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: http://astym.com/blog/2011/10/07/effective-treatment-for-tennis-elbow-presented-at-hand-surgeons-meeting.html

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.

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