Many people experience popping in their hips. Most patients come to the clinic complaining of back or knee pain, and a popping hip may be a secondary complaint. Although typically not a significant pain generator, popping in the hip is a sign of an underlying dysfunction in the hip needing to be addressed. If the popping in the hip is not attended to, more serious orthopedic issues may arise down the road.  

Causes

There are three main causes of a popping hip – external, internal, and intra-articular. External is most frequent and refers to the iliotibial (IT) band snapping over the greater trochanter of the femur. Internal is also common and refers to the iliopsoas (hip flexor) tendon snapping over a bony prominence on the pelvis or at the lesser trochanter of the femur. Intra-articular is least common and refers to a floating loose body within the joint such as a torn labrum. External and internal variations are often due to gradual onset, whereas an intra-articular loose body is often due to trauma. There is a higher incidence of hip popping in females, especially those who perform sports requiring repetitive flexion and extension of the hip such as gymnastics, dance, soccer, and running.  

How to fix it 

Popping in the hip is often related to a stability issue in the hip or the core. To address this, work to improve your hip stability in all three planes of motion. Train slowly, controlling the motion to avoid the pop. Train only through ranges of motion where you can avoid the pop, and gradually increase the range of motion as your stability improves. The external hip pop (ITB over greater trochanter) is often related to poor hip stability in the frontal plane (abduction/adduction), and increasing strength of muscles such as the gluteus medius will be helpful in decreasing the external hip pop. The internal hip pop relates to the iliopsoas muscle. The iliopsoas muscle has shared attachments with the diaphragm. If the diaphragm is not providing a solid anchor point for the iliopsoas muscle, function of the hip flexor will be impaired increasing the likelihood of an internal hip pop. For this, focus working on diaphragmatic breathing to create better stability patterns in your core. Intra-articular hip popping requires an in-depth examination to determine which structures may be injured and to determine the best course of care.

To know exactly which exercises and treatments are best for you, it is important to seek out a therapist who understands hip biomechanics and can help you address the specific stability limitations causing the pop. Whatever the cause, popping in the hip should not be ignored. Even if caused by mild muscle imbalance, a popping hip can worsen over time if not addressed early.  

Post written by Dr. Riley Kulm.  Check out his bio here.

My Least Favorite Exercise Part 2 – The Quadricep Knee Extension

Continuing with the theme of our last blog post My Least Favorite Exercise – The Clamshell, I’d like to highlight another popular exercise that should be avoided at all costs.  This week, my least favorite exercise is the quadricep knee extension exercise.  I regularly see people at the gym using the quadricep knee extension machine, and I truly worry about their orthopedic health when I’m watching them.  To perform the machine based knee extension exercise, people sit in a chair with a pad on their shins.  Next, they kick their legs straight against the resistance of the machine, contracting the quadriceps muscle.  People perform this exercise because they want to improve the strength and size of their quadriceps muscle – some may even think it’s healthy for their knees; however, the biomechanical consequences of this exercise can be highly detrimental to the health of your knees.  

Open vs. closed chain exercises

The machine based knee extension is a single joint, open chain exercise.  Open chain exercises refer to movements where the distal extremity (hand or foot) is not fixed and is freely moving in space with or without external resistance.  Examples of open chain exercises include a bicep curl, hamstring leg curl, and shoulder fly.  Open chain exercises cause an isolated muscle contraction over a single joint of movement, which some believe to be beneficial in the early stages of an injury rehabilitation program.  Open chain exercises are in contrast to ‘closed chain exercises’ where the hand or foot is fixed to the floor.  Examples of closed chain exercises include the squat, deadlift, or push up.  Closed chain exercises involve multiple muscle groups and require coordinated muscle contractions to complete the compound (multi-joint) movement.  

The forces imparted on the joints differ between open and closed chain exercises.  For open chain exercises (quadricep knee extension) the force imparted by the weighted resistance is transmitted back up the leg and into the knee joint.  This force can cause compression in the knee joint, putting increased pressure on the meniscus, ACL, PCL, and patella-femoral joint.  In contrast, with closed chain exercises (deadlift) the force imparted by the external resistance is transmitted into the ground.  For instance, in a deadlift, the force from the load is pressed through the feet into the ground rather than up the body into the knees and hips.  

The second problem with the exercise is that it is a repetitive concentric exercise.  Remember from my last post, concentric muscle contractions occur when the muscle is shortening and repetitive contractions over time can cause a shortening and tightening of the muscle fibers even while at rest.  Ignoring the eccentric (muscle lengthening) component of a muscle’s function can be detrimental to movement patterns and ultimately put you at an increased risk of injury.  Additionally, a short and tight quadriceps muscle can pull upwards on the patella, altering the mechanics of the patella-femoral joint and cause conditions such as patellar tendinitis which is also known as Jumper’s knee.  

What to do instead – deadlifts, squats, single leg squats, reverse lunges

If you want to strengthen your quads and the rest of the muscles in your leg, the best exercises are closed chain, compound movements that integrate the feet, hips, and core to create a functional and stable lower body.  My favorites are deadlifts and lunges because you can add a lot of weight without placing much force on the knee joint (when performed properly). 

As I said previously, closed chain exercises like the squat and lunge transmit force down into the ground, which is why they are popular for building speed and explosiveness in strength and conditioning programs. 

Post written by Dr. Riley Kulm, DC.  

Check out his bio here.

The most common hip exercise I see prescribed to patients for hip pain is the ‘clamshell’.  The clamshell exercise, shown in the picture below, is commonly used to increase the strength of the gluteus medius muscle with the goal of improving hip stability. The clamshell is prescribed for conditions such as hip impingement, low back pain, or knee pain, and is commonly used to strengthen the glutes during post surgical knee rehabilitation programs. While the clamshell targets the gluteus medius muscle, one of our main stabilizers of the hip, there are functional limitations to the exercise which can cause adverse effects on a patient’s movement patterns and overall function of the lower extremity. 

The issue with the clamshell exercise is it is a repetitive concentric exercise. A band is used around the knees to create resistance of the top leg moving into abduction (leg moves away from body). The gluteus medius is a primary hip abductor, and is thus contracted when the patient separates the top knee away from the bottom against the band’s resistance.  A ‘concentric’ muscle contraction refers to a contraction where the muscle shortens as it contracts. This is in contrast to an ‘isometric’ contraction where muscle length does not change during contraction, and also an ‘eccentric’ contraction where the muscle contracts while lengthening. The problem with only training the concentric phase of muscle contraction is over time the muscle fibers will become short and tight. Remember, muscle fibers are shortening during a concentric contraction, and doing so repeatedly will cause a gradual tightening of the muscle.  A short and tight muscle often equals a weak muscle and weakness in the gluteus medius muscle puts your low back, hips, and knees at risk for injury.  Muscle function should be a coordinated blend of isometric, concentric, and eccentric contraction to maintain proper muscle function and physiology.  

To determine if you have a short and tight gluteus medius not functioning properly, look for a ‘gluteal hollow’ – a concavity easily visualized on the outside portion of the glute complex.  While some believe hollow hips to be aesthetic, they indicate poor function and stability of the hip. Ideally, the glute complex should be full and round with no hollowing.  Notice the hollowing in the hips of the bodybuilder below.  The athlete is overdeveloped in the gluteus maximus muscle and underdeveloped in the gluteus medius and gluteus minimus muscle.  Despite having an impressive muscular build, the function and stability of this athlete’s hips are suspect.  Contrast the bodybuilder’s hips with the athlete on the right.  The football player on the right has a round and full shape throughout the entirety of the glute with little to no hollowing in the outer aspect of the hip.  The football player has strong and stable hips in all planes of motion allowing him to jump, change direction, and accelerate effectively.  

What to do instead –  the DNS 7 month hip lift exercise

If your goal is to strengthen the gluteus medius muscle and improve hip stability in all planes of motion, the Dynamic Neuromuscular Stabilization (DNS) 7 month hip exercise is your go to movement.  The DNS 7 month hip exercise linked here, is a movement pattern based on the 7 month developmental pattern as outlined by the Prague School of Rehabilitation. The 7 month hip lift is a transitional movement from a side sitting position into a quadruped position, and it incorporates all 3 phases of muscle contraction for the gluteus medius muscle.  

To perform, lay on one side with your hip flexed to just below 90 degrees. Initiate the movement by rotating your pelvis forward on top of the bottom leg. Doing so will lengthen the gluteus medius on the bottom side and you may even feel a stretch in the hip. Once the pelvis is fully closed down on top of the bottom leg, load weight into the bottom knee and use your strength to lift your hip off of the ground. You should feel the muscle contract on the outer portion of the bottom hip (gluteus medius).  Hold at the top for 2-3 seconds and then slowly lower down to the ground. Focus on slow and controlled raising and lowering of the hip, which forces your body to coordinate isometric, concentric and eccentric contractions – closely replicating the demands placed on the gluteus medius muscle during sport and everyday life. Start with 3 sets of 6 reps for this exercise. Expect to be sore in the outer hip as this exercise is challenging and forces the gluteus medius to function in ways it may not have for a while.  

Post written by Dr. Riley Kulm, DC.  

Check out his bio here.

 

 

Core Exercises – Do’s and Don’ts 

Many patients understand they need to strengthen their core in order to live functional and pain free lives. However, most do not know where to start. The popular opinion is exercises such as sit-ups, crunches, bicycle crunches, and Russian twists are the primary exercises to improve core strength. Unfortunately, these commonly performed exercises are not the best choice when looking to add strength and functionality to your core. 

The Problem with Sit-ups and Crunches

Sit-ups and crunches are perhaps the most regularly performed core exercises. These exercises are effective at increasing the tone of the six-pack or rectus abdominis muscle group.  While great for aesthetics, a tight and toned six-pack is not essential for a functional core and may even be detrimental. The issue with sit-ups and crunches are the forces placed on the spine during these exercises. Both involve repetitive flexion of the lumbar spine and most of modern society already gets too much ‘lumbar flexion.’  Lumbar flexion means rounding forward of the low back. The low back is in flexion when we are sitting in our car, at work, or on the toilet. The low back is flexed when we pick items up from the floor with improper form. The net result of so much lumbar flexion is placing undue stress on the discs, muscles, ligaments, and nerves of the low back. Sit-ups and crunches involve repetitive flexion of the low back and thus add fuel to the ‘flexion fire’ we get all throughout the day. 

The Problem with Rotational Core Exercises and Stretching 

The Russian twist and bicycle crunches are other commonly performed core exercises that are not ideal for the function of the core or spine. The Russian twist is performed by balancing on your pelvis with legs suspended in the air and knees bent while the upper body is held at roughly a 45 degree angle. Next, the athlete uses their hands or a medicine ball to twist back and forth in an attempt to work the abdominal obliques. Bicycle crunches are similar except the individual is on their back and the rotational crunch is combined with a straightening of the opposite leg and hip. The first problem with the Russian twist is it is extremely difficult to keep the spine in a neutral position and many individuals round their backs due to a lack of core strength and balance. Once again, many people are developing a detrimental position of lumbar flexion during this exercise.  

Another issue with the Russian twist and bicycle crunch is the forced rotational load it places on the spine. Functional movement specialists now agree the main purpose of the core is to resist forces placed against the spine rather than actually creating movement.  The lumbar spine only rotates 2-3 degrees per segment and thus requires more stability in the rotational (transverse) plane compared to mobility. I’ll explain exercises such as the Pallof Press and Cross Press in a future blog post, as both are excellent exercises for improving core stability in the rotational plane.

Basics of Effectively Performing a Core Exercise

Before we get into the specific exercises I teach my patients, I’ll explain why form is important for any core exercise you perform. First, the spine needs to be in a neutral position. A neutral spine may look different for each person, but the spine should be straight and may have a slight extension curvature. Extension is the opposite of a flexed and rounded position of the spine. The two variables that affect proper neutral spine positioning are your rib positioning and your pelvic posture. Many patients have what is called ‘flared ribs’. This means your ribs are protruding upwards and forwards and may even be visible. When the ribs are in this position the diaphragm muscle cannot function properly and core strength will suffer. Use an exhale breath to push your ribs downwards towards the floor to place them in a more ideal position. 

Secondly, you need to be aware of the position of your pelvis. Think about your pelvis as a fish bowl filled with water. If you have what we call an ‘anterior pelvic tilt’ your pelvis is dumped forward and water will be spilling out of the metaphorical fish bowl. Less commonly, patients may adopt a ‘posterior pelvic tilt’ where the water will be spilling backwards.  Both of these pelvic postures are detrimental to neutral spine positioning, as well as core strength. Always think about keeping your pelvis tucked under you so water cannot spill out of the fish bowl. By making sure your ribs and pelvis work together to maintain a neutral spine, you will safely perform core exercises.

Practice these Core Exercises:

3 Position Plank

The 3 position plank is a sequential exercise involving a front plank, right side plank, and left side plank. Each position is held for 10 seconds before switching positions.  Do your best to avoid dropping to the ground when switching positions. Switching positions every 10 seconds forces the brain and nervous system to react to a new stability pattern frequently and is thus more typical of how we move in life and sports. Additionally, by switching positions every 10 seconds we better guarantee perfectly executed reps. 

Dead Bug

The dead bug is another excellent option for building your core strength. Lay on your back with your hips, legs, and arms raised.  Simply holding this position is a difficult exercise in itself and is an effective way to exercise your core. Make the movement more dynamic by reaching one arm over your head and slowly lowering the opposite heel towards the ground.  Alternate sides, and perform in succession while making sure to keep your ribs down, low back glued to the ground, and head supported and slightly elevated to protect your neck. 

Bird Dog

The bird dog exercise teaches you to move your extremities while maintaining a neutral spine. The exercise does an excellent job of mimicking real athletic activities you will face in daily life. Get in a tabletop position with your hands stacked under your shoulders and your knees stacked under your hips. Your chin should be tucked and the back of your neck long with no creasing of the skin. Slowly move one of your arms forward while simultaneously extending the opposite leg backwards. The back leg only needs to be about 2 inches off of the ground to avoid hyper-extending your low back. Hold the completely extended position for a count of 2 and then return to neutral. Alternate sides while keeping a neutral spine and make sure to not let your pelvis rotate and shift excessively. Imagine there is a glass of water resting on the base of your low back and you do not want to let it spill! 

My goal with this blog post is to provide you with safe and effective exercises for improving the strength and function of your core. Enjoy!  

Post written by Dr. Riley Kulm, DC.  Check out his bio here.

Brief History of Yoga

Yoga originated in ancient India circa 3,000 BC and offers an excellent blend of meditation, respiratory training, and movement. Practitioners of yoga enjoy the relaxing benefits of a class, most commonly performed in a heated room. Anyone who has taken a yoga class understands the mental focus and physical resiliency required to successfully complete a practice. In fact, the breathing practice utilized in yoga called ‘pranayama’ is very similar to the diaphragmatic breathing exercises we teach our patients in the clinic.

Should I be doing yoga?

Yoga has gained immense popularity in this country over the last decade. As a result, many patients ask for advice on whether or not they should be practicing yoga. My overwhelming answer is yes! Any physical practice that promotes movement, whether it is yoga, pilates, weightlifting, or running – is beneficial to the human body and should always be encouraged.  However, the main caveat I give my patients when it comes to yoga is they need to understand which movements are healthy for their body’s and which movements are potentially damaging. Certain injuries or movement deficiencies can put the body at risk if you don’t know when to modify the yoga pose or to avoid it all together.

Low back pain and yoga

Let’s look at some examples.  Chiropractors treat many patients with low back pain.  Many patients experience increased back pain with sitting, picking items up off the floor, and bending forward to tie their shoes.  The common theme is rounding postures of the low back, termed ‘flexion’ is provocative for these patient’s low backs. We term this type of back pain ‘flexion intolerant low back pain’. A patient with flexion intolerant low back pain should avoid flexion based activities while their low back is in the healing stages. Very often, these patients respond well to exercises or static positions that place the low back in extension – adhering to the natural lordotic curve of the lumbar spine.

If after assessment in the clinic the Chiropractor decides the patient will benefit from extension based exercises or static positions,  the patient will be counseled to avoid all flexion based activities or postures for the low back (bending forward, prolonged sitting, etc.) during the initial stages of rehabilitation.  If you have taken a yoga class, you are familiar with the numerous forward folds and sustained toe touches that are done during the class to stretch out the calves and hamstrings. If a patient is experiencing flexion intolerant low back pain, performing 20-30 forward folds in an hour practice is harmful to the body.  In a patient prone to back pain, persistent forward bending places stress on the discs, nerves, ligaments, and muscles of the low back. Even Child’s pose position places the low back in end ranges of flexion and should be avoided for most acute back pain patients. Instead of forward folding, perform the downward dog position which will give similar benefits of stretching the calves and hamstrings while keeping a neutral spine.

Shoulder/ neck pain and yoga

Inversion pose requiring extreme amounts of neck, shoulder, and scapular stability.

Another example is a patient with shoulder and/or neck pain.  Handstands, headstands, and other inversion based poses are very popular in yoga. Teachers cite the benefit of reversing the gravitational flow of blood in the body for improvements in circulation.  While I agree with this notion, patients with shoulder and neck pain should not be putting this amount of stress on their muscles and joints. Performing a proper head or hand stand requires extreme levels of shoulder and scapular stability – something many beginning yogis do not possess.  If you have shoulder or neck pain and are new to yoga, do not try and impress the rest of the class by forcing yourself into an inversion pose. Instead, ask your teacher to show you a regressed version that does not place as much stress on your neck and shoulders.

Knee pain and yoga

Standing tree pose. Notice how the knee is in end ranges of flexion and is also placed under rotational stress.

Last, the athlete with knee pain needs to be careful with certain yoga postures. Patient’s with current knee pain or a history of knee pain and surgery need to be cautious with certain yoga poses.  Popular poses that impose large amounts of stress on the knee joint include the full squat (frog pose), hero pose (sitting on heels and laying backwards), pigeon pose (lying body weight on top of figure 4 pose), and standing tree pose.  The common theme with these positions is they add load to the knee joint in extreme ranges of flexion and rotation. When the knee is forced into end ranges of flexion and rotation, the muscles and ligaments of the knee are placed under stress, which is amplified if previous or current injury exists. Instead of fighting through the pain to complete the class, work on poses like the lunge, warrior 1 and 2, bridge pose, and chair pose.  These poses will strengthen the muscles and ligaments of the knee in less extreme ranges of motion.

Pigeon pose places high amounts of rotational stress on the knee.
Warrior 2 pose. Notice how the knee is not in extreme end ranges of motion. This position builds strength and stability in the front knee.

Your Yoga Practice

Practicing yoga should be challenging but pain free and relaxing at the same time.  If you are constantly fighting through pain in yoga, you are missing out on the many benefits of a successful practice. Do not feel bad about modifying your practice to work around injuries.  Always remember it is YOUR practice, and not everyone else in the room. Make sure to communicate all injuries to teachers before the class starts so they can help you with modifications to make sure you get the same benefits as everyone else.  As always, if you have a lingering injury that does not seem to be getting better, make sure to consult a health care professional who can diagnose and correct your specific issue.

Post written by Dr. Riley Kulm, DC.  Check out his bio here.

Train like a pro

Elite athletes understand they need to build durable and resilient muscles, joints, ligaments, and tendons. The best way to do this, aside from a healthy diet (nutrition blog post) and adequate recovery practices (sleep blog post), is resistance weight training.  When we lift weights, we place an external load on the body, mimicking the forces encountered in sports. Forces placed against the body are present in both contact and non-contact sports.  When participating in non-contact sports such as running, throwing, and golf, forces are still exerted from contact with the ground or from internal forces the body places on itself during movement. This week we will dive into the key principles of strength and conditioning that will help you train like a pro.

Keep it simple

Most people would be surprised by the simplistic workouts of the world’s top athletes. There is a misconception professional athletes are using state of the art equipment unavailable to the average person. While elite athletes do have access to incredible facilities and equipment, most pros are still using simple squat racks, barbells, dumbbells, pull-up bars, and kettlebells – equipment we almost all have access to.

Traditional bodybuilding training focuses on single joint, single muscle group exercises. While effective for improving aesthetics, these movements do not increase functionality in the athlete or mimic the demands encountered in sports. The key is to focus on compound, multi-joint exercises like the deadlift, squat, pull-up, bench press, and weighted rows. These exercises will stress multiple muscle groups, requiring they work together to move the load.

Focus on closed chain exercises

Closed chain exercises are when the body part being moved is anchored to the ground or an immovable object, like a pull-up bar.  The direction of muscle pull is towards the ground or immovable object. Force is being transmitted through the ground, not through the air when you perform exercises such as deadlifts, squats, push-ups, pull-ups, or lunges. These exercises recruit larger muscle groups and require they work together to move the load. Closed chain exercises also require greater stabilization of the spine, which is essential for protecting the lower back during sports.

Contrarily, open chain exercises are when the arm or foot is free to move and is not anchored to the ground or an immovable object. The direction of muscle pull is inwards toward the body when you perform exercises such as bicep curls, bench press, hamstring leg curls, or quad knee extensions. The muscle is mainly recruited in the concentric (shortening) phase of muscle action. As such, open chain exercises are less functional to the athlete and should not be the focus of a strength and conditioning program.

Control the eccentric portion of the lift

Many injuries in sports occur when the muscle is asked to contract while it is in the process of lengthening. Bicep tendon tears, hamstring tears, and achilles ruptures are common injuries that often occur in the eccentric phase of muscle action. This type of contraction causes the most tearing of muscle fibers, whether injury occurs or not.  A simple example of eccentric muscle action is during the bicep curl. As the weight is lifted, the bicep is acting concentrically, meaning it is shortening while it is contracting. As you slowly lower the weight, the bicep is eccentrically contracting, meaning you are putting it under load as the muscle lengthens.

By focusing on slow lowering in movements like the squat (descent), deadlift (lowering the bar to the ground), and pull-up, you can target the eccentric muscle actions, making your body more durable and resilient to injury.  As an added bonus, muscle growth is stimulated most by eccentric exercises.

Adopt a pull to push ratio of 2:1 or 3:1

This ratio will maintain the balance of your posterior (back) and anterior (front) muscle chains.  Proper balance and upright posture depends on balance between these two chains of muscles. Most people are insufficient in their posterior chain (calves, hamstrings, glutes, triceps, upper back muscles) and overly sufficient in their anterior chain (quads, upper abdominals, pecs, and biceps).  A reason for this pattern is the anterior chain muscles are the ones typically associated with an aesthetic body and are trained more often than the posterior chain muscles. When it comes to function, a strong posterior chain in balance with the anterior chain is key. A strong posterior chain will help you develop more force in your running stride, take and receive hits in contact sports, and stick a landing after a vault in gymnastics.

Pulling exercises include pull-ups, deadlifts, seated rows, dumbbell rows, and lat-pull downs.

Pushing exercises include push-ups, bench press, incline DB press, landmine press, and strict press.

SAID principle  

Finally, it is important your gym training closely mimics demands encountered by your sport.  The Specific Adaptation to Imposed Demands (SAID) principle states the biomechanical and neural adaptations your body makes to training will be specific to the movements being trained. For example, if you want to get better at running, you should not bench press every time you go to the gym. Conversely, if you are an offensive lineman in football, obtaining a strong bench press will be essential to success in your sport. Choosing exercises that either recruit the muscle groups you plan to use or movements that look similar to the ones you perform in your sport is crucial to training like a pro.

Have questions? feel free to reach out to Dr. Riley at [email protected]

Post written by Dr. Riley Kulm, DC. Check out his bio here.