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To Heel Strike or Not?

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

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

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

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

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

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

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

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

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

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

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

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

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

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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!

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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:

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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

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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
pat.casey@vertexpt.com
803.973.0100

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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.

References:

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

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Five Most Common Bladder Irritants In My Personal Diet

So, what are bladder irritants anyways? Bladder irritants are anything that causes the inner liner of the bladder and the muscles of the bladder (mainly the detrusor muscle) to contract, causing a feeling of urgency to empty. In most instances, this isn’t any problem at all. You feel you need to urinate, possibly with some urgency, and you find your way to the restroom. However, in individuals with increased sensitivity to the bladder or urinary tract this can become a symptom that controls their life. Diagnoses such as “Overactive Bladder” (OAB) or Interstitial Cystitis can become extremely frustrating, however these diagnoses aren’t the end-all-be-all. These diagnoses can be controlled with food restrictions/choices, pelvic floor physical therapy, exercise, and cognitive-behavioral changes.

Now, back to the main title – what do I eat/drink the most often that are bladder irritants?

  1. Coffee: I LIVE off coffee. However, the acidity in this drink causes an irritation of the bladder, which leads to a sense of urgency for urination.

 

  1. Carbonated Beverages: Sodas and carbonated water are bladder irritants, however the reason behind their irritation to the bladder is not well known. In my case, this is carbonated water – I just can’t get enough of the bubbles!

 

  1. Chili and Spicy Food: The reason behind this irritation is the acidity, which irritates the bladder causing a need to empty (and rid the bladder of this irritation). I love the challenge of not sweating through my clothes when eating spicy foods! Or acting like my mouth is not in complete agony.

 

  1. Alcohol: This irritant can be caused by the diuretic properties of the solute, which causes more urine to end up in the bladder. Also, the sweeteners and fruit juices that can be combined with alcohol are also bladder irritants. My alcohol of choice? IPAs – hipster or not, the bitterness of the beer and the sweetness of the fruit of choice is delicious.

 

  1. Acidic Fruits: Tomatoes, oranges, strawberries – all of these fruits have some degree of acidity associated with them. As such, they cause irritation to the bladder liner and urinary tract, which leads to more frequent urination. I eat strawberries/blueberries everyday in my oatmeal and yogurt!

Overall, consuming these foods/drinks won’t cause you to have to run to the restroom. What’s the explanation for that? Solvent! Water! The more water you drink, the more dilute the solution and the less likely your bladder is to become irritated by the acids, sweeteners, and carbonation. The more you understand about your pelvic floor and your digestive system, the better able you are to spot a problem and the better you understand yourself!

If you’re noticing a urinary frequency that is higher than 5-7 times per day, or an inability to control voiding (leakages)– this may be a sign of bladder irritation or pelvic floor dysfunction. At no point is leakage “normal” – regardless of the number of children you’ve carried. If you’re concerned about anything you’ve read or noticed, contact your primary care physician or contact Dr Tristan Faile, PT, DPT at Tristan@vertexpt.com for more information. 

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Exercise: Add Life to Your Years

As we age, it can be tough to maintain a regular exercise routine. We have other things going on in life, and not to mention any aches and pains that may have developed along the way! The truth is that exercise can improve the quality of life for anyone at any age, but may in fact be even more important as we get older.

In physical therapy, we have a common saying that we often find ourselves telling our patients: Exercise is Medicine. It sounds cliché, but it could not be more true. While you cannot prevent every injury, and can’t predict when a body part will start to hurt, there are many health factors you can control. And exercise is one of the most efficient and effective ways to do that. Here are a few of the many benefits that you can expect to gain from regular physical activity:

  • Heart Disease

Exercise improves blood circulation, which is very important for preventing heart disease. Even moderate intensity physical activity has been shown to decrease the risk of heart disease and premature death. It is also highly effective for improving cholesterol and blood pressure! The American Heart Association1 reports that those who are physically active and at a healthy weight live about 7 years longer than those who are sedentary and obese.

  • Weight Control

It’s true, you can’t out-exercise a bad diet, but you can certainly make your diet work better in your favor. Both aerobic and resistance exercise increase your overall caloric expenditure, which means what you eat will be less likely to be stored as fat. It’s not just the calories you burn while exercising, either: your body will be burning more calories throughout the day even while resting! Think of your body as a furnace, and calories will just be fuel for the fire, rather than sitting around and piling up waiting to get used.

  • Diabetes Prevention and Management

General exercise is one of the first things we recommend for people with diabetes or pre-diabetes. To move, your muscles utilize sugar that is either stored in the body or free in the bloodstream. This means that not only does exercise has a direct positive impact on blood sugar immediately, but it can also improve insulin sensitivity, making it easier for your body to utilize sugar when it is already available. Of course, this does not replace any other medical management you may require for diabetes: always talk to your doctor about any lifestyle changes that can affect long term health conditions.

  • Improved Mental Health and Function

Several studies show that exercise has a positive impact on mental function and acuity, regardless of your age. In one systematic review of the literature, researchers concluded that exercise even helps improve brain function and depression in individuals with Alzheimer’s disease.2 When you exercise, your brain produces a protein called brain derived neurotrophic factor, or BDNF.3 This protein enhances mental function, and improves anxiety and depression in mice, and is thought to do the same in humans. Along with the production of endorphans, this can leave you feeling much better when you have a regular exercise routine!

  • Longevity

As we age, losing independence can be one of the most difficult things for a person and their family to go through. In clinical practice, this is one of the top priorities (if not THE top) for many patients in their older years. The number one thing I tell people to do to if this is something they’re worried about? You guessed it: Exercise.

According to the CDC4 show that even moderate intensity exercise at 150 minutes per week (that’s only 30 minutes a day, 5 days a week!) leads to significantly less chance of disease and early death. The healthier you are, the more you can do on your own. But not only that! Exercise is the only way to maintain your muscle mass and bone mineral density, which naturally decline as we age. If muscles get too weak, or bones too brittle, we are at significant risk of falls, injury, or hospitalization. Performing some regular aerobic and resistance training can keep you stronger, longer!

 

So: If you have a regular routine, keep it up! If not, the thought of starting one can be a daunting task. Talk to your physical therapist or physician about different options and they can help work with you to develop a plan. It doesn’t have to be much – 20-30 minutes of walking on most days of the week is enough to see significant benefits. Not only will it help you add years to your life, it will also help you add life to your years!

-Sean Jacobs, DPT, PT, CSCS

 

 

References:

  1. American Heart Association: Physical Activity Improves Quality of Life (2015). http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/Physical-activity-improves-quality-of-life_UCM_307977_Article.jsp#.W28yuuhKg2w
  2. Gremeaux, V., Gayda, M., Lepers, R., Sosner, P., Juneau, M., & Nigam, A. (2012). Exercise and longevity. Maturitas, 73(4), 312-317.
  3. Sleiman, S. F., Henry, J., Al-Haddad, R., El Hayek, L., Haidar, E. A., Stringer, T., … & Ninan, I. (2016). Exercise promotes the expression of brain derived neurotrophic factor (BDNF) through the action of the ketone body β-hydroxybutyrate. Elife, 5, e15092.
  4. Center for Disease Control and Prevention: Physical Activity and Health (2018). https://www.cdc.gov/physicalactivity/basics/pa-health/index.htm
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What Joining CrossFit Taught Me as a PT and an Athlete

My first introduction to CrossFit was by Olivia Ferguson – my best friend on my softball team at Francis Marion. She started the fall of our senior year, and I would tag along to not be alone in the apartment. But I wasn’t really interested in it. As I went to PT school the following year, the consensus was that CrossFit kept us in business. Those crazy athletes just moved around erratically and injured themselves, which led them to physical therapy. My first knowledge of Brandon Vaughn (part-owner of Vertex) was that he had a private practice within a CrossFit box – and that was a lucrative business model because they were always injured! Never did I think I would actually join a box myself or ever do CrossFit.

What I realized once I was out of PT school and began practicing was that all of my pre-conceived notions were totally false. CrossFit wasn’t a place where people did exercise with reckless abandonment.

I wanted to do Olympic Lifting because of Summer Strong. I knew without any introduction to Oly Lifts that I would end up injuring myself…and I knew I didn’t have friends. So, I finally decided to drink the Kool-Aid.  I joined CrossFit Soda City in June of 2017. What I realized the more that I went was that I found my new “thing.” I’d played softball in college for the physicality and for my Patriot-family.  I’d competed in Obstacle Course Races for the community and the challenge. And now I’d joined and began to love CrossFit for the community and the challenge.

So, what I learned joining a Crossfit Box is this:

  1. These people are way nicer than any other people you’ll ever meet in any gym environment. They genuinely care how you’re doing and what’s going on in your life.
  2. CF is not dangerous, if you’re being smart about it. You’ll always have people who take it too far – every box has “that guy.” But on average, people want to do it right and don’t want to get injured.
  3. CF gives you that competitive environment if that’s what you’re looking for. You push yourself hard because you have something to prove to yourself or you have a love of competition. If you don’t want to go hard, you don’t.
  4. CF helps you become a better mover. If you practice those motions, you build a better motor program for the motion. You get cleaner in your bar movements. You get better and faster.
  5. CF changes people’s lives. People become motivated to become healthier. It’s not JUST about losing weight. It’s about getting strong: mentally, physically, and emotionally. It helps you see who you are and how strong you are. Can you get through “Fran,” can you get through the MetCon when you’re dog tired and worked 10 hours that day? Yes. You can. You’re a beast.

I love my gym-Fam. Is CrossFit for everyone? Absolutely not. That’s why we have so many options – Pilates, Barre, Yoga. It doesn’t matter what you do, as long as you move. Once we STOP moving, we’re much more likely to sustain injuries. Find your thing, Jelly Bean!

-Tristan Faile, PT, DPT, OCS, CF-L1

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Open WOD 18.5

7min AMRAP:

3-6-9-12-15-18-21-etc.

Thrusters – 100/65

Chest-to-Bar Pullups

 

 

18.5 – ANALYSIS

Here it is, the finale. Whether you’re happy with the first four weeks or not, we’ve come to the bitter-sweet ending. And we’re going out old school.

The Fran Ladder from 2011 was, in my opinion, the most painful open workout from that year. Once again, we get to see how far our fitness has come since “the good ol’ days”. The classic pairing of thrusters and pullups never gets any easier, no matter how the rep scheme is spliced together, and those of you on the bubble of Regionals have the next 4 days to show how bad you really want it.

In a ladder ascending by 3’s, it is normally a pretty good idea to start off slow and gain momentum throughout the workout. When it’s a 7 minute AMRAP, you may have to come out guns blazing and hope for the best during the later rounds. Annie did just that, and it paid off. While all of the Icelandic girls were fairly even through the first 3mins of the workout, Annie’s transitions were more slightly more aggressive, and her turnover rate during each of the thrusters was slightly quicker. She may have just gotten lucky that neither of the other “Dottirs” were able to catch her on that given night, but she did set a world record in the process. In any case, it will be the little things here that make the big difference in the end. Sara’s no-reps combined with slow transitions put her (relatively) far back in the race by the last 90 seconds. Katrin displayed some thruster inefficiencies that allowed Annie to get out in front early on and keep the lead.

Long story short: Move well, and move with purpose.

 

MOVEMENT TIPS

Thrusters

  • Control – Controlling the Front Squat portion of the thruster will be key for several reasons during this workout: 1) an efficient squat will directly decrease your overall energy expenditure per rep, and 2) an efficient squat = a faster squat. Keep the chest up, don’t let those elbows drop, and accelerate through the entire movement.
  • Breathe at the Top, Unless you Can’t – Early on in this workout, an easy way to pace these thrusters will be to take a quick breath at the top of each rep. This will allow you to stay tighter during the squat, and help keep the panic at bay. That being said, if you are standing there with the bar locked out overhead taking large, gasping breaths, it’s time to just drop it and actually get some air.
  • Shoulder Pop, then Punch – Just before the overhead press, many athletes neglect the momentum generated from the last little bit of the squat. Shrugging the shoulders just as you finish standing up can help “float” the bar up several inches, decreasing the amount of work on the triceps and delts to finish the press. With a relatively light weight, try to “pop” the bar up off the shoulders, then finish with a violent punch overhead. It might seem ridiculous to focus on such a small detail, but small details can save a lot of energy over the course of 50+ reps (and if that number seems small, that’s 5 reps into the round of 18 thrusters).

Chest to Bar Pullups

  • Make Your Reps Count – Common themes tend to emerge when talking about gymnastics movements performed at high intensity. With C2B’s, making each rep count is no exception. There is no fixing a missed rep, and each no rep has essentially the same energy demand of a good rep. So don’t waste your hands, lats, or sanity on barely missing the bar with your chest. Which brings me to my next point…
  • Break Before You Need To – By this point, you should have already focused on the kip during the 18.1 and 18.3 (toes-to-bar and bar/ring muscle ups). The C2B’s require nothing new on that front, but they will disappear faster than the other exercises did. For that reason, having a plan to break these up will likely lead you to success. The sets themselves will vary based on individual capacity, but it usually means stopping 2-3 reps shy of getting “close calls”. In the round of 21 pullups, Annie broke off a set of 11, followed by 6 and 4. She didn’t wait until she failed a rep to come down and rest. Just pick manageable numbers for your skill level, and get quick sets done early. That will save you valuable resting time and energy throughout the rest of the 7 minutes.

 

PACING STRATEGIES

Regionals, or Close:

  • Quick Transitions – I feel crazy for even feeling like I have to say this, but transitions will make or break this workout. The girls tonight finished the round of 12 in 1:48. That equates to 8 transitions for 60 reps in 108 seconds. The beginning of this workout needs to be very, very quick. Unfortunately, everyone will have to break their thrusters and/or pullups into smaller sets at some point during the workout. For those breaks, you should have individual sets and goals in mind. The transitions, however, should not be viewed as “planned rest” early on in the smaller rounds. Utilize those smaller sets to take advantage of quick transitions to get out ahead of the workout, then ease back into a slower pace in rounds 9 and 12.
  • Go Unbroken Through 12 – I might be wrong, but if you break the 12 Thrusters or Pull-ups, I’m not sure there is enough time to regain the ground later in the workout. If necessary, plan on breaking the 12 Pull-ups into two sets of your choice. Any more than that might be digging yourself into a pretty big hole. For most athletes, the round of 15 will probably be where “it” hits the fan. Have a plan to break up the 15’s, but even they should be bigger sets with small rest breaks.

Definitely Not Regionals:

  • Break Early, But Find Out What You’re Made Of – This workout allows you to do something we rarely ever do anymore: come out at full intensity and see what happens. Personally, I think every athlete should do this a couple of times per year just to see how far they can really push before fatigue or “quit” set in. If you don’t have any aspirations on taking this season to the next level, consider this an option. HOWEVER, if you’re just trying to beat your buddy and win a monetary (or food-related) bet, that is not the best strategy. The best way to maximize your score will be to identify your weakness during this workout (thrusters, pullups, or fitness in general), and work at a pace that will NOT take that aspect to failure. For example, if your C2B will be the limiting factor, make sure you break early enough that you do not miss any reps. While this may seem frustrating, it will allow you to go faster on the thrusters and get more reps overall than you would by consistently failing reps every round.

 

THE WARMUP

General Warmup:

  • 8min Assault Bike – Start easy, increase intensity each minute to the finish.
  • Rest 2mins – move around, start air squatting, stretching, etc.
  • 4 Rounds on the Assault Bike – 30 sec Hard: 30 sec Easy. Don’t blow up on the first one – keep the intensity high throughout each 30 second interval.
  • 25-50 Band Pull-Aparts or Face Pulls – Warm up the posterior shoulders
  • Banded Shoulder Stretching: If you typically do this to open up the shoulders, be sure to stretch out the pecs and lats. If this is not something you normally do, don’t start now.

 

Dynamic Movement Prep:

30 Seconds at Each Movement x 2 Rounds:

  • Spiderman’s – in a pushup position, bring one leg up and outside your arm. Try to sink your elbow down to the ground, then reach back up to the ceiling. Switch sides, and repeat.
  • Deep Squat Hold – get into a deep squat, focus on getting your back upright, and driving your knees out to exaggerate the demands of the rower. Use a rig or band around hips for support if needed
  • Scap Retractions on Pullup Bar – Retract for 5 seconds, briefly relax and repeat.

Thrusters:

With an empty bar:

  • 10 Overhead Presses + Pause at the top – Exaggerate the lockout position. Make sure your overhead motion is warmed up and ready to go.
  • 3 Pause Front Squats – Take 3 seconds in the bottom to establish a good position
  • Full Clean into 5 Thrusters x 2 Sets
  • Thrusters – Get moving, take some lighter weights for several sets. Work up to something heavier than your workout weight for a set of 5 Thrusters (Rx Guys: 115-135, Girls: 85-95)

Chest-to-Bar Pullups:

2 Rounds on a Pullup bar (rest between exercises as needed):

  • 10 Hollow-Arch Transitions
  • 10 Full Kips (Think Kipping pull-up, without the last chin-over the bar part)
  • 5 Chest-to-Bar Pull-Ups (Kipping or Butterfly)

 

Specific Workout Prep:

 

EMOM x 3:

3 Thrusters – Workout Weight

3 C2B Pullups

 

After Round 3 of the EMOM, go right into…

6 Thrusters – Workout Weight

6 C2B Pullups

*Move Fast, Focus on rep speed and Transitions. This should set the tone for how fast you will open up the workout. Remember – Quality saves Energy.

 

After this last warmup piece, you should already be sweating and ready to go. Get your mind right, move around, but don’t get cold. Ideally, you should have about 5-8mins between your last warmup round and Go Time.

 

 

-Go crush it.

 

Sean Jacobs, PT, DPT, CSCS, CF-L2

 

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