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Hamstring Rehab Progression

Lets start with the basics- the term “hamstrings” refers to a group of three muscles that run along the back of the thigh- the semimembranosus, semitendinosus, and biceps femoris. As a group, these muscles generally act to extend the hip (bring the thigh backwards in relation to the trunk) and flex the knee (bring the lower leg back and up toward the glutes). Hamstring injuries commonly occur more slowly with overuse, or suddenly with forceful eccentric contraction. (The term “eccentric” contraction means that the muscle is lengthening under load). Common complaints after a hamstring injury can include pain, tightness, increased discomfort with motions that lengthen the hamstring, and walking with a “stiff legged gait”.

In the following few paragraphs, I will walk you through the general progression that I like to use when helping people return to functional and athletic activities after a hamstring injury.

Step 1- Calm down discomfort
This can be done in many ways including:

-Dry Needling
-Body tempering
-Isometric exercises
-Foam rolling
-Soft tissue mobilization

These interventions are useful for decreasing discomfort, and allow for improved activity tolerance for a period of time immediately afterwards. In other words, once pain has decreased, people are typically able to work through a greater range of motion and activate the hamstrings more. Dry needling and body tempering require help from someone that knows what they are doing, like a licensed professional, but soft tissue mobilization, isometric exercises, and foam rolling can easily be done on your own. One thing that I like about using isometric exercises is that they allow you to continue working the hamstrings while also decreasing pain. A couple of the isometric exercises I like to use are listed below. The key with these types of exercises is to hold the desired position for a prolonged period of time, up to 45 seconds if possible.

Isometric long lever bridge


Isometric elevated bridge

Step 2- Bridging

Once pain and discomfort has decreased noticeably, I like to then start working through some modified bridges. Bridging is a good way to start to move the hamstrings a little more while minimizing the lengthening that occurs through the muscles. This is because the knee can be held in a static position while the hamstring muscles are lengthened/shortened across the hip joint. (Only getting stretched at one of the two joints that this muscle group crosses). This is a good way to reintroduce smaller amounts of mobility, especially during a period of time when lengthening the hamstrings might still be irritating. Bridging is usually done to target the glutes, but this exercise can be modified to make the hamstrings pitch in more. To target the hamstrings during this exercise, move your heels out away from the glutes. This takes some of the work off the glutes and shifts it down to the hamstrings.

Long lever bridge to single leg progression

Elevated bridge to single leg progression

Step 3- Lengthening/ mobility work

Once we know that bridges are tolerated well, it’s a good time to try light exercises that will require lengthening of the hamstrings across both the hip and knee joints. These exercises can be easily modified to keep the movement within what feels tolerable. Ideally, you will start to notice decreased discomfort with successive repetitions as the nervous system allows the muscles to lengthen more. A couple of my favorite exercises to accomplish this are listed below.

Banded primer

Hamstring slider

Step 4- Loaded eccentrics.

Once lengthening the hamstring across both the hip and knee is tolerated well, I will then move into eccentric loading of the hamstrings. Here is where you really start to get a lot of bang for your buck, as you start to rebuild the strength and resilience that will help you return to your prior level of function and decrease the risk of future injury. For this, I like to use different hinge movement variations, starting out by drilling proper technique within tolerable/available range of motion, and then progressively loading this movement. Some hinge progressions are shown below

Hinge with dowel
(focusing on proper technique, and maintaining contact at the tailbone, back of the head, and the portion of the spine between the shoulder blades)

Goat Bag Hinge




Step 5- Plyometrics
Once we know that the hamstrings are strong and tolerate loaded functional movements well, it is time to speed up the movements/rehab exercises performed and introduce more athletic activities. Some of my favorite exercises for this phase of rehab are listed below

Banded KB swing

Russian KB swing

Hamstring slam

Hamstring medball kick

Step 6- Athletic activities
Once plyometric movements are tolerated well, it is now time to start re-introducing more sport specific activities. Activities that fall into this category depend on the person, but include things like sprinting, cutting, and jumping

Important things to keep in mind through the rehab process-

Keep discomfort within tolerance-

Allow discomfort to help guide you throughout this process. Typically, performing exercises that feel tolerable, even if they feel somewhat uncomfortable, will help you

make sure that you are pushing your limits. I typically tell people that “tolerable” discomfort is usually rated as about 3-4/10 pain or below. Pushing your limits in this way will help you do enough to create the adaptations necessary for recovery without flaring up your discomfort. If an activity causes your discomfort to rise above this level, or to a level that you would consider “intolerable” then you should back off. Additionally, I tell people that if their discomfort starts feeling worse with each set/rep, then that specific activity may be too much, and I would recommend modifying the activity if possible. If this is not possible, then they should simply move on to the next exercise they had planned.

Along these same lines, it is important to keep in mind that just because you may be experiencing pain or discomfort, it does not mean that you are causing further tissue damage. This is another reason why I recommend operating within “tolerable discomfort”. For more info on this topic, I recommend reading Dr. Brandon Vaughn’s blog post on our site – “The Pain is in Your Head!” and watching the animated video at the bottom of the post, which can be found here: http://vertexpt.com/2019/09/09/the-pain-is-in-your-head/


The key word here is relative. Rest does not mean sit on the couch until your hamstring feels better. A passive approach to recovery will only cause you to become weaker and more deconditioned, increasing the odds that you suffer another injury. Throughout the rehab process, it is important for people to continue to perform activities that do not increase their discomfort. It is important to prevent a hamstring injury from causing you to become deconditioned or weak in other areas. Because of this, it is crucial that you continue doing things within your normal fitness program or daily life that are tolerated well such as upper body exercises, squats and lunges within a comfortable depth, biking, walking, household responsibilities, yard work etc.

Rate & maintenance of progress

Sometimes within a short period of time, people are able to work from the initial phases of this rehab progression to the later stages very quickly. I commonly see people that are able to work all the way from step 1 to 4 in one PT session. However, this does not mean that 2-3 hours later they will able to get off the couch and pick up where they left off. For a period of time, it will likely be necessary to use pain relieving interventions or lower level activities in order to warm up before more challenging ones. However, as your tolerance to higher-level activity improves, you will likely find that you don’t need to spend as much time on lower level exercises and things aimed toward decreasing pain. Furthermore, it may be a good idea to hold onto the exercises and pain relief strategies that work well for you, and continue to use them as a warm up or recovery tool. Different people will respond differently to various interventions, and take different amounts of time to fully recover. This is due to a number of different factors. Because of this, it is important to stay patient, figure out what works best for you, and continue pushing the limits of what feels tolerable until you are back to 100%.

Questions? Thoughts? Feel free to email me at casey.powers@vertexpt.com

Casey Powers PT, DPT



Blood Flow Restriction in 500 Words

Blood Flow Restriction (BFR) Training has been one of the most important recent additions to the worlds of orthopedics and sports rehab.

How It Works

By partially restricting arterial (“fresh”) blood flow to a working muscle, we can restrict the amount of oxygen available to that muscle. Exercise in an anaerobic environment (“lacking oxygen”) forces the muscle to produce higher amounts of lactic acid. We can “trick” the muscle into thinking it is working hard, giving you that deep high-intensity workout burn, while only doing very easy exercise. That build-up of lactic acid causes not only causes increased muscle fiber recruitment, but also causes the body to increase production of Growth Hormone (GH), and subsequently Insulin-Like Growth Factor 1 (IGF-1). These 2 hormones are extremely beneficial for rehab. Growth Hormone increases collagen synthesis throughout the body, which is a clear advantage when rehabbing an injured tendon or ligament. With larger, stronger tendons, it also doesn’t hurt to have larger, stronger muscles – IGF-1 has been known as a major driver of muscular hypertrophy.

They physiologic gains don’t stop there! Myostatin is a gene in the body that limits muscle growth. (Myo = Muscle, Statin = Stays the same). By downregulating the myostatin gene, BFRT can help the body grow more muscle, which is very important during rehab from some injuries and surgeries.

Why it is Relevant

There are 3 different types of muscle fibers in skeletal muscle:

  • Type I, which are aerobic, slow twitch and low-force producing. Think “endurance” fibers that are small, but long-lasting.
  • Type II X, which are anaerobic, fast-twitch and high-force producing. Think “explosive fibers” that are large, strong, and get tired quickly.
  • Type II A, which are somewhere in between. They are fast-twitch, but medium-force producing and partially aerobic (though exhaust faster than Type I fibers).

Type I fibers are utilized for most of the low intensity things you do during daily life. You don’t need to access Type II fibers until you are doing high intensity sprints or heavy lifting. Using BFR allows us to access the Type II fibers during light activities, which directly leads to increased muscle strength and hypertrophy despite not being able to load the muscle adequately (due to pain, post-operative status, etc.). This will expedite the rehab from orthopedic surgeries, and will also help maintain muscle mass while dealing with various overuse injuries.

A study performed by Park et al. in 2010 showed that walking with blood flow restriction applied to the legs led to an 11% improvement in in VO2 Max over just 6 weeks. This experiment was done on Division II Basketball players, not un-trained individuals. This has major implications for endurance athletes rehabbing an over-use injury – keeping a high level of cardiovascular function during times of limited capacity is crucial for returning to peak performance.

Blood Flow Restriction cannot (and should not) replace heavy loading during rehab, but can act as an intermediary supplement with similar effects until heavy loading can be safely performed.

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Core and the Pelvic Floor

There are only two reactions to “core exercises” – either you LOVE them or you HATE them. The muscles that are commonly referred to as the “core” are the front abdominal muscles – the rectus abdominis (6-pack), transverse abdominis, and obliques. They’re what everyone wants, but are incredibly hard to achieve without a strict and clean diet…or an incredibly high metabolism. What’s not commonly thought of as the “core” though, are the OTHER muscles and structures that make it up. The core is made up of your respiratory diaphragm at the apex of the abdomen, the abdominal muscles in the front, the lumbar paraspinal muscles in the back, and the pelvic floor muscles at the base. These groups together help keep your body strong and stable, as well as performing other duties we won’t touch on here. And these muscle groups can be exercised in a myriad of ways – both the traditional “core” exercises (such as crunches) and not so commonly thought of exercises (such as squats). What I seek to do with this blog is hit on 4 commonly performed exercises that strengthen the core and how they impact the pelvic floor. These exercises are: low front planks, sit-ups (butterfly), bird dog, and squats.

Low Front Plank

The plank is great for activating the spinal muscles as well as the abdominal muscles. However, is an exercise that brings to mind a “NEVER do that” connotation. Many believe that due to the impact this exercise can have on the pelvic floor, it’s an exercise that should NEVER be done. But I don’t believe that are true “nevers” in life. Planks can really help wake up the abdomen – whether used as a warm-up or a strengthener. To say you can “never again” do a plank is ridiculous. But at the same time, jumping into a 5 minute plank 2 weeks postpartum is also ridiculous. It’s something that needs to be consistently performed and increased at a safe progression.

The reason the pelvic floor can be affected is because of possible pressure created on it while in the plank position. If your abdomen and low back isn’t taking the brunt of the demand, then your pelvic floor may take on more of that work. So, rather than jumping straight into an “as long as possible” plank, maybe do short intervals first – making sure the pelvis is tucked and there isn’t sag in the low back. Then progress from there!


This is what first comes to mind when trying to predict what others will think of when considering “core” exercises. What I think of first when I consider a sit-up in a workout is “why do I want to add a sit-up in?” If it’s because I want them to get better at sit-ups or because they have a sit-up test coming in the future, then I’ll likely throw it in there. If it’s because I want them to feel like they’re really moving, but also be able to slow down the amount of movement, then I’ll likely throw them in there. If the reason is because I want to do core work, I might choose another exercise that will bank in on more muscle groups at the same time.

The sit up will target specifically the abdominal muscles – and possible the hip flexors depending on how you’re set up in this movement. It doesn’t really activate the low back or the pelvic floor as much – meaning it won’t assist in co-contracting different muscle groups. Because of the increase in intra-abdominal pressure, it also means that if you’re not strong enough for this exercise it will put more pressure on the pelvic floor. If the pelvic floor (like with the plank) isn’t ready for that demand, then it’ll cause issues (either in incontinence or eventual pain).

There’s some concern with diastasis recti with sit-ups. With a diastasis recti, there’s a split in the rectus abdominis muscle – what is traditionally considered the “6-pack muscles.” This occurs in 100% of women in the 3rd Trimester, due to the amount of space required for the growing fetus. However, in most women it either resolves completely or is asymptomatic. Diastasis remains in 32-46% of women, causing pelvic floor dysfunction or low back pain. However, what we’re looking at when deciding on if sit-ups are appropriate is the absence or presence of that pelvic floor dysfunction or low back pain. In the absence of low back pain/pelvic floor dysfunction, with a baseline strength, and with having a benefit to performing sit-ups, then get it!

Bird Dogs

Bird dogs is one of my favorite exercises for “core” – it encompasses so many parts. It challenges balance, it challenges the abdominal muscles, it challenges the low back muscles. It’s versatile, you can add so many things to it – from combining bands to weights to increasing hold times. You can add pelvic floor contractions with it, and add pelvic floor relaxation to it. Like I said, it’s incredibly versatile!

The biggest benefit there is to adding a bird dog in, whether as a warm-up to ensure the low back and abdominal muscles are firing well before getting into movement, or as part of a core-circuit, is that it enhances co-contraction behaviors in the muscles. This muscular co-contraction means everything is going to work and move together better. With the core being made up of specifically 3 different muscle groups – this is vastly important when considering a “core” workout.


Squats are likely the least-thought of core-exercise. However, studies show that squats – especially heavy squats – increase the activation of low back muscles (especially the lower portion of the back). And that activation of the trunk musculature on heavy squats, creating a ballooning effect, can increase the stability within the squat. However, now that we’re getting into heavy squats and the intra-abdominal pressure pattern for heavy squats – it’s a great time to talk about what happens to the pelvic floor with this activity.

When the breath is held in the lungs, the diaphragm is kept in a descending position. Because of its relationship to the pelvic floor, that means the pelvic floor is held in a stretched position throughout the movement. Like any other muscle group, if it’s held in a stretched position it has a harder time contracting and assisting to hold up. Meaning that incontinence within this movement is likely – or pressure creating prolapse – due to the forces on the pelvic floor. Does this mean it will definitely happen to you? NO! But like everything else in this blog post, you have to train for that. You can’t move from squatting 105# to squatting 300# and not expect things to fail out on you or at the very least to have some sort of issue. It also means that you need to train specific motions within the squat to keep your pelvic floor from failing (which in itself would be a separate blog post).

SO! We’ve gone through the 4 core-muscle strengthening exercises that I chose. What do you do with this information now? Use it! Plan your programming with your core in mind – plan your patient’s exercises with the core in mind. What the core actually does, what muscles actually make it up, how it works in conjunction with other muscles, and the multiple ways that the core can be challenged. A body goes through a myriad of movements throughout the day – and most of the time they aren’t the exact same movement. Meaning you, your patient, your athlete – their life is variable, and as such – their exercises need to include variability!


Gluppe, S., Hilde, G., Tennfjord, M., Engh, M., Bo, K. Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial. Phys Ther, 2018; 98 (4): 260-268

Ko, M., Song, C. Comparison of the effects of different core exercises on muscle activity and thickness in healthy young adults. Phys Ther Rehabil Sci; 2018, 7(2), 72- 77

Tillaar, T., Saeterbakken, A. Comparison of Core Muscle Activation Between a Prone Bridge and 6-RM Back Squats. Journal of Human Kinetics, 2018; 62, 43-53

Olsson, A., Kiwanuka, O., Wilhelmsson, S., Sandblom, G., Stackelberg, O. Cohort study of the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life. BJS Open, 2019; 3: 750-758

Garcia-Waquero, M., Moreside, J., Brotons-Gil, E., Peco-Gonzalez, M., Vera-Garcia, F. Trunk muscle activation during stabilization exercises with single and double leg support. Journal of Electromyography and Kinesiology, 2012, doi: 10.1016/j.jelekin.2012.02.017

Hamlyn, N., Behm, D., Young, W. Trunk muscle activation during dynamic weight-training exercises and isometric instability activities. Journal of Strength and Conditioning Research, 2007; 21(4): 1108-1112


Shoulder Impingement Part 3: Addressing Shoulder Stability

In the first two parts of this shoulder impingement series, we reviewed shoulder impingement pathology and how to address mobility restrictions commonly seen with this condition. As you may recall from the first post, shoulder strength and stability are also potential contributors to shoulder impingement. It is not uncommon to see someone suffering from shoulder impingement who has full range of motion and great mobility but lack the strength to support the motion, especially when under load (like overhead pressing). This inability to adequately support the shoulder can contribute to mechanical changes within the joint and surrounding tissue which can then lead to injury. In this article we will go over some exercises and drills for common stability issues that may contribute to shoulder impingement.

Posterior Shoulder Strength:
It’s common to see an imbalance between the front (anterior) and back (posterior) shoulder muscles. Strengthening the back deep rotator cuff and scapula muscles can reduce this imbalance and improve general shoulder mechanics. Below are some of our favorites. Other common gym exercises to work on posterior shoulder strength include reverse flies, face pulls, pull-a-parts, and high rows.

Load Bearing Stability/Balance:
Being able to train the shoulder under load is important to return to sports and overhead weighted activities. Oftentimes, strict overhead pressing is painful for those with shoulder impingement. Fortunately, there are different ways to load the shoulder and provide a similar strengthening stimulus. Loading the shoulder and pressing also engage the serratus anterior muscle, an important scapula muscle. The video below shows some examples of loading the shoulder and activating your serratus anterior using your body weight, kettlebell, or barbell.

One important function of the rotator cuff muscles is to help stabilize the ball in the socket. A great way to train these muscles and challenge the shoulder is by increasing instability (“chaos”) through the use of bands and hanging weights. These exercises also often let those with pain under heavier loads to complete an exercise with less weight but still be greatly challenged. Below are some of the ones we like to use in the clinic. Be careful though as they are generally more challenging than they look!

Kettlebell Carries:
What’s more functional than carrying weight around? Not much. And certain kettlebell carries are great for strengthening the posterior shoulder, upper back, and rotator cuff muscles. Below are a couple variations you can try with kettlebells. You can get a similar effect by using dumbbells, barbell, or sandbags.

Not everyone will have similar benefit to each exercise as each person has different strength and stability limitations. For example, one person may have a large imbalance between the anterior and posterior shoulder muscles and may benefit more from focusing on those posterior muscles. Someone else could have great overall strength but have issues with keeping a good overhead press position. This person may benefit more from overhead carries and chaos exercises. Unfortunately, it’s challenging to tease out specifically what you need. If you find yourself unable to do so, I recommend seeing a physical therapist who can further evaluate and identify areas of weakness.

If you feel you have some shoulder weakness and dealing with shoulder pain, I hope this post has been useful. Please reach out if you have any questions!



Shoulder Impingement Part 2: Addressing Mobility Impairments

In the first part of this shoulder impingement series, we reviewed the anatomy and mechanics behind it and possible contributors to this movement dysfunction, to include mobility restrictions. “Mobility” here is defined as the body’s ability to move through a joint’s intended range of motion. For example, knee mobility includes the ability to completely lock out the knee. An inability to do so would be considered a mobility restriction or impairment. Such restrictions can be due to limited muscular flexibility, joint capsule extensibility, altered joint structure/mechanics, postural limitations, or a combination of all the above. In this article we will go over some exercises and drills for common mobility restrictions that may contribute to shoulder impingement.

Pectoralis Major/Minor Tightness:

The way the pec muscles sit across the chest and attach to the upper humerus (pec major) and scapula (pec minor) can impact overall shoulder position, decreasing the available sub-acromion space. Decreased space here provides less “room to breathe” as we raise our arms past shoulder height. Check these out to help improve pec major and pec minor flexibility.

Latissimus Dorsi Tightness:

Although the lats are a “back” muscle, the muscle actually attaches towards the front part of the upper humerus. Therefore, along with restricted pecs, it can also pull the shoulder forward and decrease the available space. Here are few options to improve lat flexibility.

Thoracic Extension Restriction:

In Part 1 we discussed how the shoulder complex includes how the shoulder blade glides along the rib cage. The shoulder blade’s ability to do so partially depends on the thoracic spine’s ability to extend (bend upright/back). We oftentimes see patients and clients with more of a flexed forward posture and “stiff” going back. Here are a few of my favorites to improve thoracic extension.

Limited Shoulder Internal Rotation:

Internal rotation is the ability to rotate your hand towards your stomach or reaching for your back pocket. It can also indicate limited extensibility of the posterior (back) shoulder capsule. Restrictions can theoretically push the ball of the ball-and-socket joint forward, possibly creating irritation to the front shoulder structures. Here are some of our favorites to address this restriction.

Limited Shoulder External Rotation:

External rotation is the ability to rotate your hand out or cocking back as if throwing a ball. It is also responsible for being able to point your armpits forward and keeping elbows in when pressing overhead. Limited external rotation results in overhead movement dysfunction that can lead to shoulder impingement symptoms. Below are some exercises to work on this.

Everyone is unique, and not everyone will need the same flexibility exercises and mobility drills. If you feel you are “stiff” in an area or two, try out the associated exercises in the videos above and see how it feels. One way to assess if an exercise is beneficial is simply by testing and retesting a potential painful or “stiff” movement: try the movement (ex: overhead pressing), complete mobility work to address the restriction (ex: thoracic extension drills), then retest the movement. If the movement feels better, then it may be worth working on further.

If you feel you are restricted and dealing with some shoulder pain, I hope this post has been useful. The next part of this series will be geared towards shoulder strength and stability. Stay tuned!



Shoulder Impingement Part 1: The Diagnosis Breakdown

Shoulder impingement is arguably the most diagnosed musculoskeletal shoulder issue, especially in the functional fitness, weightlifting, and tactical worlds requiring repetitive overhead movements and heavy loading. Unlike most other musculoskeletal diagnoses, shoulder impingement is more of a biomechanical syndrome and movement dysfunction than an actual anatomical pathology. This is important to understand because, despite having the same diagnosis, those suffering from shoulder impingement can have varying impacted structures, symptoms, limitations, and causes. The goal of this article is to provide this physical therapist’s general overview of shoulder impingement and potential causes. Future posts will focus on possible treatment strategies based on identified impairments and limitations.

When researching shoulder impingement, you may see more specific diagnoses including internal versus external impingement. For this series, we will discuss external impingement, which is predominantly seen in these communities.

Simply, impingement, like the word “impinge” implies, is a mechanical encroachment or invasion of space in the shoulder, primarily in the sub-acromial space between the ball-and-socket joint and the acromion (boney roof over the joint). This encroachment can increase friction and pinch the structures running through this space. These include the joint capsule (the bag that wraps around the ball-and-socket joint), rotator cuff muscles and tendons, bursa (fluid filled sacs to reduce friction), and one of the two bicep tendons. The body is usually resilient enough to withstand the occasional pinch and rub, but repetitive exposure overtime develops associated pathology like tendonitis, bursitis, and microtears.

Fortunately, shoulder impingement is dependent on motion and is not a constant, always present, encroachment unlike a large disc bulge pinching a nerve. Typically, the sub-acromial space is unimpacted when the shoulder is resting, and most folks dealing with impingement are fine if the arm stays at or below shoulder height. Why is this? Well, like mentioned earlier, impingement is a mechanical syndrome; therefore, symptoms are dependent on shoulder motion (aka shoulder mechanics). Let me further elaborate.

The shoulder joint is more than just the ball-and-socket joint. It also consists of the acromioclavicular joint (aka AC Joint, where collar bone meets the shoulder blade) and the scapulothoracic joint (the shoulder blade floating along the rib cage). For you to raise your arm overhead, motion occurs in all three, especially the ball-and-socket and scapulothoracic joints. Initial movement is primarily the ball rotating and gliding in the socket; however, that only accounts for about 50-70% of the movement, depending on which way it is being raised. The rest of the movement comes from the shoulder blade gliding along the rib cage and rotating in order to point the socket upward. Shoulder impingement occurs when this combination of joint movements isn’t clean and the humerus (arm bone) jams up against the acromion, pinching all the structures between. Let’s take a moment to review some potential reasons this occurs in different individuals and why treatment needs to be individualized based on the person’s impairments and not the diagnosis alone.

Mobility, or lack of, is often a contributing factor to shoulder impingement. We will see folks strong as ox in their readily available range of motion; unfortunately, they oftentimes lack the mobility to easily get into a full overhead position with pressing, snatching, and pull-ups. Common contributors include tight muscles connecting directly to the humerus (ex: lats, pec major) and limited extension of the thoracic spine (mid/upper back). Additionally, postural limitations can play a big impact as it impedes the scapula’s ability to glide and rotate. Ideally, at rest while sitting or standing upright, the shoulder blade is vertical. With a rounded upper back and forward-dumping shoulder (commonly seen with a slouched position), the scapula is no longer vertical and now tilted and rotated forward. This puts the shoulder in a disadvantaged position as the scapula is now unable to fully point the socket upward when raising the arm overhead. To illustrate this, sit/stand with “perfect” posture then raise your arm overhead. Now, sit/stand with “bad” posture (think Hunchback of Notre Dame) and do the same. Feel the difference?

Not everyone with shoulder impingement needs mobility work because not everyone is “tight”. Plenty of weightlifters and CrossFit athletes have the available range of motion to get into these overhead positions; however, they may lack the strength and stability to support the movement, especially under load. Insufficient strength can alter the movement mechanics and rhythm of shoulder elevation or prevent unwanted micro movements within the joint. An example of altered mechanics may be decreased strength around the shoulder blade, impairing its ability to glide and rotate smoothly and timely along the rib cage. If the rhythm is off, the scapula will not be able to move the acromion out of the way in time as the humerus continues to rise, resulting in impingement. If the person has good strength and mechanics to get overhead, they may lack stabilizing strength while in that position under load. For example, the rotator cuff muscles ensure the ball is and stays seated in the socket. Weakness here can create micro movements within the joint that can result in impingement. So, as you can see, not  everyone with shoulder pain is tight and needs to perform banded distractions from the pull-up bar.

The last contributing factor to shoulder impingement I want to quickly address is general positioning and control. Individuals that fall into this category have the readily available range of motion and strength to support the movement but have some possible movement flaws that place their shoulders in a vulnerable position. For example, I may see an athlete who only has pain at the end range of overhead pressing. When reviewing their press, they press beyond the vertical position (bar directly overhead with bar, head, shoulders, torso stacked in line when viewed from the side) and actually end with the bar more rearward, placing more strain on the shoulder by jamming the humerus into the acromion. We will see similar issues with snatches and overhead squats, especially in the bottom of the squat position. Another example is kipping pull-ups where the athlete generates too much swinging momentum with their torso and lower body resulting in excessive overhead flexion. Unlike the mobility and strength impairments previously discussed, these are treated with proper coaching, cuing, and consistent clean repetitions under lighter loads.

In summary, shoulder impingement is a mechanical syndrome and not an anatomical diagnosis. It occurs when repetitive strain is applied to the structures located in the sub-acromial space. Contributing factors can vary and include mobility limitations, strength deficits, and movement flaws.

I hope you have found this to be useful. Stay tuned for future articles with ways to address these impairments!

Dr Pat Casey PT, DPT, OCS, CSCS


Building Overall Resiliency – Part 2

The last article post focused on building mental resilience. Now, let’s move on to physical resilience. Similar to our inability to internally withstand life’s stressors, physical injuries are basically the body’s inability to handle the external stress applied to it. Sometimes, injuries are sudden traumatic events like being in a car accident and will occur regardless of physical capacity. However, most physical ailments can be prevented if the person has the capacity to withstand the stress. For example, a stronger ankle will be more likely to avoid rolling when stepping awkwardly off the curb. An experienced runner will be able to withstand an acute increase in running mileage versus a novice runner. A mom who can lift and carry 150 pounds will be able to repeatedly pick up their 30 pound kid without excessively straining their physical system versus the mom who can only lift and carry 35 pounds. In order to reduce injury risk, your body must have more physical capacity to withstand the stresses applied to it. Makes sense, right?

So, how do we build physical resilience? The same way as mental resilience… by consistently stressing the physical system enough to challenge it without significantly overloading it. Avoiding physical strain and underloading the system does not challenge the body; therefore, the body does not have any stress to adapt to. Actually, avoiding physically demanding activities and living a more sedentary lifestyle will decrease physical resilience. However, when engaged in a physical training program, it is also important to not constantly overstrain/overtrain the system. Smart programming incorporates recovery periods to allow trained muscles, tendons, joints, bones, etc. to rest, rebuild, and adapt. This recovery is key to allowing the body to become stronger and, therefore, more physically resilient in the long term.

There are many ways to gauge how hard you are pushing yourself. And nowadays, there are a plethora of gadgets to monitor all sorts of data like heart rate, heart rate variability, recovery, sleep, and more. Having a gadget is nice but not necessary as research shows perceived exertion to be pretty reliable as well. For example, the Borg Scale of Perceived Exertion is a 6-20 scale where 6 is how you feel resting and 20 is extreme max effort. The numbers correlate with heart rate (6 with 60 beats per minute, 20 with 200 beats per minute). So, if you are doing aerobic/cardio training, you can wear a monitor or simply use this scale to see how hard you are pushing yourself. A useful tool for weight training is Reps In Reserve (RIR) where you perform enough repetitions to tax the system without going to complete exhaustion or muscle failure. For most people, I recommend performing sets where you complete as many reps as you can but quit when you feel you only have 1-3 reps left “in the tank”. This is the point where you struggle with the weight but not going to complete failure. This is applicable for muscle endurance, strength, and hypertrophy training. The last tool is another scale applicable to any training (cardio, strengthening, mixed) and is a simple 0-10 Rate of Perceived Exertion (RPE). If you find yourself always below a 7 out of 10, then you are unlikely applying enough stress to your system to build resilience. If you are always pushing yourself at 9 or 10, you may be applying too much strain. Though challenging, the goal is to find a good balance of tough workouts but allowing yourself to recover. I recommend an average of 7-8 RPE over the course of a week where some workouts may be a little lighter and some more strenuous.

Alright, the topic of resilience is clearly important to me and I could go on and on about this. However, we’ll leave it at that for now. To wrap this up, I’ll leave you with another quote. This one is from Mark Rippetoe, a well-known strength and conditioning coach. I feel this quote applies to both mental/emotional strength and actual physical strength:

“Strong people are harder to kill than weak people, and more useful in general.”



Building Overall Resiliency – Part 1


“Let me tell you something you already know. The world ain’t all sunshine and rainbows. It’s a very mean and nasty place and I don’t care how tough you are it will beat you to your knees and keep you there permanently if you let it. You, me, or nobody is gonna hit as hard as life. But it ain’t about how hard ya hit. It’s about how hard you can get hit and keep moving forward. How much you can take and keep moving forward. That’s how winning is done!”

– Rocky Balboa

This quote resonates with most adults as we all have faced life’s wrath at times. This quote appropriately summarizes the importance of resiliency, which the online Merriam-Webster Dictionary defines as “an ability to recover from or adjust easily to adversity or change”. Basically, it’s not about avoiding conflict and challenge but being able to bounce back afterward. Though the above Rocky quote applies to mental and emotional resiliency, it is certainly applicable to physical resiliency. Unfortunately, like an athlete lacking in certain aspects of general fitness, many individuals do not have all the resiliency components necessary to successfully withstand life’s punches. The goal of the next two articles is to discuss the importance of mental and physical resilience and provide some tips on how to strengthen both. This article will focus on mental resilience and the next will be geared towards physical.

DISCLAIMER: I am not a mental and behavioral health expert. The information I provide in this article is from a combination of courses during my physical therapy education, experience as a healthcare provider, my own personal life experiences, and the mental/emotional resiliency training I received while serving in the Army. I encourage those with mental and behavioral health concerns to seek further assistance from a specialized licensed professional.

Mentally and emotionally, being resilient is crucial to withstand the stresses and emotional challenges of life. As a dad of two young girls, I see the need to build resiliency early in life. Though their “life problems” are not the same stressors as adults, they face their own challenges including rejection (“no, you can’t have cookies for dinner”) and having to do something they don’t want to (“you need to stop playing and do your homework”). These challenges may seem small compared to an adult’s, but they are big to them. A child’s ability to face these struggles will build their resiliency so they can withstand the harder challenges that naturally come with age.

One way to build resiliency is through exposure. Every punch you take and recover from, the tougher you get. Every time you get back up after falling, the stronger you become. Each and every successful rebound increases overall resiliency, better preparing you to handle larger challenges in the future. The caveat is that these blows must be enough to stress you emotionally and mentally but not be complete knockouts. A knockout event may be too much to overcome and create secondary adverse effects (depression, anxiety, social withdrawal, avoidance behaviors, etc.) while a life without stress does not challenge a person’s resiliency, resulting in a weakened ability to rebound. Like Goldilocks looking for the right porridge, we need the “right” amount of stress to build resiliency: not too much, not too little.

There are other ways to build mental and emotional resilience than through just exposure. Research has shown time and time again expressing gratitude consistently can be very impactful. The most common method of doing so is by keeping a daily gratitude log identifying three to five specific items you are grateful for that day. The more specific the better, and it’s more impactful to reflect on why you are grateful for it. I recommend keeping a notebook next to your bed and either start or end the day completing your gratitude log.

If you find yourself not handling a stressor well, there are other tactics to assist in the heat of the moment. Think of these as spotters for your emotional and mental resilience. First, identify if you are catastrophizing and making it worse than it truly is. It’s common to spiral downward when faced with an obstacle or stressor  (ex: doing a task wrong at work leads to thoughts of getting fired which leads to financial problems then marital issues followed by losing the house then winding up alone living in a ditch). Stopping these thoughts immediately and recognizing the spiral can be challenging, and success depends on being able to accurately identify the most likely outcome (ex: doing a task incorrectly at work likely will result in a verbal warning from a supervisor). The goal is to put the stressor into perspective, acknowledging that it’s not great but also not fatal.

Pillars of Rehab Success

Turns out pain is very complicated (see previous blog about pain science). The medical world has come a long way in understanding and treating pain, but we still haven’t found that magic pill for resolving pain. However, we do know pain is much more than just the body part involved and impacts (and is impacted by) other body systems. The goal of this post is to identify and discuss a few key lifestyle behaviors that can greatly impact the recovery process. Addressing these “Pillars of Rehab Success” along with following the guidance from medical providers will greatly increase your chances of overcoming or better managing whatever physically ails you. There are many lifestyle choices that can impact recovery, but the pillars we will be discussing in this article are sleep, diet, stress, and exercise.


Sleep is arguably the most impactful modifiable lifestyle behavior as sleep plays a role in nearly every bodily system and function. Regarding pain and recovery, our naturally produced growth hormone spikes in the deep sleep cycles. This hormone is responsible for rebuilding and growth. Additionally, our stress hormone cortisol is lowest while we sleep. This flip in hormone levels is one reason why sleep is considered restorative. The less quality sleep we get, the less restoration we achieve. Additionally, since the mental, emotional, and cognitive effects of sleep deprivation are processed in the brain alongside pain processing, there can be some crosstalk between them. It’s very common to have increased pain symptoms after a night or two of poor sleep. For most adults, we should aim for at least seven hours of sleep but try for eight or more, if possible. This typically requires being more mindful of when we need to be in bed and practicing good sleep hygiene before bedtime (avoiding stimulants, dimming lights, reducing screen time, etc.).

We know food is certainly good for the soul and the way to anyone’s heart; however, the quality of food consumed can impact pain and the recovery process. Most importantly, we need to remember the original purpose of food is to provide the appropriate nutrition to fuel our bodies. What we put into our bodies will be what our body uses to provide energy, grow, and recover. Simply put, crappy nutrition will lead to crappy fuel. Additionally, highly processed “unhealthy” foods can irritate the gastrointestinal system, generating local inflammation than can have a systemic effect. This effect can then be like fuel to a fire for someone already in pain and dealing with an injury. Ideally, we would eat a 100% healthy diet full of veggies, fruits, lean meats, fish, seeds, nuts, healthy fats, and whole grain carbs. However, going on a fulltime strict for most of us eventually leads to mental irritability and eventually caving in. If this is you, my recommendation is to aim to eat “healthy” 85-90% of the time each week. This still allows for some splurge meals/snacks while maintaining the overall fairly healthy diet for proper fueling.

Research has shown a link between persistent pain and sympathetic nervous system (SNS) overdrive. The SNS is the “fight or flight” part of our autonomic nervous system responsible for priming our bodies in threatening and extremely stressful moments. A heightening SNS is good when in that moment (facing a bear, in a battle, etc.); however, we ideally only want to spend a small portion of time in this state. Unfortunately, our SNS cannot differentiate between the stress from an actual threat or the stress of our day-to-day lives. Therefore, due to stress, many of us live each day with an amped up SNS, reducing our ability to relax, restore, and recover. If you find yourself in this category, there are several ways to help reduce stress. These include, but are not limited to, finding an appropriate outlet (ex: hobbies, exercising), talking/counseling, gratitude logs, journaling, and meditating.

It’s common to avoid all physical activity when injured or in pain. However, general exercise is very therapeutic and aids greatly in recovery. Actively moving the joints and muscles can reduce swelling better than ice and medication by mechanically pumping the fluid into the lymphatic system. Additionally, the more we move a joint, the more synovial fluid the joint will produce, which is the body’s natural WD40 lubricant. Exercising increases blood flow, bringing in oxygen and nutrition to aid in recovery while flushing out inflammation and other metabolites. Hormonally, exercise has been shown to increase endorphins, growth hormone, and protein synthesis, all of which assist in pain reduction and recovery. Now, I’m not saying to ignore the pain and injury and to train as if 100%. When hurt, it may be advised to rest a healing joint or muscle, but there are usually other ways to exercise without physically aggravating the injury. For example, if one shoulder is injured, the lower body, trunk, and the other arm can be worked. If high impact activities are bothersome, try low-impact machines or get into a pool. If one limb hurts, don’t avoid exercising the other in fear of creating imbalances. Working the non-injured side will actually assist in the injured side’s recovery. It’s important to continue cardiovascular and strength training while hurt, unless advised otherwise by a medical professional.

The above four pillars discussed are only some of the many lifestyle behaviors that can be modified and optimized to improve recovery and pain management. These recommendations are general based on my experience with orthopedic pain and injuries. It’s always recommended to see a medical provider for further evaluation, treatment, and guidance when appropriate. However, regardless of the presence of pain or injury, following the above recommendations will certainly lead to a healthier life!

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To Heel Strike or Not?

If you were to sit and watch a mass of runners going by at the local 5k race, you will see all sorts of varying running forms, techniques, and movement strategies. Noticeable differences include varying head positions, arm swings, elbow angles, spinal postures, hip movements, knee drives, stride lengths, and step cadences. A largely debated topic is landing mechanics, specifically if it’s a running sin or not to heel strike (land heel first). My goal with this article is to discuss the differences in foot landing positions as well as give my opinion as a runner and physical therapist on the subject.

The heel strike landing pattern (also referred to as rearfoot strike (RFS)) became a more widely-accepted and adopted technique with the creation of the cushioned running shoe. Prior to shoe companies adding extra cushion under the heel, it was near impossible for someone to consistently heel strike for miles and miles without crushing their calcaneus (heel bone) into oblivion. Therefore, most (if not all) runners “back in the day” were midfoot or forefoot strikers, allowing the soft tissue structures of the feet and legs to absorb more of the load. Many advocate a midfoot or forefoot landing pattern now since it is more “natural” when not influenced by the modern advancement of the cushioned running shoe.

So what’s the big deal between strike patterns? Great question!

Heel striking is exactly as it sounds and occurs when the runner lands heel first (usually on the outer heel) with their ankle flexed and toes up. Most runners nowadays are heel strikers. The benefits of heel striking include the naturalness of it for most runners (especially novice) and the decreased soft tissue strain when compared to the other landing types. However, heel striking increases the amount of force experienced by the leg bones, hips, and knees because the foot and ankle is unable to absorb some of the load like with midfoot and forefoot runners. Though the max peak force experienced is similar between the different landing patterns, heel strikers typically experience more overall forces due to 1) an increased initial peak force with landing (see image below), and 2) increased contact time with the ground required to go from landing to push off. The increased force exposure and absorption may increase a heel strike runner’s risk for general joint pains and boney stress injuries compared to forefoot and midfoot runners.

Midfoot striking occurs when a runner lands flat footed with relatively equal distribution of weight throughout the foot while forefoot runners land more on the ball of their foot. These landing patterns are commonly described as more natural styles of running because running barefoot would likely require adopting one of these landing patterns to help distribute the landing forces. Unlike with heel striking, the foot and ankle are able to absorb much of the force, reducing the forces experienced in the leg bones and joints proximal to the ankle. Additionally, these landing patterns usually result in a quicker step cadence, resulting in an overall decreased contact time with the ground. Though there may be reduced stress to the leg bones and joint structures, there is oftentimes increased strain to the soft tissues, especially those in the foot and lower leg. This is why runners transitioning from heel striking to midfoot/forefoot landing are advised to transition slowly. These runners do not experience the same initial contact peak force as heel strikers do; however, the max experienced force is relatively the same.

Source: https://www.researchgate.net/publication/319104024_Common_Running_Overuse_Injuries_and_Prevention

So, is one landing pattern better than the others? Well, it depends on who you ask. Below is this runner’s and physical therapist’s opinion.

If you have ever tried changing your own landing pattern or tried teaching someone else, it is extremely challenging and frustrating for all parties involved. It can be awkward for the runner and can take months to master a new running technique while slowing ramping up mileage to avoid overuse injuries. Plus, many runners cannot accurately identify their own landing patterns (many think they are midfoot/forefoot runners but on video analysis are actually heel striking). Therefore, I do not believe changing the strike pattern is necessary for most runners as there are other components of the running that may be easier to modify with bigger results: foot placement and stride cadence.

A common issue associated with heel striking is overstriding, meaning the landing foot is hitting the ground ahead of the runner. It’s hard to do so when landing midfoot or forefoot. The further out front the foot lands, the harder the impact typically experienced through the leg. Additionally, the foot will spend more time in contact with the ground as it becomes the supporting post for the body transitioning over into the next step. In general, increased time with an external force can increase injury risk. Also, when the foot lands ahead of the body, it creates a temporary braking force. Newton’s Law of Physics states a force will create an equal and opposite force, so a foot landing out in front will create an impact force right back at the runner. If the goal is to keep moving forward, eliminating opposing backward forces would be good, right? If a runner can decrease their stride length so that the foot lands more under their body instead of outfront, it can significantly reduce the overall force absorbed, decrease contact time with the ground, and reduce/eliminate the backward impulse generated.

Source: https://groups.google.com/forum/#!topic/just-south/KdopHHtEU2o

Increasing stride cadence (step frequency) is another fairly easy modification a runner can make to reduce strain and improve running efficiency. Given a set overall speed/pace, the runner with a slower cadence must have a longer stride length than a runner with a quicker cadence. This longer stride increases ground contact time and forces the body has to absorb. Purposefully increasing stride frequency helps reduce stride length and improves foot landing placement, resulting in a more efficient motion (less braking forces) and decreased load. I recommend a cadence of 160-180 steps per minute. If your cadence is significantly lower than this, do not immediately increase your step frequency to match it. Start by increasing your current step frequency by 10% and gradually increase as you get more comfortable with a quicker yet shorter step. I heard from a buddy once that a runner should pretend to be a ninja trying to sneak up on someone (think quick and quiet feet!).

In summary, there are many variances to running form and technique with arguably the most disputed being foot strike pattern. To me, there are pros and cons of each. However, I feel adjusting foot landing placement and stride cadence are more beneficial (and easier) than adjusting foot strike. By focusing on landing more under the body and quickly transitioning into the next step, a runner will likely be more successful in reducing overload forces, improving efficiency, and reducing injury risk. If constantly dealing with overuse running injuries or feeling inefficient with running, try modify one or both of these instead of focusing on how your foot is landing!

Shameless Plug: Having pain with running and issues with modifying running mechanics, come see us at Vertex PT Specialists to have one of our trained therapists evaluate your running form, help address any physical impairments you may have, and get you back to running sooner!