles that insert into the ITB are weak and tight. This tightness, combined with the other factors, leads to excessive rubbing and irritation of the ITB and the underlying bursa and bone.
SIGNS & SYMPTOMS
Iliotibial band Friction Syndrome will usually present itself as pain and tenderness on the outside of the knee. It is probably the most common cause of lateral knee pain. However, because of the length of the ITB, pain may occur anywhere from the hip to the knee, with pain occasionally radiating down the leg to the ankle. Most sufferers cannot often pinpoint the exact location of the pain.
The amount of discomfort ranges from a dull ache to a sharp stabbing pain that is intense enough to stop an athlete half way through a run. The pain comes on most frequently mid-way through a run, often after climbing a hill, or after a run. The pain is most noticeable when descending stairs, walking or running downhill getting out of a car or rising from a chair.
KEEPING THE ITB HEALTHY
Physiotherapists at City Sports and Physiotherapy Clinics in Vancouver have suggested the following set of guidelines for treatment, rehabilitation and prevention to help regain and improve flexibility of the iliotibial band. Upon initial signs and symptoms of ITB friction syndrome follow the PRINCE rules; Protection, Rest, Ice, Non-steroidal anti-inflammatory medication, Compression and Elevation.
PREVENTION
It is important to choose appropriate foot-wear that is suited for your foot type. Either ask your physiotherapist to make sure your shoes are correct for you or go to a reputable running shoe store that can help fit you in the right shoe. Shoes tend to lose their cushioning and shock absorbing ability after approximately 500 miles. If you run regularly this can be as soon as 4-6 months, so keep track of your mileage and replace the shoes when necessary. Most importantly, in order to prevent the recurrence of ITB friction syndrome, it is essential that stretching is done daily, even on your rest days.
TRAIN SMART
Maintain a year-round fitness program to avoid sudden changes to your activity level. For acute ITB Friction Syndrome reduce the mileage by at least one-half or up to the point of pain for two weeks and ice regularly after each run or cycle. Runners should avoid hills. If you run on a track or even on the side of a cambered road, make sure you change directions to allow your leg to alternate canted surfaces. Cyclists should pedal easy (80 rpm or less) with little resistance for at least one week. Gradually increase the amount of activity. Runners should not exceed increasing their mileage or their run duration by greater than 5-10% per week.
STRETCH & STRENGTHEN
Fortunately, iliotibial band Friction Syndrome is probably the best example of an injury that responds well to stretching. However, because the ITB is a relatively in-elastic tissue, stretching must be done regularly and consistently even when symptoms have subsided. It is also equally important to remember to stretch the tensor fascia latae and the gluteus maximus muscles as they come together and form part of the ITB. As well, the hamstring and quadriceps muscles should be stretched as the fascial tissue connections contribute to IT Band tightness. Cyclists should stretch extra long since cycling tightens up the lateral quadricep and iliotibial band.
STRENGTH SMARTS
Strength is also an important factor in controlling Iliotibial Band Friction Syndrome. The tensor fascia latae and the gluteus maximus muscle, as well as the surrounding hip and knee musculature must be kept strong. Exercises such as the straight leg raise, mini squats and step-ups are good exercises. The gluteals are multipurpose muscles that not only extend and abduct the leg but also include a component of rotation.
WARNING SIGNS
Always listen to your body. At the first sign of Iliotibial Band Friction Syndrome, stop. By stopping activity and spending a couple of minutes stretching out the ITB you may be able continue running or cycling for a few more kilometres. Ice and stretch again after activity. If stretching does not ease the pain don't try and push through it – you can't.
If identified and treated early ITB Friction Syndrome may only delay your training for a week or two. However, if the pain in not heeded this can very quickly turn into a chronic injury that may take several months to heal.
SURGERY
Surgery is the final option if conservative methods do not work. Make sure you are seen by a skilled orthopaedic medicine specialist who is familiar with the condition. Unfortunately there is no guarantee that surgery can relieve all the symptoms and return an athlete to pre-injury level.
A couple of things to remember: first, if you have any doubts about your current fitness level, consult a physician before beginning any exercise program. Secondly, stretches for all muscle groups should be part of your routine.
Carl Petersen is a Partner at City Sports & Physiotherapy Clinics. He is Physiotherapist for the Canadian Alpine Ski Team, and Fitness Coach to ITF & ETA players.
Iliotibial Band Friction Syndrome is one of the most common causes of knee pain. Though frequently found amongst runners, it is also seen in tennis players, cyclists and occasionally in skiers, weight lifters and soccer players.
The iliotibial band (ITB) is a thickened strip of fascia, or outer casing, of a muscle that runs up the outside of the thigh. It extends from the outside of the pelvis, above the hip, to just below the knee joint into the tibial bone. Two muscles insert into the ITB where it begins at the pelvis - the tensor fascia latae muscle and the large gluteus maximus muscle. The ITB's primary function is to stabilize the knee and hip during walking and running.
During its course from the pelvis to the knee, the ITB crosses over a bony prominence on the outside of the knee known as the Lateral Femoral Epicondyle (LFE). A bursa, a fluid filled sac that reduces friction, lies between the ITB and the bone. As the knee bends or flexes past 30 degrees, the ITB slides over the LFE and the bursa. As you straighten or extend the knee, the band slides back over the bony prominence. It is this repetitive sliding back and forth that causes irritation of the ITB and the underlying bursa causing Iliotibial Band Friction Syndrome.
ITB Friction Syndrome is an overuse injury. Pain results from inflammation of the iliotibial band itself and/or the bursa. Inflammation of the periosteum, the outer covering of the bone, can also occur, causing pain as well.
MECHANISM OF INJURY
Although ITB Friction Syndrome may simply be due to training errors like too rapid an increase in running distances, it is also commonly due to faulty biomechanics. The ITB spans two joints, the hip and the knee, making it susceptible to stress from a multitude of causes. For runners, these may include leg length discrepancies, often secondary to a rotated pelvis, excessive "bow-leggedness", over-pronation (flat feet) or excessive supination.
Over-pronation of the foot causes the tibia to turn inwards, tightening the ITB and putting it on extra stretch. While excessive supination of the foot decreases the foot's ability to absorb forces during running and walking transferring increased stress to the knee.
Common training errors that may lead to ITB friction syndrome include persistent running on uneven or canted surfaces and increased knee flexion from over striding such as during downhill running. Cyclists may have their cleats positioned so that they are turned in too much or their seat height may be too high.
Mal-alignment problems of the pelvis, knee and foot need to be assessed and corrected or else, despite your best efforts, ITB Friction Syndrome can become a chronic injury. Talk to a reputable physiotherapist or sport medicine practitioner to determine if your IT Band symptoms are being exacerbated by mal-alignment.
Lastly, although this syndrome is commonly caused by over-pronation or leg length discrepancies, it is often the fact that the iliotibial band itself is tight and short. As well, the muscles that insert into the ITB are weak and tight. This tightness, combined with the other factors, leads to excessive rubbing and irritation of the ITB and the underlying bursa and bone.
SIGNS & SYMPTOMS
Iliotibial band Friction Syndrome will usually present itself as pain and tenderness on the outside of the knee. It is probably the most common cause of lateral knee pain. However, because of the length of the ITB, pain may occur anywhere from the hip to the knee, with pain occasionally radiating down the leg to the ankle. Most sufferers cannot often pinpoint the exact location of the pain.
The amount of discomfort ranges from a dull ache to a sharp stabbing pain that is intense enough to stop an athlete half way through a run. The pain comes on most frequently mid-way through a run, often after climbing a hill, or after a run. The pain is most noticeable when descending stairs, walking or running downhill getting out of a car or rising from a chair.
KEEPING THE ITB HEALTHY
Physiotherapists at City Sports and Physiotherapy Clinics in Vancouver have suggested the following set of guidelines for treatment, rehabilitation and prevention to help regain and improve flexibility of the iliotibial band. Upon initial signs and symptoms of ITB friction syndrome follow the PRINCE rules; Protection, Rest, Ice, Non-steroidal anti-inflammatory medication, Compression and Elevation.
PREVENTION
It is important to choose appropriate foot-wear that is suited for your foot type. Either ask your physiotherapist to make sure your shoes are correct for you or go to a reputable running shoe store that can help fit you in the right shoe. Shoes tend to lose their cushioning and shock absorbing ability after approximately 500 miles. If you run regularly this can be as soon as 4-6 months, so keep track of your mileage and replace the shoes when necessary. Most importantly, in order to prevent the recurrence of ITB friction syndrome, it is essential that stretching is done daily, even on your rest days.
TRAIN SMART
Maintain a year-round fitness program to avoid sudden changes to your activity level. For acute ITB Friction Syndrome reduce the mileage by at least one-half or up to the point of pain for two weeks and ice regularly after each run or cycle. Runners should avoid hills. If you run on a track or even on the side of a cambered road, make sure you change directions to allow your leg to alternate canted surfaces. Cyclists should pedal easy (80 rpm or less) with little resistance for at least one week. Gradually increase the amount of activity. Runners should not exceed increasing their mileage or their run duration by greater than 5-10% per week.
STRETCH & STRENGTHEN
Fortunately, iliotibial band Friction Syndrome is probably the best example of an injury that responds well to stretching. However, because the ITB is a relatively in-elastic tissue, stretching must be done regularly and consistently even when symptoms have subsided. It is also equally important to remember to stretch the tensor fascia latae and the gluteus maximus muscles as they come together and form part of the ITB. As well, the hamstring and quadriceps muscles should be stretched as the fascial tissue connections contribute to IT Band tightness. Cyclists should stretch extra long since cycling tightens up the lateral quadricep and iliotibial band.
STRENGTH SMARTS
Strength is also an important factor in controlling Iliotibial Band Friction Syndrome. The tensor fascia latae and the gluteus maximus muscle, as well as the surrounding hip and knee musculature must be kept strong. Exercises such as the straight leg raise, mini squats and step-ups are good exercises. The gluteals are multipurpose muscles that not only extend and abduct the leg but also include a component of rotation.
WARNING SIGNS
Always listen to your body. At the first sign of Iliotibial Band Friction Syndrome, stop. By stopping activity and spending a couple of minutes stretching out the ITB you may be able continue running or cycling for a few more kilometres. Ice and stretch again after activity. If stretching does not ease the pain don't try and push through it – you can't.
If identified and treated early ITB Friction Syndrome may only delay your training for a week or two. However, if the pain in not heeded this can very quickly turn into a chronic injury that may take several months to heal.
SURGERY
Surgery is the final option if conservative methods do not work. Make sure you are seen by a skilled orthopaedic medicine specialist who is familiar with the condition. Unfortunately there is no guarantee that surgery can relieve all the symptoms and return an athlete to pre-injury level.
A couple of things to remember: first, if you have any doubts about your current fitness level, consult a physician before beginning any exercise program. Secondly, stretches for all muscle groups should be part of your routine.
Carl Petersen is a Partner at City Sports & Physiotherapy Clinics. He is Physiotherapist for the Canadian Alpine Ski Team, and Fitness Coach to ITF & ETA players.
Pelvic Malalignment and Neck Disfunction
Neck dysfunction due to pelvic malalignment
Recently I treated a road cyclist who has had a couple of years of persistent neck pain. This prevented him from reading the paper and made computer work and time-trialing on the bike uncomfortable. He had had a severe car accident 20 years ago where he had been knocked unconscious as well as suffering from a fractured jaw. 4 years ago he had a motor bike accident. 2 weeks prior to seeing me had had been on holidays at the beach where he had been doing a lot of boogie boarding, touch football and generally playing with his children when severe left sided neck pain occured.
Movement restrictions in his neck were left rotation 1/2, right rotation 2/3, left lateral flexion 2/3, right lateral flexion 1/2, all of which were restricted by pain and muscle spasms. Flexion was restricted to 3/4 and extension was unremarkable. Palpation revealed a right shifted C2 with countershift/rotation/lateral flexion of C1, as well as some stiffness in the thoracocervical junction and mid thoracic regions. Additionally, the scalene muscles and levator scapulae were in spasm and the sternocleidomastoid muscle was dominant. Generalized atrophy of the trunk muscles (trapezius, serratus anterior and pectorals) were present. However, the biceps, triceps and deltoids were well defined.
Treatment consisted of joint mobilizations to the upper C/S, thoracocervical junction and mid thoracic regions. Additionally, soft tissue work (massage and dry needling) was performed to the trapezius, levator scapulae and scalenes. Exercises for scapula stability were given in addition to supine bridging soccer ball rolling for his T/S kyphosis, (deep neck flexor endurance and trunk stability), as well as Mulligans techniques for self mobilisation of the thoracocervical junction. This resulted in overall improvement of the acute condition, however the underlying chronic condition was still present after 6 treatments.
The client had only taken up road cycling in the past few years, and hence I decided to look at his posture on his bike. What became immediately obvious was reduced left hip flexion with concommitant left anterior ilial rotation, which resulted in significant flexion and left rotation of the lumbar spine. This continued up into the thoracic spine with over-reaching of his left arm as a result of the pelvic poisitioning. Such over-reaching created significant instability in the scapula, which in turn caused reduced serratus anterior - external obliques, latissimus dorsi - transverse abdominus function.
Interestingly, the anterior rotation of the ilium was potentially a contributing factor to reversed gluteal-hamstring timing as well as premature fatigue and cramping of the hamstring muscle. However, palpation of the lumbar spine revealed tenderness and stiffness at the L3/4 levels on the left. On further questioning the client then revealed an episode of severe low back pain several years ago. Straight leg raising (SLR) with dorsi-flexion (DF) was reduced to 60 degrees (versus 80 degrees on right). Prone knee bend was reduced to 120 degrees. Both iliopsoas muscles were highly activated in sitting, but responded somewhat to lateral diaphragmatic breathing. The left piriformis was tight and the right SIJ was tender.
Treatment consisted of muscle energy techniques (MET's) to the pelvis and lumbar spine, as well as yoga poses of 'down dog', 'the triangle' and a modified 'warrior pose' incorporating lateral flexion and lateral breathing. Dry needling techniques were applied to the piriformis and quadratus lumborum. Rotation MET's were specifically directed to the L3/4, L4/5 region, as well as MET's to the left hamstring for the anterior ilial rotation. A combined MET of L3/4 rotation and hip external rotation (Piriformis-Iliopsoas) was performed which corrected the ROM of the SLR as well as improved cycling posture. Additionally, an immediate improvement of C/S rotation and lateral flexion was noted to what I would describe as hypermobility (chin over shoulder and ear to shoulder ROM). This was remarkable even for me. Due to the large improvements in ROM seen, I added global as well as specific stabilisation exercises which included a modified 'plank' and modified sideways body lift with 'the clam'. The modified plank included 'scapula push-ups', small amplitude stepping and hip abduction. Deep abdominal and hip stabilisation exercises were introduced where the differentiation of iliacus from psoas major, and superficial from deep stomach muscles was emphsised in a functional manner. Additionally, diaphragmatic breathing - pelvic floor synergy was practiced in sitting, standing, and during cycling. Additionally, the Alexander technique of 0/C1 elongation was used to enhance diaphragm - scapula function as well as to improve overall posture. Stretching of the low thoracic spine into extension was introduced into a cycling exercise. The 4 point kneeling position was used to practice pelvic rotation whose aim was to improve deep hip rotator activation as well as achieve thoracic spine rotation with scapula stabilisation.
Finally, it was also ascertained that he was right eye dominant. Hence, one leg balance exercises whilst juggling a rolled up newspaper keeping his right eye shut was introduced for occulomotor - cervical co-ordination function. Additionally, some occulomotor tracking as well as stabilisation exercises were given as a self assessment and treatment technique.
Functionally, his time trialing has improved from 46 minutes 3 seconds to 42 minutes 36 seconds. After 2 years of not being able to read the paper his ability to read the paper has improved from 5 minutes to painfree status. Computer work had been restricted to 30 minutes but was also now painfree. Hence, evidence based practice was attained as the values and beliefs of the client were satisfied.
Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected
Recently I treated a road cyclist who has had a couple of years of persistent neck pain. This prevented him from reading the paper and made computer work and time-trialing on the bike uncomfortable. He had had a severe car accident 20 years ago where he had been knocked unconscious as well as suffering from a fractured jaw. 4 years ago he had a motor bike accident. 2 weeks prior to seeing me had had been on holidays at the beach where he had been doing a lot of boogie boarding, touch football and generally playing with his children when severe left sided neck pain occured.
Movement restrictions in his neck were left rotation 1/2, right rotation 2/3, left lateral flexion 2/3, right lateral flexion 1/2, all of which were restricted by pain and muscle spasms. Flexion was restricted to 3/4 and extension was unremarkable. Palpation revealed a right shifted C2 with countershift/rotation/lateral flexion of C1, as well as some stiffness in the thoracocervical junction and mid thoracic regions. Additionally, the scalene muscles and levator scapulae were in spasm and the sternocleidomastoid muscle was dominant. Generalized atrophy of the trunk muscles (trapezius, serratus anterior and pectorals) were present. However, the biceps, triceps and deltoids were well defined.
Treatment consisted of joint mobilizations to the upper C/S, thoracocervical junction and mid thoracic regions. Additionally, soft tissue work (massage and dry needling) was performed to the trapezius, levator scapulae and scalenes. Exercises for scapula stability were given in addition to supine bridging soccer ball rolling for his T/S kyphosis, (deep neck flexor endurance and trunk stability), as well as Mulligans techniques for self mobilisation of the thoracocervical junction. This resulted in overall improvement of the acute condition, however the underlying chronic condition was still present after 6 treatments.
The client had only taken up road cycling in the past few years, and hence I decided to look at his posture on his bike. What became immediately obvious was reduced left hip flexion with concommitant left anterior ilial rotation, which resulted in significant flexion and left rotation of the lumbar spine. This continued up into the thoracic spine with over-reaching of his left arm as a result of the pelvic poisitioning. Such over-reaching created significant instability in the scapula, which in turn caused reduced serratus anterior - external obliques, latissimus dorsi - transverse abdominus function.
Interestingly, the anterior rotation of the ilium was potentially a contributing factor to reversed gluteal-hamstring timing as well as premature fatigue and cramping of the hamstring muscle. However, palpation of the lumbar spine revealed tenderness and stiffness at the L3/4 levels on the left. On further questioning the client then revealed an episode of severe low back pain several years ago. Straight leg raising (SLR) with dorsi-flexion (DF) was reduced to 60 degrees (versus 80 degrees on right). Prone knee bend was reduced to 120 degrees. Both iliopsoas muscles were highly activated in sitting, but responded somewhat to lateral diaphragmatic breathing. The left piriformis was tight and the right SIJ was tender.
Treatment consisted of muscle energy techniques (MET's) to the pelvis and lumbar spine, as well as yoga poses of 'down dog', 'the triangle' and a modified 'warrior pose' incorporating lateral flexion and lateral breathing. Dry needling techniques were applied to the piriformis and quadratus lumborum. Rotation MET's were specifically directed to the L3/4, L4/5 region, as well as MET's to the left hamstring for the anterior ilial rotation. A combined MET of L3/4 rotation and hip external rotation (Piriformis-Iliopsoas) was performed which corrected the ROM of the SLR as well as improved cycling posture. Additionally, an immediate improvement of C/S rotation and lateral flexion was noted to what I would describe as hypermobility (chin over shoulder and ear to shoulder ROM). This was remarkable even for me. Due to the large improvements in ROM seen, I added global as well as specific stabilisation exercises which included a modified 'plank' and modified sideways body lift with 'the clam'. The modified plank included 'scapula push-ups', small amplitude stepping and hip abduction. Deep abdominal and hip stabilisation exercises were introduced where the differentiation of iliacus from psoas major, and superficial from deep stomach muscles was emphsised in a functional manner. Additionally, diaphragmatic breathing - pelvic floor synergy was practiced in sitting, standing, and during cycling. Additionally, the Alexander technique of 0/C1 elongation was used to enhance diaphragm - scapula function as well as to improve overall posture. Stretching of the low thoracic spine into extension was introduced into a cycling exercise. The 4 point kneeling position was used to practice pelvic rotation whose aim was to improve deep hip rotator activation as well as achieve thoracic spine rotation with scapula stabilisation.
Finally, it was also ascertained that he was right eye dominant. Hence, one leg balance exercises whilst juggling a rolled up newspaper keeping his right eye shut was introduced for occulomotor - cervical co-ordination function. Additionally, some occulomotor tracking as well as stabilisation exercises were given as a self assessment and treatment technique.
Functionally, his time trialing has improved from 46 minutes 3 seconds to 42 minutes 36 seconds. After 2 years of not being able to read the paper his ability to read the paper has improved from 5 minutes to painfree status. Computer work had been restricted to 30 minutes but was also now painfree. Hence, evidence based practice was attained as the values and beliefs of the client were satisfied.
Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected
Neck and Back Pain Due to Malalignment
By Dr. Chad AsplundMar 4, 2003, 15:18
Neck and back pain are very common in cycling. Many riders experience occasional or recurrent neck and back pain related to their riding. Neck and back pain are especially common in the early season when riders are increasing both their mileage and time in the saddle. In order to avoid early season overuse injuries, riders should initially ride at high cadence and low resistance and only increase training mileage by 10% weekly, gradually building to goal mileage.
Neck pain can be exacerbated by several factors to include riding position and technique. Riding in drop handlebars for long periods increases the load on the arm and shoulders as well as hyperextension of the neck, leading to pain. If the virtual top tube length (top tube plus stem length) is too long for the rider, or if aero bars are used, hyperextension of the neck is further increased.
Prolonged hyperextension of the neck and associated muscle strain may lead to trigger points in the muscles of the neck and upper back. Trigger points are small rubbery knots that form in muscle and adjacent muscle sheaths (fascia), which may send pain signals to the brain and contribute to a pain-spasm-pain cycle. Trigger points are frequently caused by direct blunt trauma, or by repetitive micro trauma, as is seen in overuse athletic injuries.
Riders suffering from neck pain should inspect the fit of their bicycle. One way to reduce neck hyperextension is by raising the handlebars, or using handlebars with a shallower drop. Another method is to reduce the virtual top tube length, by using a stem with a shorter extension. Moving the saddle forward would also reduce virtual top tube length, but the rider should be cautious as improper fore/aft saddle position can lead to knee pain.
Changes to riding technique can also help with neck pain. Rigid riding position transmits more shock directly to the neck and shoulders. Riding with unlocked elbows and changing hand position (i.e. from drops to brake hoods) can alter neck posture minimizing pain. The rider may also alter his head position during the ride, in essence stretching the neck muscles while riding.
Back pain is also very common in cycling. Cycling position leads to prolonged back flexion, resulting in muscle pain in the unconditioned back. The low back is the primary muscle group generating power and controlling the movement of the bicycle. If the back is not well conditioned and flexible, muscle fatigue and strain will lead to pain.
The virtual top tube length, and the amount of spinal flexion in the riders back should be investigated in cyclists with back pain. If the handlebars are too low, the flexion (lordosis) of the spine is exaggerated resulting in increased pressure in the lumbar spine. If the top tube length is too short, the sacral spine will flex, increasing pressure on the interspinal disks. Ensuring that the handlebar height and top tube length are correct should help minimize back pain.
Pelvic position also contributes to back pain, as a malaligned pelvis will cause strain to the back musculature. Tight quadriceps will tend to pull the pelvis forward, while tight hamstrings predispose to backward pelvic tilt. Also, the strength of the abdominal muscles is critical to maintaining stable pelvic positioning. Pushing large gears, or extended hill climbing may fatigue the gluteus and the hamstrings, causing the pelvis to tilt backwards, aggravating the back musculature and causing pain. Core muscle group strengthening and lower extremity stretching will help with proper pelvic positioning and should lead to pedaling efficiency.
Frequent changes of riding position can help with back pain. Moving hand position from the drops to the brake hoods to the top of the handlebars allows for changes in posture, reducing strain on the back. When climbing or pushing a big gear, moving slightly back on the saddle will decrease strain on back. Back pain while sprinting can be helped by moving slightly forward on the saddle.
Riders whose neck or back pain is refractory to the above techniques should decrease their weekly mileage by 10% until the back pain disappears. During this period of mileage reduction, they should also avoid climbing and sprinting, and use a high cadence, low resistance spinning technique. Ice and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, may be used to provide pain relief. NSAIDs should be taken with food, and if the pain is not resolving within 1 week, medical evaluation is recommended. Medical management may include continuation of NSAIDs, trigger point injections, and possible a referral for physical therapy to improve core strength and flexibility.
In summary, although neck and back problems are very common, they can usually be managed by a combination of bicycle adjustment, technique change, and minor medical treatment.
Chad Asplund, MD
Neck and back pain are very common in cycling. Many riders experience occasional or recurrent neck and back pain related to their riding. Neck and back pain are especially common in the early season when riders are increasing both their mileage and time in the saddle. In order to avoid early season overuse injuries, riders should initially ride at high cadence and low resistance and only increase training mileage by 10% weekly, gradually building to goal mileage.
Neck pain can be exacerbated by several factors to include riding position and technique. Riding in drop handlebars for long periods increases the load on the arm and shoulders as well as hyperextension of the neck, leading to pain. If the virtual top tube length (top tube plus stem length) is too long for the rider, or if aero bars are used, hyperextension of the neck is further increased.
Prolonged hyperextension of the neck and associated muscle strain may lead to trigger points in the muscles of the neck and upper back. Trigger points are small rubbery knots that form in muscle and adjacent muscle sheaths (fascia), which may send pain signals to the brain and contribute to a pain-spasm-pain cycle. Trigger points are frequently caused by direct blunt trauma, or by repetitive micro trauma, as is seen in overuse athletic injuries.
Riders suffering from neck pain should inspect the fit of their bicycle. One way to reduce neck hyperextension is by raising the handlebars, or using handlebars with a shallower drop. Another method is to reduce the virtual top tube length, by using a stem with a shorter extension. Moving the saddle forward would also reduce virtual top tube length, but the rider should be cautious as improper fore/aft saddle position can lead to knee pain.
Changes to riding technique can also help with neck pain. Rigid riding position transmits more shock directly to the neck and shoulders. Riding with unlocked elbows and changing hand position (i.e. from drops to brake hoods) can alter neck posture minimizing pain. The rider may also alter his head position during the ride, in essence stretching the neck muscles while riding.
Back pain is also very common in cycling. Cycling position leads to prolonged back flexion, resulting in muscle pain in the unconditioned back. The low back is the primary muscle group generating power and controlling the movement of the bicycle. If the back is not well conditioned and flexible, muscle fatigue and strain will lead to pain.
The virtual top tube length, and the amount of spinal flexion in the riders back should be investigated in cyclists with back pain. If the handlebars are too low, the flexion (lordosis) of the spine is exaggerated resulting in increased pressure in the lumbar spine. If the top tube length is too short, the sacral spine will flex, increasing pressure on the interspinal disks. Ensuring that the handlebar height and top tube length are correct should help minimize back pain.
Pelvic position also contributes to back pain, as a malaligned pelvis will cause strain to the back musculature. Tight quadriceps will tend to pull the pelvis forward, while tight hamstrings predispose to backward pelvic tilt. Also, the strength of the abdominal muscles is critical to maintaining stable pelvic positioning. Pushing large gears, or extended hill climbing may fatigue the gluteus and the hamstrings, causing the pelvis to tilt backwards, aggravating the back musculature and causing pain. Core muscle group strengthening and lower extremity stretching will help with proper pelvic positioning and should lead to pedaling efficiency.
Frequent changes of riding position can help with back pain. Moving hand position from the drops to the brake hoods to the top of the handlebars allows for changes in posture, reducing strain on the back. When climbing or pushing a big gear, moving slightly back on the saddle will decrease strain on back. Back pain while sprinting can be helped by moving slightly forward on the saddle.
Riders whose neck or back pain is refractory to the above techniques should decrease their weekly mileage by 10% until the back pain disappears. During this period of mileage reduction, they should also avoid climbing and sprinting, and use a high cadence, low resistance spinning technique. Ice and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, may be used to provide pain relief. NSAIDs should be taken with food, and if the pain is not resolving within 1 week, medical evaluation is recommended. Medical management may include continuation of NSAIDs, trigger point injections, and possible a referral for physical therapy to improve core strength and flexibility.
In summary, although neck and back problems are very common, they can usually be managed by a combination of bicycle adjustment, technique change, and minor medical treatment.
Chad Asplund, MD
Saturday, December 13, 2008
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