Ortho on the go
Ortho on the go
Chronic Lower back pain
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Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves. Hello and welcome back to the podcast. Very excited for this episode. This is the second episode with Tessa regarding chronic conditions within the low back. Tessa has provided us a video with some exercises that can help with people with acute and or chronic low back pain. This video can be found on the YouTube page, or a link to the video can be found in the description of this podcast. Please feel free to check this out. These are great exercises that you can do that will help with your low back condition. Now, uh on to the podcast. And you mentioned, which I think is amazing and quite, you know, you found this in me, which I thought was quite funny, is how weak and stiff my hips are and my adductors, especially, if not abductors, how weak they are and how much that's contributing to my low back symptoms. And I've tried to be diligent about, you know, uh exercising those specifically and getting those better. Um you had mentioned that you've seen that a lot. So do you feel like a lot of these, you know, athletic patients that you see that do single-leg, double leg sports, squatting activities that have this more chronic presentation of low back pain, a lot of the times is these are functional deficits, you know, as you said, hip mobility problems or hip strength problems, correct?
SPEAKER_00Yeah, I I think it's honestly very interesting. Like I'll get an athlete in my clinic who's like lifting extremely heavy weights and like performing really well in the gym, and then I'll test their hip abduction, and it's just like uh four minus, which is like very weak on the scale of like a manual muscle test. Um, or I'll have them do like a lateral or anterior forward like heel tap functional test, and we'll see like a ton of P valgancy things happening. Um so yeah, I'd say like that's like a a very like an area that I typically see in people that have a chronic uh problem that like maybe was missed or just never really assessed in in their care before.
SPEAKER_01Yeah, I feel like this is again, uh leads back to some of my my kind of thought process behind more functional orthopedics. When I see patients that come into clinic that aren't presenting with this acute low back pain, um I often will do similar functional testing as you do. You know, I'll test to see if they have any tightness in one hip versus the other, I'll test to see if they have any intractional rotation deficits, single leg, double leg stance deficits, single leg, double leg kind of squatting deficits. And oftentimes you'll see significant changes in their ability to kind of, you know, balance and or squat. You know, uh, you know, I get a lot of young uh female athletes that come in, um cheerleaders, gymnastics, you know, volleyball players that have this kind of recurrent low back pain, and you know, their weakness in their abductors, weakness in their adductors, their inability to maintain good hip stabilization during single double egg scans, and even kind of their squat form is so off that you know, I show that to the parents. I say, hey, look, you can see these deficits here. If we can correct these deficits, we can likely correct this functional low back pain. There's likely no structural underlying problem that's causing it. And if there is, you know, oftentimes these functional corrections can be helpful for these patients.
SPEAKER_00Yeah, I really think you're doing like an awesome job like from the PA side of things and how you're assessing uh clients. I feel like you're almost like a little bit into that he tea space or athletic training space, which I think is awesome, but then you have that PA background too. Um I did a soccer um prevention clinic a couple years ago, and I asked like all the girls to um squat, and out of like the entire clinic, there was maybe two PK that could squat with like pretty solid quality form, and one of them, her parents were PTs. So I don't know if that was interesting, but like, yeah, I think like the more we can get, like, especially that's like high school athletic population, I see often is like clids don't know how to move as well as we'd like them to. And I think a lot of that's contributing to them having more injuries.
SPEAKER_01Yeah, I I try to, you know, when I have PA students or people come in and shadow me or kind of doing the rotations with me, I try to incorporate andor teach them the importance of these functional evaluations. You know, as you said, when somebody comes in with acute pain, you don't have to put them through all the evaluations because it's not going to change what you're gonna do. We're gonna try to calm those acute symptoms down. But, you know, I had a I had a volleyball player come in the other day, and you know, she had that kind of classic um low back pain. It would hurt worse after she, you know, participated in sports, but would relieve by the next day. She can go about her functional daily activities and school activities without significant symptoms. And we could consider getting an MRI on her, but she doesn't have consistent symptoms, she doesn't have ridicular symptoms, and she had a lot of functional deficits on her exam, that it seemed to be more of something like you said, uh, you know, soft tissue correction that I sent her to see you guys in physical therapy, you know, to help. Um and I oftentimes think if you can show the parents, I don't know if maybe not all your population has parents with them, but if you can show the parents, even the athletes, if you can show them in a mirror, hey, when you're doing this single or double-legg squatting activities, look how you're shifting your hips one way versus the other. Um, that's showing that you're compensating for something, whether your body has some stiffness in that hip and you know doesn't want to mobilize well or it thinks it's going to be painful and it's trying to avoid that side. Um, I think those feedbacks can help the athletes or the parents say, hey, um, physical therapy and these types of corrections can be often helpful.
SPEAKER_00Yeah, and I think like that client like is likely just weak in the back too. Like, I think a lot of um like sports performance, um, even like coaches and things are not always loading the back. And so, like, really actually strike them in the back is very helpful in that case as well, in addition to all the hip um and functional deficits. A lot of the times I'll have clients do this test that's called a bearing sortsons test. And basically what they do, you do is you have them get their hips all the way to the edge of the table with their head and trunk like off the table, and you have them do a back extension to neutral and you're holding their legs. They should be able to hold like a minute to a minute 20 without back pain, without like having a lot of weakness there. And uh it's very interesting, like the amount of people that cannot do that test, or they'll start to have symptoms after a certain amount of time where that's just also cues me into like their irritability levels, too. So that's a really cool test that I'll do also with um people that are like not in a very cute, acute situation.
SPEAKER_01Oh, that's a good one. I'm gonna have to look that up and maybe incorporate that in a little bit because I I think those kind of tests like that can be quite helpful to the patient to show, hey, you should be able to do this. And if you can't, this may show that you're you're weak in this area. Obviously, we all train abs and do sit-ups and sometimes overtrain that anterior chain stuff, but under train that posterior chain stuff, which oftentimes leads to these chronic issues, back, hip, you know, knee, and those types of issues, which I'm sure you see quite a lot as well.
SPEAKER_00Yeah, I think I'm I'm doing a lot of education on like uh showing the difference between a squat and a deadlift. Often these two movements can kind of get merged together. Uh, the biggest fault I see in the squat um is people are like losing their spinal stability in their squat, and then that's just creating a lot of more strength forces. And if that's already happening in like a body weight squat and then they add load onto it, that can just escalate the issue. And then with the dead lift, people are um not always maintaining that neutral-ish spine position. Um, so I'm teaching them a lot about proper positioning. I really like um, and I'll make a video of this um using like a PBC pipe and teaching them like a three-point contact hinge, because then it can teach them how to stack um their like thoracic and lumbar spine and even their cervical spine as well while they're doing a hip hinge. Um and then that transfers into their movements when they're actually loading themselves.
SPEAKER_01Yeah, I think that's excellent. I think that's something I I neglected as well. But when I kind of started to get into more um exercise crossfit type activities and started to do a lot of these uh deadlifts and squatting activities and had low back pain with them, you know, through my own kind of research, I realized how poor I was stabilizing my trunk and maintaining that neutral spine during a lot of these activities. And so I put my pride aside. I lowered the weight and I kind of just did slow reps at this low weight to kind of maintain that form and then progressed up from there once I felt like I was, you know, good at that. You know, same thing with you know wearing belts. I feel like we always, you know, a lot of us wear belts to kind of say, hey, we have low back pain with these activities, and this belt is going to help us, but we probably don't use the belt appropriately, right? We don't breathe into the core and kind of you know um maintain that stable um, you know, core uh to kind of hold in those types of activities that the belt is really meant for. Um and so I I I often find I try not to use a belt because I don't want to use that as a as a crutch to say, hey, I can look at you with this, if that makes any sense.
SPEAKER_00Yeah, I think um what you did with kind of like taking some load off and really working with some stability is huge. I often really like having people like that have that stability issue, like in those squat, um, start with like box squatting and really working on controlling uh that and then slowly progressing deeper from that. And sometimes too, if we can just even elevate people's heels, it puts them in a little bit better position until they can kind of learn that motor control, and then we can kind of take that away as they get better. And then as far as the belt goes, yeah, I often feel like people utilize belts incorrectly andor too often. I think usually when they should be utilized, when we're getting above like 85, 90% of someone's like one ref max going for like a nine out of 10 RPE um on a lift, that's the best time to utilize that belt. Um, but yeah, people don't always uh use those belts correctly. They're maybe just only thinking about like pushing their core out forward. And we want to have more of a 360-degree expansion into the belt and kind of feeling tension throughout the whole belt. Um, and so I do see that as a very common issue with uh weightlifting belts.
SPEAKER_01Yeah, I feel like that's something that needs practice, and it took me a long time to get that kind of, hey, breathe into the stomach, fully expand into that belt, and then brace your core in that position. You know, a lot of us just want to flex our abs and say, hey, that's bracing our core, but it's it's not. You got to breathe into the stomach, expand that stomach into the belt, and then stabilize in that position. And that's the position then you like receive the bar in for your squat or you start your deadlift in. Um, and that's where you're gonna get that neutral spine or that stable core. And that's that's what I feel like you can practice with these lower weights um and and get that down. And then as you get that down and you and you, you know, it'll probably leave a lot of your low back symptoms with doing these exercises, then you can progress up to some higher weights once you get good at that kind of stabilization.
SPEAKER_00Yeah, it's really interesting when you um, or as a PT, if I if someone's like telling me they have pain with whatever lift, and I'll sometimes put a belt on for some tactile feedback and some bracing education, and we get them bracing and then they do that movement and they don't have pain. So it can make so much of a difference in your stability and just your mechanics, if you can get that proper brace going. And I I like how you kind of have those two cues, like you're breathing into the belt in all directions, and then bracing on top of that is a really good combination.
SPEAKER_01Yeah, it's funny. So one of the one of the girls I had in recently, she was a cheerleader and she um was the base and the cheerleader. And she said every time she would be the base and she would lift up, you know, whoever she was lifting up, she would develop low back pain. And she was one that I think she wasn't bracing her core well enough, and this was putting that shear stress across her lower back, you know. And because she probably had some weakness within her, you know, posterior rector spinae area and just core in general, um, was probably putting increased forces across the area. So she was one that I kind of talked about breathing and I talked about bracing the core, but you know, also sent her to see the therapist and kind of discussed that as well. But that's even another position where these young athletes who are having to lift something over their head, that's important that they brace in these positions because they may have weakness that causes these increased forces across their spine.
SPEAKER_00Yeah, especially in those overhead lifts. Like a lot of people don't think of that as like I need to brace and think about my core at all. Um, but that's actually like when we need that even more because the weight is like so much farther away from us. Um, it's that whole physics uh standpoint. We need that to be proximally to be able to move things like farther away from our body.
SPEAKER_01Yeah. All right. Well, one more thing I just want to talk about that I I thought of while we were talking, which I think is a fun subject to talk about, which you probably get asked a lot is can I work out, can I exercise through my pain? Right? So so many patients come in and they say, Hey, I have low back pain, I have acute onset, I have, you know, and we already talked about the acute onset, we want movement, we want blood flow to the area, but what about these chronic, you know, athletic populations that you see that say, hey, um, I have a competition coming up, or I don't want to lose my gains and I want to be able to exercise through this. What's your typical recommendation for somebody that comes in, you know, with with lower back complaints and says, Hey, can I work out through this?
SPEAKER_00Yeah, I think that's one of the um most common questions I get asked in the clinic because I I work with this population of really active adults and uh high schoolers and crossfitters. Uh, these people don't want to stop moving, which is great. Um, so it's just a matter of finding scaling options that are appropriate for them. So usually things I'm saying is during your activity, we for sure do not want to get your pain above a five. Like that is like a pretty strong cutoff I'd have with people. And then I have them kind of also you into this 24-hour window of pain monitoring. So maybe you did the activity and your pain was around a three or four during it, but then like in the evening it up to a seven, then that tells us like you were not ready for the activity. We need to scale the weight more, we need to swap the movement more. Um and so I teach all of my clients this monitoring scale so they can start to have some more autonomy with things and and utilize this to apply to so many different factors. The other thing I'm doing too is I'm always collaborating with coaches and personal trainers if anyone of my clients have these, and we kind of get everyone on the same page of like finding acceptable tolerances of pain while they're able to still keep moving. So that's the cool thing about a lot of um we can really have people modify and scale a movement in a variety of ways in order to keep them moving, even though if they're injured.
SPEAKER_01Yeah, I think that's really important too. And I always recommend that to everybody that I think it's important to keep moving. I think it's important to stay active, but modify those activities to within that pain-free realm. Um, and as you said, that's a great um way to look at it is you know, get that pain scale and try to get that pain less than a three or five, you know, out of ten on your personal scale. Um, one of the things I always you know recommend to people is uh limitations or pain the next day as well. I feel like you know your body does a good job about telling you if you did too much. And if for some reason you wake up the next morning and you have pain, and if it's pain that maybe improves throughout the morning and kind of you're able to get back to your normal functional activities, maybe stay at the level that you're at, whether it be running or the exercise level that you're at or the weight that you're at for another couple of days, just to let your body acclimate to that, get that kind of neuromotor control with those activities. But if you're having increased pain and possible limitations where I have to take the next day off, then obviously it's your body's way of telling you, maybe I did a little too much. I need to back off my activities 10 to 15%, kind of stay at that level for three to five days, and then maybe escalate up from there once I kind of, you know, my body accumulates to that. And I think that's helpful feedback for the patients as well.
SPEAKER_00Yeah, I think that like the next day is like a big telling factor, especially if they're feeling like increased stiffness or that kind of sensation too. That's another cue of like if we're starting to lose like range of motion after doing the activity, um, that's another sign that we're probably trying to do too much too soon.
SPEAKER_01Yeah. Well, I appreciate your time. I feel like we could go on talking about this for another few hours. Um we enjoy these subjects and we both kind of like this aspect of orthopedics and and you know um body mechanics and kinesiology in general. Um, would love to get you back on and like we talked about, maybe have a CrossFit kind of discussion, as there's I think a misnomer as far as uh injuries and crossfits. Um if if anybody's listening to this and they want to schedule, let's say, a PT session with you or or you know, get in to see you for an evaluation, how would they how would they get a hold of you?
SPEAKER_00Yeah, so they can get a hold of me through our website, which is just summit-physio.com. Otherwise, uh you can follow us on Instagram at summitphysio.co. Um you can always give us a call or text. Our photograph is 719-419-8833. And then we can all we always offer free consults. So there are 15-minute calls. Um, we can kind of just see if we're a good fit and see if we can help you. And even if uh you're someone that we think someone else is a better provider for, we can point you the right direction. Or if we think you need additional care before coming to see us, we can kind of help mitigate that too. But um, yeah, that's how you can get in contact with us.
SPEAKER_01Yeah, I think you guys do a great job with that. I think it's great for the patients to come in and see you with these acute or chronic problems. And you guys, you and your um, your partner cat do a great job as far as um if you think somebody's kind of exceeded the level or has concerning symptoms, you'll often text me and say, hey, I'm gonna send this patient in to have them get checked out, maybe get some x-rays or MRIs just to make sure nothing else more significant is going on. And I think that feedback between the therapist and the providers can, andor that communication between the therapists and providers can be quite helpful and you know get the patients the best outcome, which is what we're all in this for.
SPEAKER_00Yeah, we really like having like a wide network of providers, um, especially when things are outside of our scope and we are maybe needing a pr a surgical consult or um just another perspective on things. Um so it's been really great to look with other providers like you.
SPEAKER_01Awesome. Well, I appreciate your time. Uh, thanks for uh spending your your morning um uh talking on the podcast, and and we'll get this out. And as you said, I think you'll send a video with some of these kind of exercises you discussed, and we'll add that to the podcast so people can see um the exercises that we briefly talked about um as well. And uh you're you said your social media has, I think, these exercises quite often on there and blogs regarding these common injuries on there. So I think all very helpful to patients and athletes. So I appreciate your time.
SPEAKER_00Yeah, thanks so much for having me. I appreciate it.
SPEAKER_01Thanks for listening to the podcast. This was a great conversation with Tessa regarding both acute and chronic low back pain. I hope you enjoyed this. I enjoyed it quite a bit. Please follow them on their social media at Summit Physio and Performance. Uh, please follow Ortho on the Go podcast on social media at both Instagram and Facebook. Uh again, please reach out regarding any topics you'd like to hear cover covered or conversations you'd like to hear covered. And uh f stop by the YouTube page. Uh, the YouTube page will have the exercises that we talked about that Tessa put together. It'll be at the end of the YouTube page as well as a link should be in the description of this podcast. Thank you.