"Hinge points and movement deviations may not be pertinent to pain, but they tell a story about how someone chooses to load their joints and program their movements." -Jim Heafner PT, DPT, OCS
Many therapists agree that there is no single 'best posture.'Most would also agree that we do not have 'dysfunctional movement,' but rather movement deviations. As I tell many of my patients, "No movement is a bad movement; no posture is a bad posture. To live fully, we must perform them all." Therefore, movement habits and patterns do not equate to pain. While I agree with this philosophy, we simply cannot neglect posture and movement. As physical therapists, our job is to identify positions of relief to calm down the system & provide novel stimuli to reprogram the system. In this post, I discuss my personal experience with low back pain. I discuss my assessment and treatment from a movement perspective and pain perspective.
Posture and Movement Perspective
Last year I was experiencing mild to moderate right sided low back and right anterior hip pain that would increase while performing lat pull downs and back squats. Symptoms increased at the end-range of the concentric phase of the lat pull down and deep in the squat position. I would describe the pain as compression and pinching in both the low back and anterior hip. Out of curiosity, I took pictures (see below) performing these movements to see what was occurring mechanically.
Hinge point in R low back at L2 region with side bending
Excessive lumbar flexion with forward trunk positioning during the squat
Hinge point at L2 region during lat pull down
While hinge points are common and not correlated with pain, I happened to have a hinge point at the location of my low back pain during the lat pull down. This skin fold appeared because I would hyperextend through the thoracolumbar junction during lat pull downs. As seen in the squat photo, I had considerable lumbar flexion, forward trunk positioning, and out-toeing bilaterally.* If I performed an abdominal draw in maneuver (emphasizing TrA) during any of these movements, I felt significant relief of symptoms** While I did not have any EMG done, it felt as if the lower abdominal activation allowed my anterior hip flexors to 'turn off' relative to their previous state.***
*Do not worry pain scientists, I know we naturally flex through the lumbar spine and some people naturally lean more forward depending on their tibia to femur ratio. **Do not worry global strengthening folks, I know there is no evidence to support TrA activation. ***I won't get into the topic of inhibited vs. facilitated muscle groups in this post.
Pain Science Perspective
I am aware that hinge points and movement deviations on a squat are not a cause of pain. As I wrote in a blog post earlier this year, "The research does not support either good or bad posture. We cannot confidently say that poor posture causes problems OR good posture prevents problems. This is because posture alone does not equal pain. Several studies have been published over the past few years that confirm pain is unrelated to our anatomical tissues. For example, 34% of asymptomatic people >60 years old have been found to have rotator cuff tears. One in three people WITHOUT SHOULDER PAIN have a rotator cuff tear. "
However, I simply could not do enough self-neuroscience education to decrease the pain (maybe I didn't believe myself...who knows.) Despite offloading and gradually reintroducing weight to the movements, my brain continued to recognize the movements as painful.
At this point, I hit a crossroad. Do I...
1) Continually load the painful patterns to desensitize the movements
This would follow the pain science path of treatment
2) Take a standard postural approach- focus on proper squat mechanics, core activation during lat pull downs, hip mobility to offload the sense of anterior impingement
This would follow the movement and posture path of treatment
Personally, I chose to perform a combination of both options. My top 3 interventions:
Hip external rotation mobility
1) Lumbar extensions were performed to improve lumbar extension range of motion as well as improve the loading pattern into extension as I squatted. While the first few repetitions were painful, the repeated loading desensitized movement and allowed me to maintain an upright position in the squat. 2) Hip External Rotation mobility was performed to improve the joint mobility in my hips. I perceived that tight hip joints were limiting my capacity to squat. From a mechanical standpoint, improved hip mobility allowed me to disassociate lumbar motion from pelvic motion. The increased hip mobility allowed me to maintain a neutral spine position and load through the posterior chain. 3) Thoracic mobility was performed to help maintain an upright posture during squatting movements and allow for improved shoulder mobility while performing lat pull downs. Additionally, improved thoracic mobility gave me a sense of better scapular muscle activation.
Incorporating Movement & Pain Science
In my situation, combining my knowledge of pain and tissue damage with the more mechanical approach of proper alignment was very effective. Since the brain is the control center of all input and output, it recognizes when someone is using too much energy to perform a task. For example, the forward head posture is not inherently painful, but chronic forward head positioning is an inefficient use of energy. To hold the head in a forward position, the anterior and posterior muscles are not working in equilibrium. The brain must expend more energy, time, and attention to keeping the head in a forward position. It has nothing to do with pain, and everything to do with efficiency. The combination of approaches was beneficial because I brought awareness and perception to areas that needed stimulation, and simultaneously calmed down areas that were already too sensitive to movement.
In conclusion: the treatment approach will be different for everyone. We all think, move, and act in unique ways. Many of our daily actions are performed reflexively without thought or awareness. Bringing increased perception to a painful region while modulating their pain will allow someone to understand why the pain is occurring and how to control symptoms.