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: https://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 (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.

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.”



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!

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!

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:

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

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