Yesterday saw a woman with bunion problems and we were able to temporarily reduce the size of her bunions by changing how she stood. Now the trick will be to get her to walk better, thereby correcting the mechanical issues, I believe to be behind her foot, hip, and back pain issues. I’m really enjoying experimenting with this as I believe our anatomy supports my theory. Of course, I have a lot to learn, however, to tweak it and make it applicable to everyone.

The plantar fasciitis has been more difficult to treat. I can make the pain go away with my simple taping technique but getting people to actually alter their gait pattern consistently has been the problem. I’m now also experimenting with a simple knee taping technique to help change their gait mechanics even if they’re not thinking about it. This is an interesting mental leap for me as I generally haven’t considered the knee affecting the foot. Instead I’ve always thought of the foot affecting the knee. I think this should help though. We’ll see! I’m also understanding that, for those with chronic plantar fasciitis, the foot mechanics are in a “deep hole” of poor function and so taping right off the bat is the right way to go instead of just altering gait patterns.

Ultimately my theory is that we should not need foot orthoses to fix our foot mechanics given the proper guidance.  This, in light of the fact that I cast for foot orthoses, would be a major revelation in the industry. What I am learning, however, is that changing foot strike patterns on a regular basis is more difficult than I expected. For those unable (or unwilling)  to change their patterns, foot orthoses are a good choice–assuming they are casted correctly (which many are not).

Anyway, my experiments continue and I am heartened by my results!

Let’s look at the anatomical players first. The sciatic nerve originates in the lumbar spine as nerve roots exiting the spine then coming together to form the sciatic nerve which passes through the back of the pelvis and continues down the leg. Often the pelvis can become tilted forward (anterior pelvic tilt), backward (posterior pelvic tilt), or rotated so that one of the pelvic bones is tilted forward while the other is not. The vast majority of sciatic pain I treat results from either an anteriorly tilted pelvis or one that is rotated.

This happens when the muscles in the front of the pelvis become symmetrically tight as with an anterior pelvic tilt or they can become asymmetrically tight creating a rotated pelvis. Correcting this tightness goes a long way toward correcting sciatic pain.

Pelvic Asymmetry Copyright Boone Publishing, LLC. 2009

Usually people with these issues also present with weakened or poorly performing gluteal muscles (the rear-end muscles). These usually turn off as a result of poor standing posture or walking mechanics. Turning these muscles on while walking or running, together with stretching the muscles in the front of the pelvis help restore normal pelvic mechanics which then restores normal spinal mechanics. The spine responds to the pelvis because both are linked so closely together. Fixing the pelvis will help fix the spine.

Let’s look at sitting and sleeping postures that relate to sciatic pain now. When sitting, most often I find the knees are resting too low in relationship to the hips or the legs are too close together. This creates an anterior pelvic tilt and consequent spinal extension (arching) which can create sciatic pain. Another problem would be sitting asymmetrically so one leg is loaded more than the other. This can create a rotated pelvis also contributing to asymmetrical stress to the spinal nerve roots.

Standing habits involve locking out the knees and allowing one or both leg bones (femurs) to rotate inward too much. Both of these habits also create varying degrees of anterior pelvic tilt either symmetrical or asymmetrical.

Typically people with sciatic pain sleep on their sides which allows spinal sidebending and rotation to occur. Sleeping presents one of the hardest stresses on the spine because you are in this position for 6-9 hours each night. This can cause damage if care isn’t taken to pay attention to your body. Often what I find helpful is folding a bath towel lengthwise and placing it under the waist. This removes sidebending and rotation stresses to the spine regardless of which side you are lying on. Consequently it helps sciatic pain.

These tips and others can be found in my book, Fixing You: Back Pain.

Know Your Anatomy

The first place to start is the shoulder. Problems here affect how tennis elbow or golfers’ elbow develop. The most common issue is that the shoulder blades sit too low on the trunk and too far out to the side (I’ve mentioned this in previous posts). This sets up a domino effect whereby the upper arm bone to rotates inward which then causes the forearm to rotate as well. This is when tennis elbow or golfers’ elbow emerges.

This commonly happens in people who spend a lot of time at a computer. But, frankly, I see it in athletes or blue-collar workers as well. The muscles of the shoulder and forearm then adapt to this posture causing deep forearm rotator muscles to become lengthened or weakened while others become shortened (Figure 1.).

Figure 1. Deep Forearm Rotators (Copyright Boone Publishing. 2010)

Treatment is usually delivered to the muscles lying on top of these deep rotators. Mostly because it is in these muscles most people feel pain. These superficial muscles are merely reacting to deeper problems in the muscles lying against the elbow bones (pictured). Treatment of the superficial muscles requires multiple visits for painful therapy which delivers marginal results at best. The real problem is that the shoulder blade is not resting or moving correctly which sets up the elbow joint for problems which then leads to tennis elbow or golfers’ elbow.

The Fix

The solution? There’s good and bad news: The good news is that fixing tennis elbow or golfers’ elbow can happen quickly. The bad news is it’s not simple. You must first correct the shoulder blade issue which is feeding the recurring elbow pain. Then address the deep forearm rotators that have altered to accommodate the shoulder and arm position as well. Doing one without other can’t correct the problem for the reasons mentioned above.

However, I’ve made it as simple as possible in my new book, Fixing You: Shoulder & Elbow Pain. In it I present the problem and solution so anyone can understand the roots of their pain and fix them. So, if you’re tired of wearing that forearm strap, endless visits to a therapist for treatment, or icing your elbows after work or a game of tennis or golf, then do yourself a favor and get to the root of the problem. It’s time to fix your elbow pain!

Rick Olderman is a sports and orthopedic physical therapist, personal trainer, Pilates instructor and speaker. He is the author of Fixing You: Back Pain, available at www.FixingYou.net. Email Rick at Rick@FixingYou.net or call 303-477-4212.

To me this highlights the importance of addressing how you do things as much as what you do. She happened to have a hypermobile spine which made it difficult for her to stabilize well. She was out of touch with her body and couldn’t connect with her abdominals to stabilize the pelvis or spine. So focusing on habits such as how she stood up, sat down, slept, and worked at her desk was where we were really going to make a difference quickly. She was amazed.

This was deeply satisfying to me because she came to me a couple years ago with back pain and I wasn’t able to make a big difference in her pain. Now I know why. I didn’t focus on the things she did 99% of the day and instead focused on anatomical problems I found. This was a good lesson for both of us!

After examining both women, I found they had very similar problems in that the shoulder blades were sitting too low on the trunk (Figure 1.).

Figure 1. Depressed Right Shoulder Blade (Copyright Boone Publishing. 2009)

Also the  humeral head was sitting too far forward in the shoulder socket (Figure 2) causing pain in the front of the shoulder. I taped both the humeral head and the shoulder blades in a corrected position and their pain was eliminated–until the tape was taken off a few days later. This told me my diagnosis was correct. But how could I get them to hold these corrected positions on their own? Our attempts at specific corrective strengthening only met with irritation of their pain.

Figure 2. Humeral Anterior Glide (Copyright Boone Publishing. 2010)

Because the shoulder blades’ position on the trunk is partially determined by ribcage orientation, I revisited this aspect of their pain and found that by elevating their rib cages, pain was eliminated. This did two things: 1. it reduced the anterior tilting of the shoulder blade and, 2. activated key scapular positioning muscles that were deficient. The other maneuver I discovered to be of great help was asking them to place their painful side’s hand on the opposite shoulder. This elevated the painful shoulder blade and posteriorly  glided (pushed back) the humeral head into a corrected position in the shoulder socket. Both felt about 80-99% relief from their symptoms during the following week.

Both are now able to begin their strengthening program without pain. If  irritation does occur, they know exactly how to eliminate it, finally giving them a means to control their own pain.

Both of these women had one more issue in common. They were self-conscious of their breast size and therefore slouched  their shoulders. Over time, I believe this established the environment for these mechanical issues to become painful. Both commented that upon fixing their posture, they felt they were sticking their chests out too much, drawing attention to themselves. They clearly saw the mechanical connection, however, as their pain returned after resuming their slouched postures (Figure 3). Ultimately they needed to come to terms about their personal issues of drawing attention to themselves in order to be better.

Figure 3. Posture & Shoulder Blade Position (Copyright Boone Publishing. 2010)

This reinforces to me that, although my point of view focuses more on the mechanical causes of chronic pain, there are also significant emotional or psychological causes. I believe often there exists a combination of dietary, musculoskeletal, and psychological issues that contribute to chronic pain. There are probably others as well. Each person’s pain is a function of a different combination of these issues. My training is in understanding the musculoskeletal aspects of pain but occasionally I bump into someone with more psychological issues instead.

http://ruhefitness.audioacrobat.com/download/RickOlderman-FixingYou_net.mp3

I feel like a parent witnessing my kids take their first unsure steps! Yes, there will be some wobbling and mistakes but if they stick with it and think about the underlying causes of their pain, they’ll be not only walking but running before you know it! It’s very exciting and satisfying to know I am making a difference in these people’s lives whom I’ve never met.

I wish I could be there to guide them personally and make sure they do all the right things. In a way, I can. I just had my first Skype session with someone who purchased my book. It went quite well. Better than I expected. Ideally though, I hope readers feel they can go it themselves. I think it’s important to understand that everyone has all the tools within them to fix their back pain.

If you talk to enough people (or visit enough websites), you’ll find someone who swears by Pilates or Yoga as the end-all-be-all solution for their chronic pain. And rightly so. These disciplines take the body through positions and movements that it normally wouldn’t go through. This is what has helped those with chronic back pain. I’m a big believer in these two disciplines and any others that responsibly help people feel and understand their bodies movement habits or functional deficits.

What you don’t hear about, are those others who were not helped or even made worse by their experiences with these disciplines. Yes, there are many. So, how is it that the same movement philosophy, and even the same instructor, can be the cure for one person and not the other? The answer lies in a lack of understanding of functional anatomy as it relates to movement and chronic pain.

Ultimately many practitioners have only a general idea of how the body moves or how specific muscles work. But they don’t understand how that movement, or lack of it, exactly relates to chronic back pain (or pain elsewhere in the body). So typically you are taken through a series of moves that are exactly right for your problem and others that are exactly wrong for your problem. In the case of back pain, most pain can be boiled down to either excessive arching (extension) of the lower spine or by excessive flatness (flexion) of the lumbar spine. I’ve posted a 1-minute test on YouTube to help you figure this out. Of course there are varying degrees of these problems and reasons contributing to them but you’ll get the idea using this simple test.

If you look at a typical Yoga or Pilates repertoire, you’ll notice that about half the exercises involve stretching the spine into extension while the other half stretch it into flexion. So by the end of your session, you will have done the perfect exercises for your back pain–and the wrong exercises as well. That’s why so many receive temporary relief of their pain but it always returns.

In addition to being a physical therapist, I’m a Pilates instructor myself and am not picking on these disciplines. They can truly be just what the doctor ordered–if the doctor understands exactly what your problem is. Many do not, however. Fortunately understanding the roots of your pain are quite simple. Once you know why your back hurts, you can hone your workouts to focus on those exercises or poses that directly correct these issues and avoid those that contribute to it. Finding an instructor that understands these root causes can be a beautiful experience of letting go of pain and fear of movement and reclaiming your life.