Posture and Mid-back Pain

The last post addressed "swayback" posture and its effects on the lower back.  Given that the lower back serves as the "base" of the spine, altered posture in this region must be compensated for somewhere else.  The next "link in the chain" is the mid-back or thoracic spine.

Referring back to the picture from the last post; as we move up from the lower back, you can see the accentuated outward "C" curve in the mid-back or thoracic region.  Notice how this increased "kyphosis" causes the shoulders to move forward.  Note also how this posture tends to collapse the chest and bring the head forward (We will address this in the next post).

The increase in kyphosis in the mid-back can cause lengthening and weakness of the paraspinal muscles in this area.  This allows the chest muscles to become tight and pull the shoulders further forward which can lead to shoulder issues.

If allowed to remain or even progress over time, this type of posture in this part of the spine can start to cause the vertebrae to become wedge shaped (See picture below).  Once this occurs this posture is very difficult if not impossible to reverse.

How do we prevent it from getting to this point?  A colleague of mine shared this quote with me many years ago and I have used it often.  "Extension equals function".  This increase in kyphosis or worsening of the outward "C" curve is what we refer to as a flexed posture.  Imagine trying to do overhead tasks or maintain good balance if you looked like the picture above on the right.  Trying to do things in a flexed posture tends to set us up for injury.  Being in a more erect, extended posture allows the muscles that support the shoulders and spine to work more effectively and normalizes the pressure on the discs.

How do I improve my posture if I look like the picture above?

1.  As mentioned above, extension equals function, so extend, extend, extend -- within reason.  Do not push into pain or be overly aggressive but a nice way to help reverse this over flexed curve is to lay on an exercise ball.  This helps improve mobility in the spine to achieve a more upright posture.

Don't have an exercise ball?  Roll up a couple of towels forming a "log" and lay over that.

2.  Strengthen the supporting muscles.  The two exercises below are great for improving strength of the muscles that support the shoulder blades and the muscles that help keep your spine supported in good posture.  Don't have a theraband?  Use a towel and make it an isometric exercise.

3.  Stretch out those tight pecs.  The exercise below not only stretches the pecs, but by pressing your arms back into the wall as you are moving up and down you are also strengthening the spinal muscles and scapular stabilizers.  This is also a great exercise to do during the work day to get us out of the flexed posture we tend to adopt at our desks.

Next post we will take a look at how poor posture can affect the neck.

Posture and Lower Back Pain

As noted in my last post, posture can be linked to pain in a number of areas of the body.  One of the more common areas where we tend to see posture as a potential cause of pain is in the lower back.

The lower back or lumbar spine develops a mild inward curve as we progress through early childhood.  In utero, we are basically in a very flexed, "C" shaped position.  After we are born and are exposed to the outside world we start to develop "secondary curves".  One forms in the neck from raising our head to see when crawling or lying on our stomachs.  Another forms in our lower back as a result of standing.

As mentioned above, these curves were meant to be mild, gradual curves.  These gradual curves or "lordosis" helps support the body weight and helps to minimize wear and tear on the discs that reside between the vertebrae.  The picture on the left below demonstrates the lumbar curve.  The grey structures between the manila colored bones are the discs.  The yellow structures are the nerves that exit the spine between the vertebrae through something we call the intervertebral foramina.  In English -- holes between vertebrae.

 When in ideal posture, we maintain this curve as depicted above which minimizes stress on the discs and allows sufficient space in the foramina for the nerves to exit.  Deviation from this curve causes stress on the spine and associated structures and over a long enough period of time -- pain.

When the spine becomes too curved inward or "hyperlordotic" the space where the nerves are exiting becomes narrowed.  The back portion of the disc also becomes compressed.  We tend to call this position "swayback".  Below is a picture of what this posture would look like.

Referring back to the first picture in this post, imagine what the posture on the right above is doing to the space between the vertebrae where the nerves exit.  You are correct!!  Significantly narrowing it!!  This can not only cause pain in the lower back, but pain in the lower extremities as well due to compression of those nerves.

So if I look like the picture on the right, what do I do???  There are 3 simple things that you can do to help improve this posture and reduce pain.

1.  It is typically beneficial to do some exercises that help stretch out the shortened lower back muscles and "flatten" the curve.  Refer to Yoga for Back Pain or Alternative to Yoga for Back Pain for examples of exercises that help stretch out these muscles and flatten the lumbar curve

2.  The next thing to address would be stretching out the hip flexor muscles that are often tight in these cases which causes the pelvis to tip downward in the front, increasing the lumbar curve.  The picture below is a great way to stretch the hip flexors and quadriceps without further increasing strain on the lower back.

By holding the thigh tight to the chest you flatten the lower back and prevent further hyperextension.  If you have a "swayback" posture, holding this position and letting the other leg hang off of the bed, bench, sofa, you will get plenty of stretch in the hip flexor muscles in the leg you are not holding.  Maintain this position for 60 seconds on each leg times 2 repetitions.

3.  Strengthen your abdominal muscles.  By having this accentuated inward curve or "hyperlordosis" the abdominal muscles which basically run from your rib cage to your pelvis become stretched out and weak and are no longer supporting the spine as well as they should.  Below you will find 2 different exercises that I find particularly helpful.  These are the "basics".  After a few weeks of these 2 exercises you can advance to something more difficult.  It is imperative, however, that you start here as more demanding abdominal exercises without the proper foundation can cause you to hyperextend the lower back and cause more pain.  Here are the 2 "starter" exercises.

Draw-Ins.  Lying on your back or when seated, "pull" or "draw" your belly button in toward your spine.  Hold for several seconds and release.  Repeat 30 times.

Posterior Pelvic Tilt.  Lying on your back, press your back into the floor by tightening the abdominal muscles.  Hold for several seconds and release.  Repeat 30 times.

Obviously, this is only one of many different lower back postures that can cause pain, but probably the one I most commonly see.  In my next post we will address how this posture in the lower back affects the mid-back and then we will explore how altered posture in the mid-back will affect the neck.

Your Mother was Right

I don't know about you, but for most of my life I have listed to my mother say, "Stand tall, chest out", "Don't slump", "You'll get round shouldered".

I am sure I am not the only one who has heard words similar to these.  As much as I hate to admit it, though, she was right!!

I spend a good part of my day explaining to people how posture can affect their lower back pain, hip pain, shoulder pain, neck pain, etc.  In fact, I plan to spend the next few posts focusing on this very idea - posture as it relates to pain in different parts of the body.

So, what is ideal posture?  It is the middle example in the figure below.

Treadmill versus Overground Running

Probably a bit late to write this as we are now coming out of Winter and into Spring and the majority of us that run will be heading for the great outdoors, but as noted in my last post, I wanted to address the contrasts between running on a treadmill and running outdoors.

Before I get into the differences between running on a treadmill and running outdoors, I must confess that I am a purist at heart.  I much prefer running outside.  That being said, there are many reasons to run on a treadmill versus running outside and I would never discourage one from running on a treadmill if the alternative was not running at all. I, do, however, feel the need to point out some major differences between the two alternatives.

One of the most significant differences between running on a treadmill and outdoors is that muscle activation patterns are different.  On a treadmill, the "ground" or belt is moving underneath of you.  Because of this, you are not having to push off as much which reduces the amount of muscle activation in muscles in the back of the leg and thigh or what I like to call part of our "posterior chain".  You can mitigate this by elevating the treadmill to a 1% grade, but it is still a bit different as the "ground" you are pushing off of is giving way.

Another difference is your ability to maintain an ideal stride length.  Most treadmill decks are somewhere between 5 and 7 feet long.  Most of us are very concerned about being "shot out the back" of the treadmill and therefore stay near the front.  This tends to make us alter our stride length a bit in order to maintain our position on the belt which can cause us to artificially lengthen or shorten our stride.

The treadmill is also only so wide.  This is probably one of the least important difference as we don't want to run with a lot of side to side motion even when running outside as this is a big waste of energy, but at the same token we don't have as much freedom to place our feet wherever we want or change the separation between our feet as easily.  This is not a huge issue but being able to alter this separation subtly changes the way you are using your running muscles.  Some may argue that this is a bad thing.  I, on the other hand, tend to think that it is beneficial for the muscles to experience a little different stress from time to time during your run to help stave off fatigue and help prepare them for unexpected terrain.

Speaking from personal experience, the treadmill tends to "lock you" into a pace.  This can be a good thing if you are doing a tempo run that is supposed to be at a particular pace -- assuming the treadmill is calibrated :)  This can also be a bad thing if it means you are running more quickly than you need to be.  Whether we realize it or not we are constantly changing our pace when we run outdoors, be it due to terrain or just because something in our brain or body decides we need to speed up or slow down.  It is hard to spontaneously do this on a treadmill, obviously.  Additionally, if you are like me, once we find a decent pace, it is really difficult to hit that up or down arrow to change it.  Especially the down arrow as now we KNOW we are giving in to fatigue or weakness or whatever and slowing down.  Of course, now that we have GPS watches we can see that when we are outside as well, but it is easier to ignore.

Running on the treadmill means you don't have to deal with the elements.  This can also be a good thing, especially if it is crazy hot or very cold, rainy, snowy, etc.  However, if you plan to do a race or running event and it is not being held indoors, acclimatizing to the heat or cold is an absolute necessity.

Lastly, the terrain on a treadmill doesn't change.  The belt or deck is the same with every footfall.  This can be good as it allows for consistency.  However, playing devil's advocate, running on uneven terrain is a good way to develop foot and ankle stability and strength as the muscles are constantly being challenged to adapt to subtle changes in the running surface.  One could argue that this could set you up for injury as you may roll your ankle or develop an injury due to the foot and ankle having to work to propel you forward AND adjust to the terrain.  Very true.  But like anything, the more you train your ability to accommodate for these changes in terrain the better you become at adapting to it.  This actually REDUCES the likelihood of injury, even when running on even surfaces like a treadmill as your feet and ankles are more "fit" for lack of a better word.

This list of differences between treadmill and overground running is by no means exhaustive.  This is not intended to get you off of the treadmill either.  This is simply just to point out that although the treadmill is a very good training tool, it is not the same as running outdoors.  At the end of the day, how you log your miles is up to you.  I am much more concerned that you ARE logging miles than HOW you are logging them.

One Exercise to Help Reduce Injuries in Running

Sounds too good to be true, right?  One exercise that can help reduce the likelihood of being injured when running?

Well, in the time that I have spent evaluating runners whether it be in the office or at running clinics, there is one area of weakness that almost shows up invariably.  I have evaluated runners after running anywhere from 2-20 miles and also when completely rested.  No matter if rested or after running, one thing that a lot of runners have difficulty with is being able to balance on one leg with their eyes closed. Try it.  How long can you go before losing your balance?

So do you really need to be able to balance on one leg to run better or to prevent injury?  Potentially.   The ability to balance on one leg, especially with your eyes closed is a good indication of how well the foot and ankle react to changes in position.  The more efficiently the joint receptors and muscles of the foot and ankle respond to these changes, the less excursion the joints and muscles of the foot and ankle go through.  By minimizing this movement in the foot and ankle, the muscles have to work less to stabilize the foot and ankle and can use their energy more to push you forward.

No matter where you do most of your running, chances are the surface is not perfectly level, save for a treadmill -- we'll get to that in a future post (treadmill versus overground running).  The subtle differences in terrain as we run present challenges to the foot and ankle that they have to adapt to. Couple this with the fact that you are having to control 4-5 times your bodyweight when running.  If you are having trouble remaining stable on one foot on level ground imagine trying to run on an imperfect surface like a road or especially a trail with 4 people on your back.

Every time your foot strikes the ground it has to adjust for the imperfections in the surface.  We cannot use our vision to help us adjust for this and have to rely solely on the joint receptors and muscles of the foot and ankle to make the corrections and to make them very quickly or else we risk rolling our ankle.

If we estimate that we strike the ground an average of 2,000 times per mile at 4-5 times our bodyweight  that's a lot of opportunities for muscles, ligaments, tendons to become stressed.  That is also a lot of times for muscles to have to react to the changes in terrain.  The more inefficient they are at correcting for this, the more fatigued they become.

 All the different things that happen to the foot and ankle and their response is very complicated.  However, improving their ability to withstand these challenges is very simple.   Practice standing on one leg with your eyes closed.  Try doing this for 1 minute on each leg.  Work up to being able to balance on one leg with eyes closed for 1 minute without losing balance.  If you can reach this goal then your risk of injury will be significantly reduced and your muscles will be less fatigued when you run as they will adapt more quickly and effectively to changes in terrain.

So it comes down to 1-1-1.  That's one minute on left leg-one minute on right leg-goal of one minute without loss of balance.