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!

, ,

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!

, ,

Trunk and Core Strengthening

It seemed like for a while the biggest fitness craze was core stability training with every fitness and rehab guru flooding the internet and social media with exercises using every combination of positions, movements, and equipment possible. I’m sure I saw someone doing quadruped bird dogs with ankle/wrist weights with a resistance band pulling them one way while maintaining balance on a BOSU ball that a buddy was unpredictably tapping to create perturbations on an unstable service. Yeah, exercises like that can be effective and meet the intent, but it doesn’t need to be that complicated. Additionally, oftentimes such exercises can be too challenging and complex for the “Average Joe”. In this article, we’ll dive into a simple way to progress trunk and core stability exercises. But first, let us quickly dive into a quick anatomy review and the why behind the importance of maintaining a strong trunk.

The trunk musculature can be divided into two categories based on their primary function: movers and stabilizers (note: each trunk muscle can have both a mover and stabilizer function but has a primary role of one over the other). The movers are the bigger muscles located more externally and primarily work to move the body in different directions. This includes the abdominals (flex the spine), paraspinals (extend the spine), and the obliques (side bend and rotate the spine). Stabilizers are deeper and function to maintain a spinal trunk position at rest and during movement. These include the transverse abdominis (TrA), quadratus lumborum (QL), and the lumbar multifidi (LM) muscles.

When looking at the trunk and reviewing its function, it helps to view the entire system as a three-dimensional cylinder around the spine and guts. The abs and anterior portion of the TrA comprise the front of the cylinder, the obliques with the lateral TrA fibers make up the outer walls, and the LM and paraspinals solidify the backside. Like a soda can, this cylinder also has a top (diaphragm) and a bottom (pelvic floor musculature). A healthy and properly functioning cylinder will be able to generate pressure against all walls within it, locking down and stabilizing the trunk during exertion (like the stiffness of a full unopened soda can). A poorly pressured cylinder will not be as strong and stiff (like the walls of an empty opened can). Now, the cylinder does not need to be fully pressurized all day, everyday but only when needed to complete the task. And the amount of pressure generated can and should be based on the demand. For example, generating 100% pressure and stiffness is needed for a max deadlift effort but not for picking up an empty laundry basket. Having an appropriately pressurized cylinder will reduce injury risk by maintaining proper mechanics and evenly distributing the force to the right load-bearing structures.

Now, how do we initiate a trunk strengthening program correctly with a good progression? There are certainly different strategies and approaches out there. For the most part, there isn’t a necessarily “right” or “wrong” way as long as the exercise and dosing is appropriate for the person. For example, it may not be a good idea to perform heavy deadlifts right away for a deconditioned individual with acute low back pain. I personally view trunk strengthening progression as a three phase process:

Phase 1: Isometric holds maintaining a static position for a designated period of time, starting with a shorter time then increasing duration to build endurance and confidence. Examples include front planks, side planks, and back bridges.

Phase 2: Build off the isometric holds from Phase 1 by incorporating an unweighted or minimally resisted dynamic limb movement. The purpose is to train the trunk to remain stable and strong while moving the arms and legs. Examples include bird dogs, dead bugs, and rolling planks.

Phase 3: This phase is where I introduce more dynamic movements and heavier loads to challenge the trunk strength and endurance. These are oftentimes referred to as more “functional” exercises as they replicate natural movements and carry over to tasks we commonly perform during the day. With these exercises, the trunk is usually not the primary focus or working muscle group but serves more of  a supporting role (but extremely important, nonetheless!). Examples include kettlebell swings, deadlifts, and weighted carries.

Check out the videos below for examples of this outlined progression for the lateral and posterior trunk musculature.



As you can see, phasing a trunk strengthening program like above helps progressively build up the trunk strength and endurance appropriately. It doesn’t seem smart to overload a patient or client with heavy deadlifts if they aren’t able to hold a basic unweighted back bridge for more than ten seconds, right? Overloading a patient or client too soon without the proper baseline strength and endurance will increase injury risk, aggravate an existing injury, create frustration, and/or compromise trust with the provider/trainer. Let’s train and rehab smarter!

This isn’t rocket science but hopefully seeing a phased trunk strengthening progression is beneficial for you. The goal is to start small and progressively build strength and confidence while keeping it simple!

, , ,

The Pain is in Your Head!

We oftentimes hear the phrase “pain is in your head” used to motivate others around us while suffering
through a physically intense endeavor. I frequently heard this or similar renditions while in the Army
during training events like our semi-annual fitness tests, long unit runs, and grueling ruck marches. The
meaning of statements like this is to reinforce the power of the mind over the body, to mentally fight
through the physical discomfort. However, it turns out that pain is actually experienced in our heads and
NOT actually where pain is felt. Pain truly is in our heads. Now bear with me as I elaborate.

You see, the painful body part is too “dumb” and not equipped to produce pain. Let’s use tweaking the
low back while lifting something heavy, for example. Within the tissues of the low back are special
receptors and nerves that simply detect whatever might be a threat to the body. This includes local
chemical responses from inflammation, exposure to high forces of pressure, and extreme heat or cold.
These nerves detect this stimulus but do not know how to utilize this information; however, they know
who does…. the brain! So, these low back nerves that detected a potential threat send a signal away
from the local area to the spinal cord which then relays the message up to the brain for further
processing. Once received, the brain makes note of where the message is coming from, what type of
message was received (a potential threat!), and the current situation (bending over picking up
something heavy). It quickly processes the message to produce the output of pain.

Believe it or not, pain is a blessing protecting us from further harm. If it wasn’t for pain, I wouldn’t be
able to detect the sharp rusty nail I am stepping on and quickly pull my foot away from it, preventing
getting tetanus. Without pain, I wouldn’t know if my appendix was about to rupture, potentially causing
a fatal event. Pain forces me to the doctor to get the appropriate treatment. Pain prevents us from
running on a sprained ankle, causing further harm to sensitive tissue. Without pain to protect us and
guide us, we wouldn’t have survived long as a species!

Not only can the brain receive and process information from pain receptors and nerves, it is also the
body’s headquarters for processing any and all information related to our senses, movement, internal
health, cognitive processing, emotional state, and overall well-being. The brain will use other information
to fine tune the output and can amplify, distort, or weaken the output based on this other data. It can
also suppress the pain output in a life or death situation. For example, a Soldier being shot in the arm in
combat may not realize it until after the firefight is over. During this scenario, the arm’s pain receptors
and nerves detected the threat and relayed the information to the brain for processing. However, the
brain quickly “decided” the arm is less threatening than the potentially fatal situation it was facing, so it
dampened the pain output to deal with it later, when not in a life and death situation.

Because the pain is processed in our heads as well as EVERYTHING else, there can be some crosstalk
between different processes simultaneously occurring that can greatly impact the pain output. For
example, a person with both chronic back pain and depression may experience more back pain if their
depression worsens. What is it about being more depressed that causes more back pathology? Nothing!
But because both the depression and the back pain are processed in the brain, they can oftentimes
negatively impact each other. The opposite is true, too. Feeling more hopeful and optimistic can have a positive effect on chronic pain. This is why managing chronic pain should include a holistic approach (a
topic certainly worth its own article).

Of course, the physiology of experiencing pain is much more complex than explained here, but hopefully
this simple description helps identify the complexity of pain and how it’s not necessarily all about the
painful body part. It’s important to remember this while going through the rehabilitation and recovery
process, especially when there is a lack of progress, worsening of symptoms, or when dealing with other
health issues simultaneously (physical, mental, spiritual, etc.).

So, in summary, the pain you and I feel is actually in our heads. No, we are not all crazy, and the pain
experienced is actual legit pain. We just need to remember this as we recover and heal as there can be
many other factors that can influence the rehab process and pain symptoms. By understanding and
acknowledging this, we are able to identify non-pathological reasons why pain may worsen, and this
gives us a little more control over what often seems to be an uncontrollable situation.

For more information, check out this 5-minute animated video:

, ,

Squatting with Knee Pain

So, your knee is starting to give you a little trouble when you squat. Many times, people come to us having been told they need to stop squatting and rest it, or that “squatting is bad for your knees, you should never go that low.” And don’t get me started on the “knees shouldn’t go past your toes” myth… All of this couldn’t be further from the truth! If your healthcare provider is telling you otherwise, it’s time to find someone else. A big part of getting you back to 100% is volume management. This means your recent squat volume may have been a little too much for your tissues to handle and we need to take some time to calm them down and build them back up. But in the meantime, we can still find ways to get after it in the gym!

An experienced PT will not only assess your knee and design an appropriate loading program, but evaluate your squat mechanics, make future programming recommendations, and most importantly, find a way to keep you moving! Our goal with physical therapy is not about telling you what you CAN’T do, but helping you figure out what you CAN do. Rather than telling you to stop squatting, we work with each patient to figure out a squat variation that allows them to continue moving without increasing their symptoms. This could simply be moving them toward a more hip dominant squat to decrease the demand on the knees.

An easy rule of thumb is to move across the squat continuum to variations that utilize a more vertical shin. For example, if you’re having symptoms when you front squat, try a high bar back squat. When the load moves from the front rack to the upper back, the torso angle changes and the squat becomes more hip dominant vs ankle/knee dominant. Having an issue with high bar back squats? Try a low bar variation, or try box squats. This will let you really load the hips and keep your shins more vertical. From there we can keep adjusting by increasing the height of the box, decreasing range of motion to further remove the demand on the knees. There is a variation out there that will let you keep squatting, you just have to find it!

Over time, as the specific interventions for the knee continue to progress, we can gradually work back into the variation of the squat that was causing symptoms. Your rehab should be an active process, and there is no reason you can’t keep squatting!

Have questions? Send us a message at josh@vertexpt.com

, , ,

You Threw Your Back Out! Now What?

Most of us have experienced that sudden unexpected sharp low back pain and the inability to fully stand up erect afterward. If you haven’t yet, chances are you likely will at some point. Unfortunately, we oftentimes do not expect it to happen as it either occurs with the most obscure unthreatening activities (picking up a pencil, wresting with your kids, getting out of the car, etc.) or when we believe we are physically prepared to take on load (deadlifting, squatting, etc.) but the aftermath tells us otherwise. So, when it happens, what should you do?

First, don’t panic. Take a moment to catch your breath and evaluate the situation. Yes, it can be extremely painful and alarming but 99.999% of the time it isn’t life threatening. To assist ruling out more severe pathology (cancer, spinal cord injury, etc.), think about the how the pain started and the resulting symptoms. Below are some criteria to help:

  • Is the pain associated with a low-traumatic specific cause or mechanism (picking something up, twisting, etc.)?
  • Does the pain change with movement and/or position (ex: worsens with bending, better with sitting, better with walking, worse in the morning, etc.)?
  • Are you experiencing any other concerning symptoms (ex: changes in bowel/bladder function, nausea/vomiting, numbness/tingling, unexplained weight fluctuations, paralysis or severe sudden weakness, dizziness, headaches, etc.)?

If you can answer “yes” to the first two questions and “no” to the third, then the pain is likely “mechanical”, meaning it is not life threatening and is associated with the movement-related parts of the body. More severe and worrisome causes of back pain typically present as a constant unrelenting pain without an identifiable cause, pain that does not change regardless of movement/position, and pain along with other worrisome symptoms like those in question three above. Additionally, high-velocity traumatic causes of back pain (high-speed car accident, fall from high surface, etc.) should also be medically evaluated to rule out fractures. If you deem your pain as life threatening or suspect a fracture, definitely get it medically evaluated as soon as possible. If not, then congrats! You are the proud owner of acute low back pain and should keep reading.

Next, keep moving. Old school medical advice directed back pain patients to stay off their feet and oftentimes prescribed “bed rest” for prolonged periods. Turns out this treatment strategy is more harmful than good. Current medical literature supports continued activity, starting with lower level activities and gradually increasing workload until back to prior level of function. Sitting and laying around avoiding aggravating movements may seem logical to allow the body to heal; however, it’s common for individuals to actually feel WORSE after prolonged periods of rest. The longer you stay away from being active, the higher the risk of becoming deconditioned, weaker, and stiffer while potentially developing fear avoidance behaviors and acute depression if avoiding activities typically enjoyed.

With that said, it is not wise to continuously push through painful movements with the “pain is weakness leaving the body” mentality. Doing so can aggravate healing tissues (similar to picking a healing scab) as well as increase your body’s sensitivity to movement, resulting in higher pain levels. (Note: Pain is a very complicated output of the brain after it receives/processes multiple stimuli, to include pain receptors. The complexity is a whole other article on its own, but you can trust me on this!). So, the goal is to avoid the far ends of the activity spectrum: not enough and too much. Like Goldilocks, you need to find the middle “just right” point that keeps you moving without overdoing it. Light range of motion exercises and stretching is typically recommended along with light cardiovascular exercise like walking or riding a stationary bike. Check out the video below for some good exercises commonly prescribed for acute low back pain.

While going through the recovery process, it’s crucial to maintain an overall healthy lifestyle to promote a good healing response. Because physical activity is usually restricted initially, maintaining a well-balanced diet is key to prevent unnecessary weight gain and provide the body the right nutrients to optimize healing. Binge watching Netflix and eating a tub of ice cream is not a good approach. Sleep, too, is very important. One of our biggest healing-promoting hormones is Growth Hormone which naturally spikes during our deep sleep cycles. Additionally, our biggest stress hormone Cortisol (which limits recovery) naturally lowers while asleep. Reducing and disrupting sleep patterns therefore decreases the body’s natural ability to heal by reducing the “good” hormone we need while maintaining elevated levels of the “bad” hormone. I also recommend avoiding tobacco use and heavy alcohol consumption as both can reduce blood flow and the oxygen/nutrients delivered by the cardiovascular system, resulting in delayed healing.

The last piece of advice I can offer is to stay positive, be patient, and embrace the roller coaster ride of recovery. You will get better, it may just take some time. Each injury and person are unique; therefore, timelines, progression, and symptoms will vary. And if you have a history of low back pain episodes, each recovery will be different. Mindset is HUGE when injured (go back to the previous comment about the complexity of pain output). Feeling down and out mentally can carry over to how you feel physically. Also, remember that recovery is not a smooth ride with predictable improvements each day but more like a bumpy roller coaster ride with ups, downs, and loopy-loops (see below image). It’s common to experience a “bad day” after a “good day”. This does not indicate further harm or reinjury but is a common response as the body progresses.

So, in summary, tweaking your back happens. And, unfortunately, it sucks. However, you will recover. The body is amazing and able to heal despite all the day-to-day abuse thrown its way. There are things you can do to promote the recovery progress as described above: stay moderately active, maintain a healthy lifestyle, and have a positive mindset. Typical acute pain episodes improve over one to three weeks. If your pain persists longer, intensifies, or progresses to include “red flag” symptoms (see question 3 above), you should consult a medical provider to further assist.

Shameless Physical Therapy Plug: Seeing a physical therapist early in the back pain episode can further assist in the recovery process. If your state and health insurance allow for direct access to physical therapy without a referral (like South Carolina), I encourage seeking a physical therapist first to avoid delayed care and possibly unnecessary imaging and medication prescriptions.

I hope this is helpful. Definitely reach out to us at Vertex PT Specialists if you have any questions or concerns. Or if you are in the Columbia, SC area, we would love to help you out if your back pain continues to nag you!

Dr. Pat Casey, PT, DPT, OCS, CSCS, SFMA, CF-L1

, ,

Not all ACL Injuries Require Surgery

Pictured above is the iconic statue of Mickey Mantle outside of Oklahoma City’s Bricktown Ballpark.  Mickey Mantle is the legendary New York Yankees outfielder who started his rookie year in 1951. In the World Series game 2 of that rookie season, he sustained a right ACL injury which was never reconstructed or repaired; however he continued to play for the Yankees receiving 3 MVP awards and a triple crown in 1956. What is the impact of these facts? It means while Mickey Mantle was a professional baseball player he was a very highly competitive, professional athlete who had no ACL. He is what we call a “Coper.”

The ACL – anterior cruciate ligament – is one of the main stabilizers of the knee joint. This ligament keeps the shin bone (tibia) from sliding forward on the thigh bone (femur). The ligament is important in general stability of the knee complex – from side to side movements to running straight. The incidence of ACL tears is fairly high in an athletic population, cited in one study as 68.6 per 100,000 people. These injuries can be contact-related, meaning someone runs into your knee or body in a way that causes the ACL to rupture, or they can be non-contact, which is typically a plant-and-turn motion or a hyper-extension moment. The majority of ACL ruptures are from non-contact injuries, reportedly as high as ¾ of all ACL tears. There is some research that suggests females are more at risk of non-contact ACL ruptures compared to their male counterparts – the reason cited in some research articles as laxity in the ligamentous complex, the hip to knee angle ratios, and hormone differences between men and women.

After an ACL-tear and within management, there is a “rule of threes” suggested. One-third of all ACL-tears can resume normal activities without limitations, one-third will require a decrease in their activity levels or modifications to improve stability, and one-third will require an ACL-reconstruction to return to normal activities. The process of determining management should take the patient’s activity level and their desired return-to-activity into effect. And ACL-reconstructions should serve to return the individual to regular activities.

So, for the general population – is an ACL reconstruction required? Maybe yes, maybe no. BUT. It depends on the activity that you’re trying to get back to. Take for instance the weekend warrior who wants to be able to return to distance running? Maybe – it would depend on what the presentation looked like. Could they weight bear without significant pain? Could they perform a single leg hop? In the very beginning, depending on the swelling, both of these activities may be significantly difficult. But over time, with decreased swelling and increased muscle activation, can they do the same things without an ACL? It’s definitely possible. Secondly, the parent who walks for exercise and just wants to be able to complete regular house or yard work activities or take their kids to the park – does this person need an ACL reconstruction? Likely not.

Research has shown that pre-habilitation is key to improving the overall outcomes of ACL-reconstruction. The pre-habilitation is focused on decreasing swelling, improving muscle activation/firing, and improving movement patterns – not to mention setting expectations for outcomes. All of these interventions are a great way to determine if an ACL-reconstruction will be required. If you can do everything you wanted to do after doing pre-habilitation, then the possibility that you’re a coper is much, much higher.

So, what can you do? When you or your child gets injured, seek a physical therapy (PT) consult first.  Your physical therapist can determine the cause of knee pain is and assist in determining the next best step in your recovery.  Physical therapists see many post-surgical patients, which means we can recommend a good orthopedic surgeon if needed.  We can also get you moving safely – being able to improve range of motion and function much, much faster.  All in all, we can get you better faster.

If you have any questions about ACL injuries, ACL reconstructions, pre-habilitation of ACL injuries, rehabilitation of ACL injuries, or surgical consults please contact Dr Tristan Faile, PT, DPT, OCS at tristan@vertexpt.com.


Plutnicki, K. (2014, May 4). Mantle’s Knee Injury Was Just the Start. https://www.nytimes.com/2012/05/05/sports/baseball/mantle-sustained-yankees-other-famous-knee-injury.html

Kaplan, Y. Identifying Individuals With an Anterior Cruciate Ligament-Deficient Knee as Copers and Noncopers: A Narrative Literature Review. Journal of Orthopedic and Sports Physical Therapy, 2011; 41(10), 758-766

Boden, B., Sheehan, F., Torg, J., Hewett, T. Non-contact ACL Injuries: Mechanisms and Risk Factors. J Am Acad Orthop Surg, 2010; 18(9): 520-527