Importance of the Hip Hinge


Previously, I wrote about how bending down towards the floor is commonly used during daily movement and somehow mistakenly has also been utilized as a self-stretch. Hopefully the last article I wrote helped you appreciate how, when done repeatedly, bending down towards your toes can lead to lumbar symptoms. (You can find that article : here). I offered a suggestion regarding how performing a hip hinge is an appropriate substitute for bending through your back, and also mentioned how there are more safe ways to stretch as well. Below, I am going to describe the hip hinge and how to correctly perform the movement. As for the previous comment about more safe ways to stretch, more on that later.

I like the hip hinge for several reasons. The hip hinge is purely a sagittal plane movement through the hip joint which helps engage the posterior chain (glutes and hamstrings), which often is weaker due to anterior chain dominance (i.e. quads). Best and perhaps most importantly of all, the movement spares the spine and prepares you for several activities of daily living and is a good precursor/injury prevention tool for more athletic movements. We already know that the typical low back patient moves excessively through their low back during daily activities; but learning how to hip hinge effectively is a movement pattern that can assist the cervical spine patient who looks down too often, the anterior knee pain patient with inhibited glutes and hamstrings, and our elderly patients who need help transitioning from sit-to-stand.

Physical therapists and patients alike will tell you, learning how to correctly perform a hip hinge and then incorporating it into daily activities is easier said then done. Because most people have already trained their body to move a certain way, often times re-programming to move a different way, even though it’s more beneficial, is a foreign concept.

I have found that the most effective way to coach this movement is with the proprioceptive input gained from using a dowel rod. Having the dowel to help learn the movement provides the patient with the neural feedback to assess the movement and be more aware of inconsistencies when practicing correct form.

Here are the coaching tools I use to teach the hip hinge:

hip-hinge-with-stickStep 1: Utilize the stick to create 3 points of contact: 1)Occiput, 2)Thoracic Spine, 3)Sacrum

Step 2: Keep a slight bend in the knees with feet slightly wider than shoulder width apart

Step 3: Engage your transverse abdominis and gluteal region (teaching points on how to do these actions will have already been instructed)

Step 4: Hinge forward—push butt back and keep chest up

The spine should remain neutral throughout the entire movement and the knee should not bend excessively either. 


Hip Hinge to Save Your Spine

Somewhere along the way, bending down to touch your toes became a criteria for demonstrating appropriate levels of flexibility and also an essential movement for avoiding back pain in the mind of many individuals.

Often times when taking a subjective history of a patient, I have heard the phrase, “touch my toes” and whether they can, can’t, or have had a change in their ability to do that particular task.


I realize that being flexible is essential to being able to move through ranges of motion unrestricted and pain-free. And maybe because people seem to think it is ok to bend down and touch their toes as a form of stretching, it is also ok to perform this movement, repeatedly, to complete their daily activities. This isn’t the case. There are safer ways to stretch and safer ways to perform specific activities. (More on both of those in the coming weeks).

Yes, sometimes I have patients bend down in the clinic. Bending down to touch your toes, when used for assessment purposes, can help identify movement impairments. Gray Cook introduced The Selective Functional Movement Assessment (SFMA) and this movement based diagnostic system utilizes multi-segmental flexion (toe touching) as a movement pattern for those with known musculoskeletal pain. So that is not to say that we avoid the movement in the clinic completely. However, we must make it clear that assessment is not exercise and prescribing (or failure to correct) faulty movement can only lead to further injury.

So what about bending down (lumbar forward flexion) is undesirable? To reference Stuart McGill, lumbar forward flexion, even in the absence of moderate load will lead to discogenic troubles. A fully flexed position leads to strained posterior passive tissues and high shearing forces on the lumbar spine (from both reaction shear on the upper body and interspinous ligament strain). His lab work has shown this to be a good way to cause disc herniations.  I read an analogy of lumbar flexion and a credit card that helps illustrate the point. If you take a credit card and bend it back and forth repeatedly, it would eventually damage and/or break. That damage doesn’t occur from a single bend, but rather a series of bends over and over.

Now consider the various activities throughout our day that might tempt us to bend through our back. There are plenty— such as wearing shoes/socks or bending down to pick an object up from the floor.

A safe alternative that I think is essential in helping to avoid injury is a hip hinge. By bending at our hips (rather than the spine), we are able to keep the spine neutral and avoid the risks of repetitive bending done daily.

Correctly performing a hip hinge, however, is easier said that done. It takes more effort, can be more time consuming, and often requires coaching and cuing to be done correctly. In my next post, I will give a short description on how to perform a hip hinge.

“-itis,” “-osis,” and “Tennis Elbow” Continued

Common extensor tendinosis/tendonopathy, as discussed previously before, is one of the more frustrating conditions for both patients and clinicians alike. Part of the frustration has to do with incorrect labeling of the condition, which research has shown to be more of a tendinopathy/tendinosis. Another reason for lack of improvement is failure to perform a thorough differential diagnosis and evaluate for cervical spine involvement, radial nerve entrapments, and other conditions that may be the source of pain.

However, let’s assume that we evaluated the cervical spine and found that it was not the primary culprit. Traditional conservative treatments for extensor tendinopathy have been modalities, external strapping, taping techniques, exercises, and manual interventions-all of which I have used in the past and continue to integrate when necessary in treatment. The primary purpose, however, of this post is to introduce a few different treatment techniques that I found particularly helpful in treating common extensor tendinopathy. Both of these techniques will have separate articles written about them soon, and I have not done both together on the same day, but here is a short introduction and how I have found them to be useful with common extensor tendinopathy.

Astym_TreatmentASTYM—The theories regarding mechanisms of action for Astym® treatment were developed based on the foundation of recent histologic research identifying the primarily degenerative nature of tendinopathies, and the investigations into the use of cellular mediators, growth factors and related products to assist in the healing and regeneration of tissues. ASTYM utilizes a series of specific movements with instruments that are run firmly along the skin following the direction of the muscle, tendon, or ligament with the goal of removing unwanted scar tissue and regenerating healthy tissue. A recent study at the American Society for Surgery of the Hand’s annual meeting showed that Astym treatment was an effective tennis elbow treatment by resolving 78.3% of chronic lateral epicondylitis (tennis elbow) cases.  Here is the case study they presented:

Picture from: Dry Needling for Manual Therapists authored by Gyer, Michael, Tolson

Trigger point dry needling:  APTA defines dry needling as using thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. The needle is typically inserted in the area that causes pain and has a palpable “trigger point.” As mentioned in the previous post, all the major extensor muscles of the elbow have an attachment point at the lateral epicondyle, and all form into the common extensor tendon. Typically, when a patient complains of pain, that pain can be palpated at the common extensor tendon. The extensor carpi radials brevis (ECRB) is the most commonly affected tendon, however the other tendons can also be affected. With dry needling for common extensor tendinopathy, I am usually able to palpate for taut bands and trigger points to the elbow and forearm and treat several areas. The most common areas I have encountered and treated are the ECRB, Supinator, Brachioradialis, Triceps, ECRL and extensor digitorum. Although research on dry needling and trigger points are still relatively new, the results thus far have been pretty promising.


“-itis,” “-osis,” and “Tennis Elbow”

Recently, I had a patient come to the clinic with “Tennis elbow.” The patient was an avid pickle-ball player and bowler who reported that she goes “full-speed” with any activity that she participates in. During palpation, the patient presented with pain and tenderness to the common extensor tendon. Her grip strength was 50% of the opposite side and painful. She also reported similar symptoms 5 months ago, during which she got a cortisone shot to improve her symptoms for a short while.

So what is tennis elbow?

Lateral Epicondylitis, commonly referred to as “Tennis Elbow” is defined by WebMD as “a type of tendinitis — swelling of the tendons — that causes pain in the elbow and arm.” The suffix “-itis” means inflammation and “epicondyle” is a bone. Therefore, if you are suffering from lateral epicondylitis, you are suffering from inflammation of a bone and if you read the treatment options online, you would likely be inclined to try all the usual traditional interventions for tendinitis: rest, ice, and anti-inflammatories.

Because the pain associated from this condition has a high correlation with repetitive activities (i.e. job, sports, etc), often times rest isn’t a viable option. That leaves ice and anti-inflammatories. As with the case above, bowling season didn’t end for another 6 weeks and she had commitments on playing pickle-ball for 2-3x/week, so ice and anti-inflammatories would likely not be enough. And, If you follow the path of attempted rest, ice, and anti-inflammatories long-enough, you will likely see why this is one of the more frustrating conditions for both patients and clinicians alike.

Lateral epicondlyitis is characterized by pain over the outer aspect of the elbow. Pain and symptoms typically arise from repetitive gripping, heavy lifting, work-related tasks (auto-mechanic, plumber, etc), and sport-specific activities, most notably racquet sports such as tennis, or as in this case, pickle-ball and bowling.

Let’s assume we have already done a differential diagnosis to rule out other pathology and are led back to the elbow. The problem with lateral epicondylitis is that it seems to be a poorly named condition. The condition more commonly involves a soft tissue injury to the extensor tendon, which can be correlated in the clinic with pain and tenderness upon palpation to the extensor tendon. Although it may be possible, swelling typically isn’t present.

Also, consider that studies on lateral epicondylitis have failed to show the presence of inflammatory cells, but rather the presence of dense populations of fibroblasts, vascular hyperplasia, and disorganized collagen that may lead to microtears. More simply, the condition seems more related to an “-osis” rather than an “-itis.” And more commonly the extensor tendon, and not the lateral epicondyle.image

Consider that tendinitis is associated with pain and swelling. Tendinosis is more of a process—it’s more like a chronic irritation at the tendon-bone interface. During tendinosis, with repetitive trauma, a decrease in blood supply to the tendon occurs. Decreased blood supply will lead to a decrease in tissue oxygenation. A reduction in tissue oxygenation leads to tendon degeneration and as the tendon degenerates, it becomes weaker, which leads to microtears. It’s a degenerative process. It’s like the cord of your iphone being pulled and twisted so many times that the cable starts to become weaker and you have to shimmy it just to get a good charge going. After more bending, twisting and irritation to that iphone cable it starts to frey and loses its ability to function properly and you need to fix it.

Next post, we will discuss some treatment options for extensor tendinosis.

Do This, Not That!

Have you seen those, “Eat this, not that!” articles as it relates to nutrition, weight loss tips, and health news?

Let’s apply that principle to exercises.

How many physical therapists, personal trainers, or coaches have had their athletes do the Superman exercise? How many of us do this exercise ourselves?

The “Superman” exercise is one that I remember doing well before I started PT school in 2008. I still see it done at the gym on a frequent basis. I remember being told it is a great way to exercise the muscles that support the spine, so I understand why many people still do the exercise. At the time, I didn’t think about what biomechanically is going on with the exercise and whether it was safe to do.

The Superman exercise is when you lie on your stomach and lifts both arms and legs up to train the spinal extensors, gluteal muscles, and secondary muscles as wellsuperman-core-exercise. According to Stuart McGill, who is an expert on low back disorders, the Superman exercise creates nearly 6000 N of compression to a hyperextended spine, transfers the load to your facets, and crushes the interspinous ligaments (You can see all his work in his book: Low Back Disorders: Prevention and Rehabilitation). Simply put, it’s really bad for your back when done repeatedly. For perspective, the National Institute for Occupational Safety and Health (NIOSH) did research and testing regarding the maximum disc compression levels that your back can safely tolerate. They found that level to be 3425 N, or about 770 pounds of force.

If we do some simple conversions knowing that 1 newton = 0.22 pounds, than we see that the Superman exercise at 6000 Newtons is equal to 1349 pounds of force to the lumbar spine. That exercise exceeds the safety guidelines by nearly 600 pounds of force!

So what to do? A core exercise that I think is challenging, but also more safe is the forearm plank.


Although I haven’t seen research on the levels of compression during a plank, Dr. McGill has found that the side plank creates a force of about 581 pounds to the lumbar spine, and being in a push-up position leads to 413 pounds of force. The more traditional plank is listed under one of his advancements of the side plank exercise, so I am inclined to believe it is still well below the 770 pounds of force noted by the NIOSH to correlate with risk of back injury.

5 Exercises to Avoid Following Acromioclavicular (AC) Joint Injury

Several weeks ago, a mid-60’s male came to the clinic presenting with an AC Joint separation after falling from his mountain bike (that’s what we get for trying to take advantage of the mild Michigan winter!) This patient is very active; he regularly participates in a men’s competitive soccer league and mountain biking. After suffering the injury and experiencing signs and symptoms of pain, decreased range of motion (ROM), and weakness of the shoulder, the patient assumed surgery was his only option.

Prior to beginning therapy, the patient had consults with three different orthopedic surgeons, all of whom recommended physical therapy as an initial treatment. Upon meeting him, hearing how he injured his shoulder and the activities he wants to return to, I knew his personality type as one to push through the pain when exercising.

I asked the patient what, if anything, he has been doing at home after the injury—either to decrease pain or improve function. He mentioned that he would attempt to apply an aggressive cranially directed force to the shoulder in an attempt to correct his step deformity that was present after injury. He made a point to mention how much he visually disliked the look of the step deformity that was present after injury! When I looked at his shoulder and the amount of vertical displacement present, I presumed hat he had a grade 3 separation at minimum.

“Did that help?” I asked.

“Ehh…I’m not too sure, but it does push it back up and makes it look nicer”

Physical therapy treatment always includes education on injury prevention. I told him that what he was doing to fix his step deformity was a major no-no. In fact, what he was doing would likely make things worse over time. We discussed how the bony surfaces of the AC joint surfaces are sloped in nature of articulation, which makes the joint more inherently susceptible to dislocation. When the force applied to the region exceeds the tensile strength of the ligaments, further injury can occur. Although the coracoclavicular ligament was likely already completely torn, it didn’t seem like a good idea to repeatedly perform a maneuver that leads to further AC joint pathology as a means of treatment.

We also got to talking about exercise—what he enjoyed doing, what he was able to do pain-free, and what exercises were being performed when painful. I provided him with feedback on the exercises and described how we would create a treatment plan that would safely strengthen his shoulder with respect to the severity and limitations of his injury prior to the follow up appointment with his surgeon. Here are 5 exercises that I instructed him to avoid initially.

Dumbbell-Chest-Fly.jpg1) Pectoral flys: When AC joint pathology is suspected, PTs perform a horizontal adduction test in order to provoke symptoms. Pain when moving the arm across the body (horizontal adduction) is indicative of a positive test. The pec fly exercise replicates the horizontal adduction test and should be avoided to prevent further damage.

seated_front_barbell_press_2) Overhead press: The closed pack position of a joint is the the point at which the joint surfaces are maximally congruent, and the ligaments are most pulled taut (i.e. less space in the joint for smooth movement). The closed pack position for the AC joint is 90 degrees of shoulder abduction. The closed pack position of the glenohumeral (GH) joint is 90 degrees abduction and external rotation, or maximum abduction and external rotation depending on the source. Overhead press can lead to shearing between the lateral end of the clavicle and the medial aspect of the acromion. It also takes the shoulder through ranges of the closed pack position repeatedly. We also know that the articular disc of the AC joint is already susceptible to age related degenerative changes which can lead to AC joint arthrosis, even without a pre-existing injury.


3) Lateral pull-downs: This exercise requires starting with the arms outstretched in an overhead position and moves downward to the sternum. As mentioned above, this movement goes through the closed pack position of both the AC and GH joint and also creates repeated shearing of the AC joint.

4) Wide-grip bench press: It seems to be one of the primary complaints of people with AC joint injury. Pain when performing this exercise occurs for the same reasons listed above. Mechanically, it puts an unfavorable amount of stress and impact to the injured AC joint.

5) Tricep Dips: TrChair_Tricep_Dipicep dips apply additional, unwanted pressure to the anterior capsule of the shoulder. This can lead to anterior instability and laxity of the anterior capsule, which is the most common direction of instability of the shoulder. During the triceps dip, similar forces occur as with the example given above when my patient was trying to push his arm up to make the step deformity look better. There are safer ways to strengthen!

Cervical pain and Cell phones, continued

Previously, we discussed how repetitive cervical strain, which has been termed “text neck” in recent years, has become more of an issue. Just a few years ago, the phrase “text neck” was virtually unheard of. However, in reality, the issues with sustained and repetitive cervical flexion have been around for a very long time–they have just been given the fancy “text neck” moniker recently.

If we consider how common it is for teens, adolescents, and adults to spend several hours a day on the phone or send several thousand text messages a month, one can imagine that over the course of 20 years, the repetitive strain can lead to changes in the normal curvature of the spine. Beyond the musculoskeletal aches and pains associated with the change in spinal curvature, it can have further implications on lung capacity and create a greater workload on the cardiovascular system. Dr. Bolash of the Cleveland Clinic describes how the impaired lung capacity from sitting in a slumped posture restricts oxygen and causes the heart to work harder to distribute more oxygen-carrying blood through your body.

This is further highlighted when considering how similar forces occur with several other daily activities such as reading, writing, and meal preparation. Ultimately, some of these positions are not avoidable. The point to be made is to be more aware of our postures, avoid positions of undue stress and take proactive steps to strengthen and stabilize the muscles of the cervical spine.

We discussed how looking down while texting can equal upwards of 60 pounds of force to the cervical spine, which would be the equivalent of a 5 gallon jug of water hanging from your neck and then adding a 20 pound car tire hanging from that. (Here’s an abc news report on the issue). So the question now is what can we do to help prevent these degenerative structural changes in our neck due to repetitive overuse of our cellphones?

Let’s start with some of the easier fixes:

  • Limit your usage of cellphones and other electronics.
  • Bring the cell phone or tablet up to eye level during use; if reading use a book stand to elevate the book to eye level.
  • If you are sitting and must keep your phone down low, hinge more at your hips, keep your spine (back and neck) neutral and simply look down with your eyes
  • Utilize voice to text technology
  • Do strengthening and stretching exercises to target muscles of the cervical spine.
  • Visit a physical therapist to implement a more client-centered and extensive treatment plan. Remember that the same rules don’t apply to everyone. Each of us are at a different level of postural awareness, have different muscle imbalances, and varying levels of joint mobility. A physical therapist can help identify the appropriate program for you.

The key is prevention. Technology will continue to improve and make life easier than ever before. When I was in school, the teacher would always say to the class “you won’t have a calculator everywhere you go, so you need to learn how to do this!” Funny how that worked out! 10 years ago, I never would have thought to be able to read a 300 page novel on a 4.5 inch iPhone screen, but the option is now available. Technology will keep changing, its up to us to make sure we use these new conveniences in a safe and comfortable way.