Last weekend I had the pleasure of attending the annual Colorado Chiropractic Association (CCA) Conference. Each year chiropractors from across Colorado gather to enjoy a weekend of educational speakers, networking, and discussion of the future of the chiropractic profession in Colorado. The CCA conference offers a unique opportunity for doctors of differing experience levels, techniques, and chiropractic universities to connect with a common goal – the advancement of the chiropractic profession in Colorado.
Since there has been a scarcity of in-person continuing education opportunities over the last two years, the phenomenal speakers at this year’s conference were a breath of fresh air for the doctors in attendance. As a clinician, it’s important to regularly learn new treatments and methodologies, staying up to date with the most current research available. I truly love continuing education courses because you come back to work with a renewed sense of vigor, and are eager to try new treatments and methods to help your patients. There were many fantastic speakers at this year’s conference, including Dr. Mike Hall, DC, Dr. Alicia Yochum DC, and Del Bigtree.
Dr. Hall spoke extensively on the importance of maintaining a healthy cervical lordosis. The cervical lordosis is the natural C-shaped curvature your neck should display. Many patients present with a flattened cervical spine which may be due to prior motor vehicle accident (MVA), prolonged poor posture, or genetic predisposition. Dr. Hall spoke about how the cervical lordosis acts as an indicator of the orthopedic health and fitness of the rest of the body. Patients with good strength in their hips and legs, shoulders and arms, often present with a healthy cervical lordosis. Conversely, individuals with poor strength in the lower body and who sit at a computer all day, often have a flattening of the cervical curve. Patients dealing with chronic stress and anxiety often present with head tilts and a poor cervical curve, indicating that the emotional and physical health of the brain is represented in the health of the cervical curve. The cervical curve is a window into the neurologic and orthopedic health of the entire body.
Dr. Alicia Yochum, daughter of Terry Yochum, who is co-author of Essentials of Skeletal Radiology, a textbook universally used in chiropractic and medical radiology programs, spoke about clinical radiology cases. For each case, she asked the audience to identify the pathology and then decide the appropriate course of action in terms of treatment or external referral. Dr. Yochum also spoke extensively on the benefits of musculoskeletal (MSK) ultrasound which is a cost effective diagnostic tool for soft tissue injuries. She provided an excellent review of how to distinguish T1, T2, and STIR sequence MRI’s. As a talented presenter, she made her radiology course engaging for all attendees.
To round out an exceptional group of speakers was Del Bigtree, former Hollywood producer of ABC’s The Doctors, who now uses his production skills to educate the public on the danger of vaccines, medical misinformation, and the pursuit of health care freedom in the US. His highly acclaimed internet show, The Highwire, is watched by millions of Americans who seek unbiased information when it comes to health related topics in the US. Bigtree spoke at length on the dangers of global vaccination for Sars-cov-2, which has a 0.26% mortality rate worldwide. Noting Dr. Robert Malone, inventor of mRNA vaccines, has even publicly spoken out about the dangers of global vaccination and has urged the medical community to stop. The mRNA vaccines use a new form of technology where vaccine adjuvants can turn off the ‘toll like receptors (TLR’s) of the patient’s innate immune system. Turning off the TLR’s allow the mRNA gene therapy to quickly bypass the innate immune system and enter the patient’s cells with the goal of stimulating an immune response and subsequent antibody formation. The overlooked issue is TLR’s are an extremely vital component of our immune system and shutting them off may have deleterious effects. Bigtree noted many oncologists have contacted him saying they’ve never seen new cancer rates this high in the US, and one plausible explanation is widespread vaccination with the mRNA gene therapies. Bigtree is a prominent advocate for the health freedoms of all Americans and I am grateful to have heard him speak on such a divisive and important topic.
The 2021 conference was my second CCA conference and I left feeling refreshed, excited about chiropractic, and with a wealth of new information to share with my patients. Whether you’ve been in practice for 3 years or 30, chiropractors share a kinship with each other and treat each other with respect. I enjoyed getting to know other Colorado chiropractors such as Dr. Roman, Dr. Pearson, Dr. Starling, and Dr. Birdsall just to name a few. My deepest thanks goes out to the staff of the CCA and all those involved in orchestrating a truly fantastic weekend.
Post written by Dr. Riley Kulm, DC. Check out his bio here.
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.
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.
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.
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
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
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.
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.
We’re going to take a quick break from our ‘Treat Yourself like a Professional Athlete’ blog series to address commonly asked questions in our clinic – how much should I be stretching, how should I be stretching, and why do improvements in flexibility from stretching seem to happen so slowly?
Do you feel like you are constantly stretching and foam rolling yet are not improving flexibility? Patients regularly ask me how to become more flexible and mobile. They stretch their hips, hamstrings, and lower backs constantly, yet see little improvement in function, range of motion, or pain. For many patients, the issue is not the extensibility of their tissues, it is poor or inadequate stabilization patterns.
Create a Stable Base of Support
For the brain to allow movement and lengthening of a muscle, there must be a stable base of support. If a stable base of support is not present, the brain will perceive the movement as threatening and unsafe, and will put the brakes on. The brain does this by preventing muscles from expressing their full ranges of motion. This phenomena may show up as tight hamstrings, hip flexors, and lower back muscles.
Muscles most commonly attach to joints or on bony landmarks next to joints. With this in mind, the stable base of support required for movement is most often a joint, which includes the vertebrae in the spine. Poor stability at a joint is perceived as a ‘red light’ to movement. We call this ‘neurologic tension’ which refers to muscular tightness caused by the brain putting brakes on a movement. If all we do is stretch the tight muscle, we are not addressing the root cause of the problem – an inadequate base of support. The feet, hips, shoulders, and vertebrae in the lower back and neck are common areas where patients need to improve stability because many muscles attach to these areas.
Breathing to Release Your Hip Flexors
Many of our patients stretch their hip flexors constantly but do not see any improvement. The main muscle for hip flexion is the psoas major muscle. The psoas muscle attaches to the vertebrae in the spine, crosses the hip joint, and eventually attaches to the top of the leg near the head of the femur. If the psoas muscle does not have a stable base of support at the spine, the brain will not allow this muscle to fully lengthen, leading to tighter hips. Proper breathing patterns utilizing a diaphragm-driven belly breath and 360-degree cylindrical core stability are essential to create a stable base of support at the spine. At our clinic we teach patients how to breathe deeply into their abdomen. This is important because you must be able to breathe into an area if you want to activate the muscles in the area. Once they can breathe into the front, sides, and back of their abdomen, we teach them how to stabilize the muscles of the core using progressively more difficult exercises. Many patients notice improved hip flexor mobility simply by achieving better breathing and core stabilization patterns.
Stabilize Instead of Stretch
You should now understand how poor stabilization at joints can lead to an inflexibility of the muscles that attach at or near the joint. The focus of exercise therapies at our clinic teach patients to have better stabilization at their joints. Patients are amazed when they see active and passive ranges of motion dramatically improve once a stable base of support is created. We rarely give clients traditional stretching exercises because for the vast majority of patients, the root cause of stiffness is neurologic tension due to poor stabilization patterns.
As today’s blog post is more technical than previous posts, please feel free to reach out if you have any questions!
Post written by Dr. Riley Kulm, DC. Check out his bio here.