Quasimodo Worked on Wall Street

It’s no secret that sitting all day is slowly killing us. Humans are not designed to be hunched over desks, be it sitting or standing, for 8+ hours a day, but I’ve accepted the fact that I’m not going to change the working habits of New Yorkers. Instead, I want to chat a little about proper head and neck posture, so that you can give yourself a fighting chance at being able to look at more than just the floor when you’re in your 70s.

Good standing posture starts with the feet. In the previous Movement of the Week posts, I’ve discussed proper posture from the waist down, setting an important foundation for head and neck positioning. If you haven’t been keeping up with the moves, check ’em out here. Adjusting that pelvic position will have a significant effect on your upper back and neck positioning, thus it is imperative that you start here and work you way up.

For those of you who are already Movement of the Week Masters, let’s work our way up the spine to that neck and upper back area. While we all like to think that we look like this:

 

good posture.jpg

In reality, most of us are sitting around looking like this:

In PT parlance, this is referred to as "forward head posture with an increased thoracic kyphosis," more commonly known as "slumping", "slouching", or "the way that nearly everyone sits."

                      Side view of the human spine.

                      Side view of the human spine.

The thoracic and cervical areas of the spine when viewed from the side, have inherent curvatures. Like curve of the lumbar spine, are imperative for proper spine health and function. Standing and sitting with a slouched posture exaggerates these curvatures, causing muscle imbalances and joint dysfunction. At the thoracic spine, a slouched posture means increased spinal flexion, aka an increased likelihood of looking like Quasimodo when you get older. As that thoracic spinal flexion increases, the shoulders drift forward, causing the pecs to shorten and tighten, the back musculature to lengthen and weaken, and overall shoulder function to be significantly compromised. To demonstrate this point I want you to try this: slouch down as much as you can (while sitting or standing) with your upper back rounded as much as possible, now try to raise your arms. Put your arms down. Now sit up (or stand if you were standing before) nice and tall and try to do the same thing. Did I just blow your mind??? Here we see the important role thoracic spine extension plays in shoulder mobility and function. More to come on this in future posts.

                            Upper Crossed Syndrome

                            Upper Crossed Syndrome

At the neck, this typical desk jockey forward head posture comes at the expense of the upper cervical spine, where we see excessive extension, and the lower cervical spine where we see excessive flexion. When we slouch forward and round our backs, our neck, left to its own device, would also flex, causing our head and eyes to be pointing down towards the ground. Because our brain always wants to keep our eyes level with the horizon, it tells our neck to extend, or lift up, our head so that we can look straight ahead. In order to accomplish this, we poke our heads forward and excessively extend our upper cervical spine while the bottom of our cervical spine, most closely related to the thoracic spine, stays in flexion. In doing so, we introduce a tremendous amount of shearing at the vertebra of the cervical spine and cause significant muscle imbalances at the neck. More specifically, at the front of the neck, we see the deep flexors of the neck which are responsible for stabilization being put on stretch and becoming very weak. The posterior (back/rear) neck musculature, responsible for holding your head up all day, is placed in a shortened position, becoming tight and restricted. Tension in this area leads to headaches and altered jaw mechanics, most commonly referred to as TMJ dysfunction. Collectively, these thoracic and cervical impairments are referred to as an upper crossed syndrome. 

                                    The Wall Test

                                    The Wall Test

Check yo’self: Proper posture is not achieved by simply squeezing your shoulder blades together and retracting your chin like you’ve smelled something bad. Instead, I want you to think about making subtle changes to help bring the entire spine into better alignment. The goal of this segment is to get your ears to line up directly above your shoulders. Last week I introduced the Wall Test to you, and we’re going to revisit that concept again this week. I want you to stand with your heels, glutes, and upper back against a wall. Remember, you should have only about a hands-worth of space between the wall and your lower back. From here, gently, emphasis on GENTLY, draw your shoulders back and down to ensure that they are touching the wall. *PT Disclaimer: the cue of shoulders down and back is not necessarily universally applicable, nor is it the most functional position for overhead motions, however, the majority of people with FHP and an increased thoracic kyphosis can benefit from this cue as a starting point.* Your rib cage should not pop up when you do this. Next, retract (tuck in) your chin using the muscles in the front of your neck to get the back of your head to touch the wall. At this point, your ears should be in line with your shoulders. This right here is the ideal alignment for your head and neck.

For many of you, entering into and maintaining this position is going to be extremely difficult. While I’d love to tell you to just suck it up, in reality, your years of being married to that desk will likely cause you to forego a lifetime romance with a sweet little thing called good posture for a one-night stand with Captain Shoulder Pinch. To that end, here's a video from the great Kelly Starrett over at Mobility WOD demonstrating some mobility drills you can do to help get yourself more comfortable in that new posture. Watch the video, work on that new posture, and try to get up from your desk at least every 20 minutes. Your body will thank you.

The Selfie That Broke the Camel's Back

The Selfie That Broke the Camel's Back

Image courtesy of thedailydot.com

Image courtesy of thedailydot.com

Despite what Instagram would have you believe, arching your back and sticking your rear end out is NOT an ideal posture. A pose that seems to generate tons of ‘likes’ is what we in the biz refer to as “an anterior pelvic tilt with excessive lumbar lordosis.” While it may be tempting to place the desire to be a social media phenom over back health, I’m here to provide you with a few words from atop my soapbox as to why this may not be the best idea.

Anterior pelvic tilt, APT for short, refers to a pelvic alignment in which the front (anterior) portion of the pelvis is lower than the back (posterior) portion of the pelvis. While this is generally a position we passively adopt secondary to muscle imbalances, one can actively achieve this position by relaxing their abs, arching their back, and smiling for the camera. It should be noted that the ability to perform an anterior pelvic tilt is not in and of itself a bad thing. Additionally, the mild curvature of the low back, referred to as a lumbar lordosis, is normal and important for spinal health and proper acceptance of weight. It is when we adopt this anteriorly tilted pelvic positioning with excessively arched lumbar spine as our resting posture that we get into trouble.

Image of the psoas and iliacus muscles, collectively referred to as the iliopsoas. 

Image of the psoas and iliacus muscles, collectively referred to as the iliopsoas. 

Most people aren’t born with an APT, but rather, develop one over time from muscle imbalances caused by certain activities or lack thereof. Here’s a quick biomechanics/anatomy lesson for ya; for our purposes we’re going to use the right hip. Think of the pelvis, when viewed from side, as a dial that can be rotated either clockwise or counterclockwise. This dial has at its center, the head of the femur. What maintains this dial in a neutral position is a balancing act of muscle strength and appropriate muscle tension. Muscle tightness at the hip flexors (iliopsoas/psoas and rectus femoris) and the back extensors (erector spinae) cause the dial to rotate to the right, creating an APT. The muscles that prevent or reverse an APT via include the abdominals (rectus abdominis primarily) along with the glutes and hamstrings.

Anterior Pelvic Tilt.  Image courtesy of Mosby

Anterior Pelvic Tilt. 

Image courtesy of Mosby

Posterior Pelvic Tilt.  Image courtesy of Mosby

Posterior Pelvic Tilt. 

Image courtesy of Mosby

Aside from selfie nation, the main culprit in the development of an APT is usually prolonged sitting, aka our generation’s version of smoking when it comes to developing chronic illness. The psoas muscle is the primary hip flexor, originating at the lumbar vertebra and inserting on the femur. When we sit, our hip flexors are placed in a shortened position, which over time causes them to get tight. Additionally, if we’re always sitting, we’re likely not exercising all that much, which means weaker glutes and abs.

When we do manage to finally get out of that chair and stand up, our tight hip flexors pull on the front of our lumbar spine, and our weak glutes and abdominal musculature are unable to counter this force. This causes our back to arch and our pelvis to tilt forward. As the pelvis tilts forward, the back extensor muscles are also placed in a shorted position, causing them to tighten and maintain this APT. In this arched low-back position, the distance between the ribs and the front of the pelvis is increased. This is also the area spanned by our rectus abdominis, or 6-pack. When stretched out because of an APT, your 6-pack is unable to contract optimally, contributing to weakness, and perpetuation of the APT. What we see here are examples of the cyclical nature of causation and contribution to the APT.

Image courtesy of somastruct.com

Image courtesy of somastruct.com

The effects of this APT extend both up and down the human body. The spine arches, causing compression and pain at the low back. Further up the chain we see the altered spinal positioning creating a forward head posture with excessive strain on the neck. The hips, due to their relationship with the pelvis, rotate out of neutral alignment, with effects being felt at the knee and foot. Conversely, poor alignment at the foot, knee, or hip will have an impact on pelvic alignment and can cause an APT. In two previous articles I wrote, I discussed the implications of the Elvis knee and the arch collapse, so I won’t bore you again. But if you have forgotten, or dare I even say, didn’t read the other articles, check them out here. Lastly, this APT prevents us from achieving neutral spinal alignment, which is required for proper recruitment of the core muscles, for proper breathing patterns, and for proper movement patterns in general.

Check yo’self: Get off of the sofa or up from that chair that you’re currently sitting on to read this. Take a deep breath in and out and relax into your most comfortable and natural resting position. This next part may be easier to do in front of a long mirror. Turn sideways, and while still in this relaxed position, look at your posture. You should NOT look like you’re at the club about to have a dance-off with Miley Cyrus. Now look at the waistband of your pants and the arch of your back (now would be a good time to put pants on if you were enjoying living alone). In a neutral position, your waistband should be nearly parallel with the floor, though a mild (as in a FEW degrees) forward angulation is ok. In this position you should have a slight curvature of the low back.

photo 1.JPG

To assess the curvature of your lower back, stand against a wall with your arms down at your sides and your heels, buttocks, shoulders, and the back of your head touching the wall. Assume that same relaxed position you were in before. From here, attempt to slide your hand into the space between your back and the wall. If you can fit more than your hand in this space, you’ve likely got an APT with excessive lumbar lordosis. For those of you blessed with a little more booty, the space between your back the wall may be slightly increased. If you’re unsure if it’s excessive, find a PT and get it checked out.

Correct yo’self: If you flunked the wall test it’s time to get on the floor and get to work. While on the floor, lay on your back and bend your knees so that your feet are flat on the ground. From here, rock your pelvis forward and backwards, exaggerating that lumbar curve then reversing it and pressing your low back into the floor (as if trying to tuck your tail between your legs). Try to minimize the role that your glutes play in performing these motions, and achieve these positions by gentle abdominal contractions.

Anterior rotation (pelvic tilt) with increased lumbar lordosis

Anterior rotation (pelvic tilt) with increased lumbar lordosis

Posterior rotation (pelvic tilt) with reversal of lumbar lordosis

Posterior rotation (pelvic tilt) with reversal of lumbar lordosis

Once you’ve mastered this, stand up with your back against the wall and perform this same pelvic rocking. If this is too difficult then walk your feet away from the wall and try again. The ultimate goal of the corrective exercise is to be able to perform this pelvic rocking while standing without a wall behind you for cueing. Remember, we’re going for the Goldilocks of spinal alignment, not overly arched nor overly flat, but NEUTRAL, and just right. If you feel like you need some hip flexor stretching to help you achieve this position, try this stretch. 

For the next week, I challenge you to adopt this neutral pelvic and spinal alignment each time you’re standing. Gently contract the abs and glutes to get that pelvis to rotate slightly backwards so that your waistband is (roughly) parallel with the ground. It’s going to feel weird, but embrace it. Oh and while you’re at it, lay off the selfies. Your body will thank you. 

Elvis Has Left the Building

Elvis Has Left the Building

For the past two weeks I’ve focused on forward alignment of the feet for standing and walking. Today I want to move a little farther up the leg and discuss those glass knees of yours, you know, the ones that creak and ache every time you even think about bending them. This piece isn’t going to tell you how to reverse arthritis or get rid of that disgusting crunching you get each time you attempt to pick up your socks from the floor. Rather, I want to discuss how to optimize your knee movement to prevent things from getting any worse.

For the majority of us, standing in place and not moving a muscle doesn’t tax our knees all that much. It’s when we go to get out of our favorite chair or climb the never-ending stairs to transfer at virtually any NYC subway station that those knees begin to show their age. So what can we do to help ourselves out on a daily basis?

Image courtesy of wiscboneandjoint.com

Image courtesy of wiscboneandjoint.com

Let’s start off with a very basic anatomy lesson. The knee joint can actually be divided into two joints: the patellofemoral joint and the tibiofemoral joint, named for the bones that make up each of these joints. The patellofemoral joint is made up of the patella (knee cap) and the femur (thigh bone). This joint creates mechanical advantage for the quadriceps muscle, helping it extend (straighten) the knee. The presence of the patella increases the angle at which the quad and patella tendons insert, thus increasing leverage. Injuries at this joint are termed runner’s knee/chondromalacia patella/patellofemoral syndrome.

The tibiofemoral joint is made up of the tibia (shin bone) and the femur. It is the primary weight-bearing joint of the knee and allows for flexion and extension, along with a little bit of rotation. Additionally, the presence of two menisci add cushion and increase joint congruency. Common injuries here are ACL,PCL, and meniscal tears, along with the dreaded osteoarthritis. 

There are two different types of cartilage in the knee: fibrocartilage, which is what the two menisci are made of, and hyaline, or articular cartilage, which lines the ends of the tibia, femur, and back side of the patella. This cartilage, though far from unbreakable, is designed to withstand quite a bit of wear and tear…provided we’re moving in the correct (and by that I mean biomechanically sound with the joint surfaces loaded appropriately) way and not just twist-and-shouting our way to a knee replacement.

Image courtesy of Healthwise, Inc

Image courtesy of Healthwise, Inc

When our feet are in contact with the ground our knees absorb a large majority of the force that is generated with each step. The architecture of the knee is such that we can handle heavy loads, provided our alignment is correct. At the patellofemoral joint, the patella sits in a groove within the femur, akin to a train on a train track. Squatting, landing, or going up and down the stairs with those knees collapsing inward causes that patella-train to ride in the incorrect portion of the femur-track, creating rubbing and eventually breakdown. 

Similarly, at the tibiofemoral joint, improper mechanics - aka Elvis knees - while performing those previously mentioned motions causes stress, strain, and uneven loading at tissues not designed to handle such activity; arthritis, meniscal tears, MCL sprains, need I go on?

Check yo’self: Here’s where those stairs and that La-Z-Boy (yes, that is how it is spelled) come into play. For the next week I challenge you to observe and adjust your knee alignment each and every time you sit or stand from a supporting surface (toilets included!) and when you go up and down the stairs. Keep your knees aligned with your feet (which should be facing forward per our last two discussions) and don’t allow them to collapse inward. Contracting your glutes will help with this. I know, I know, who has time to be checking out their knees during the frantic rush-hour or in the two minutes they have for a bathroom break between clients? People who don’t want knee replacements, that’s who. Do it. Your body will thank you.

Part II: Hips Don't Lie

Part II: Hips Don’t Lie

Last week I shared with you this piece highlighting the benefits of standing with your feet pointed straight ahead. This week we bring movement into the equation and discuss the merits of moving with those feet pointed straight ahead.

Image courtesy of RunnersWorld.com

Image courtesy of RunnersWorld.com

Let’s start at the ground and work our way up. When we walk, the foot has a characteristic pattern in which it’s supposed to contact the ground. If you look at the bottom of someone’s shoe who has an ‘ideal’ stride, you’ll notice a wear pattern that goes from the outside (lateral) portion of the heel area, travels forward, then appears under the 1st and 2nd toe. This wear pattern indicates an “ideal’ interaction of the foot with the ground, which allows the foot to perform its duties of shock absorption and propulsion. When this foot positioning gets altered by turning the foot out, the muscles, bones, and ligaments of the foot are put into positions that decrease the functionality of the foot.

The foot is one of my favorite body parts because of its incredible architecture that allows for both stability and shock absorption. Without getting too technical, the foot has an intricate arch system that is supported not only by muscles and ligaments, but also by the alignment of the bones of the foot. Turning the foot outward causes this alignment to change, decreasing the boney support and thereby placing excessive stress on the ligaments and muscles that act as slings to support the arch of the foot. When we walk with our feet pointed outwards, we take a structure that is supposed to be rigidly supported by the strength of our foot bones and turn it into something that would make the Viagra reps drool. The layman calls this being flat-footed, the runner knows this as over-pronation, and the podiatrist associates this with the sweet sound of a credit card being swiped to pay for yet another pair of custom orthotics.

Walking with our feet turned out forces our bodies to compensate to get the job of forward movement done. We begin pushing off through the side of our big toe, instead of the bottom, creating a bunion. We attempt to use only our tendons to support our arch and develop posterior tibialis tendonitis and shin splints. The collapsed arch places an uneven load at the achilles and we see achilles tendonitis. Running and jumping serves to expedite the appearance of these injuries as more force is transmitted through these structures and our bodies are required to figure out a way deal with it.

Proper hip-knee-foot alignment on the Left vs improper alignment with the foot turned out and subsequent collapse of the arch and knee on the Right

Proper hip-knee-foot alignment on the Left vs improper alignment with the foot turned out and subsequent collapse of the arch and knee on the Right

If one was to attempt more functional activities such as going up and down the stairs or squatting with the feet in this outwardly rotated position, the result would be a collapse of that arch, followed by a buckling inward of the knees, with excessive stress being placed at the inside (medial) aspect of the knee. Cue MCL sprains, meniscus tears, and runner’s knee”, aka patellofemoral syndrome or chondromalacia patella (big words that basically mean your knee hurts). One notable exception to the rule is that squatting with the feet slightly turned out is permissible at times, depending on the experience of the lifter and the anatomical variations present at the hip and lower extremity; but that’s a topic for another time.

At this point you may be thinking, ‘where do Shakira and her ‘hips don’t lie’ mantra play into all of this?’ Well, in reality perhaps I should have referenced Beyoncé and those glutes, but that “hips” song is just so darn catchy. As I discussed in part one of this article, the glutes stabilize the pelvis and femur (thigh bone) and promote proper alignment at the knee, lower leg, and foot. When we point our feet straight ahead, we are able to generate more tension through the glutes, and subsequently greater stability and power at legs and pelvis. This allows for improved performance in all functional activities, from walking to power lifting, and decreased rates of injury.

Check yo’self: For the next week I challenge you to walk, go up and down the stairs, and stand up from/sit down in your chair with your feet pointed straight ahead. Bonus points if you’re able to incorporate this challenge into your exercise routine and higher-level activities during the week. Be sure to keep your knees tracking in line with your feet, preferably in-line with your 2nd and 3rd toe. By pointing your feet straight ahead and gently contracting your glutes you should notice your arches slightly elevating, while your toes and heels remain in contact with the ground. Be sure to avoid over-squeezing your glutes and walking around looking like you’ve got a stick up your derrière. Just like standing with your feet pointed straight ahead, this is going to feel strange, and new, and weird. Suck it up. Your body will thank you.

Part I: Putting Your Best Foot Forward

Part I: Putting Your Best Foot Forward 

One of the easiest postural corrections I think we as humans can make is standing with our feet pointed straight ahead. Living in NYC I am privy to a seemingly endless number of opportunities to watch people walk and stand. Let me tell you folks, we have an epidemic on our hands. The dreaded turned-out foot has become adopted by so many people it's no wonder Dr. Scholl's and Icy Hot patches have their own sections in the drug store. 

                               Muscles of the hip

                               Muscles of the hip

When we stand with our feet turned out, the hips follow, in a movement known as external rotation. In this position, the hip muscles are shortened and become tight, which leads to decreased hip strength and range of motion.

A muscle can only contract optimally if it can fully relax. Tight muscles are weak muscles, in that they are unable to fully lengthen and shorten as is required for generating maximum tension and strength. The role of the hip muscles, in addition to moving and stabilizing the femur (leg), is to stabilize the pelvis. As demonstrated in the picture below, the pelvis acts as a base upon which the spine rests. When the glutes are tight and weak, they can no longer do their job of stabilizing the pelvis. If you've ever played Jenga, you understand the importance of having a sturdy base. When the glutes don’t stabilize the pelvis, it’s like playing Jenga in an earthquake. The pelvic instability caused by hip weakness creates excessive motion at the low back, which leads to, you guessed it, back pain.

From a movement perspective, the low back and hip are best friends with complementary roles. The hips, with their ball-and-socket design, allow for multidirectional movement (just ask Shakira), while the facet joints of the lumbar spine are designed for flexion and extension (forward and backward bending).

   The ball-and-socket configuration of the hip joint

   The ball-and-socket configuration of the hip joint

           The lumbar spine as viewed from the Right

           The lumbar spine as viewed from the Right

When those hips get tight and lose motion, they also lose their function, and suddenly the low back is left to pick up the slack. The low back, structurally suited for flexion-extension movement now has a job for which it is neither designed nor prepared. Enter again: low back pain! 

Check yo'self: Let your hips and back do what they were designed to do. Stand with your toes pointed forward, weight distributed equally between both feet, not leaning too far forward or backward. For those of you with a tendency to turn your feet outwards, standing with your feet pointing straight ahead will feel strange, and you may even feel like you’re pigeon-toed (toes pointed in). Suck it up. Look down and make sure that your knees are in line with your toes, and both are pointing straight ahead. If your knees are pointing inwards, gently contract your glutes (squeeze your butt) and notice how this causes your knees to rotate slightly outward and into a neutral position. This is proper standing position (from the hips down, anyway), and this is what I want you to focus on for the next week. Whenever you find yourself standing and waiting for the train or in line at Duane Reade waiting to buy your third pack of Icy Hot patches, make sure those feet are pointed straight ahead. Your body will thank you. 

 

Tune in next week for Part II: Hips Don't Lie