1. Positioning: Find a position of comfort to decrease strain on your low back

• Positioning is important for everybody, but it becomes especially relevant to a person suffering from acute LBP. In 1964, Nachemson et al studied the amount of pressure placed on the 3rd and 4th lumbar discs in different postures, and showed that sitting puts the most pressure on your low back, followed by standing (30% less pressure than sitting), then sidelying, then lying flat on your back, and lastly lying on your back with your feet up over a bolster.  Is it any wonder that people who sit all day long tend to have more symptoms in their low backs?  Keep this in mind throughout the day.  If you sit a lot, take breaks every 20 minutes or so to stand up, walk around, and decrease the static strain on your low back.
• Your position of comfort should be pain-free, and all areas of your body should be supported, including your head and neck.  Perhaps most importantly, you need to be able to get into and out of your position of comfort without increasing the pain and strain on your low back.

2. Pain Management: Ice,  heat, supplements, and pain medication

• There is value to the use of ice or heat for the management of LBP.  To apply ice, place an ice pack or a bag of crushed ice (a bag of frozen peas will work too) on the area of pain, ideally while in your position of comfort.  Use a thin dry cloth or a damp warm towel between the skin and the ice.  Ice for no longer than 15-20 minutes.  In acute “flare-ups” ice as often as 3-4 times per day for the first 2-3 days.  Some people are extremely sensitive to ice and cold, and should use caution when applying ice.
• Heat is okay for LBP that is more chronic in nature, meaning that the acute inflammatory phase of healing has passed (at least 2-3 days following injury).  Methods of heat application include a hot shower, and heat pack, or a hot tub/bath.
• A physician should be consulted prior to taking any pain medication.  Typical medications prescribed for LBP include muscle relaxants, tylenol, aspirin, and opioid analgesics such as vicodin.  There is a difference between pain medication and anti-inflammatory medication.  For more information contact your physician, and also read this article!
• Fish oil supplements have been shown to help reduce back pains in the long run. Here are some of the best fish oil supplements out there.

3. Posture: Efficient alignment of your bones and joints

• Throughout the course of a typical day, we rarely have time to relax in our position of comfort. Rather, we stand or sit for the majority of our waking hours.  Think of how you stand.  In the pictures on the right, the person on the left stands with efficient posture.  The force of gravity acts on this person’s body in a way that all of the weight from the head, arms, and trunk (HAT) is transferred into their feet (their base of support). Note how relaxed this posture appears. The other postures shown to the right demonstrate either holding patterns, in which excessive muscle activation is needed to maintain a posture (such as the military posture in the middle), or hinging patterns, in which the weight of the HAT comes to rest on a particular region of the spine (a “hinge point”).  For example if someone were to push straight down on the shoulders of the second person from the left,  they would either bend forward through their thoracic spine (midback), or “hinge” in their lumbar spine (low back).  This hinge point becomes hypermobile over time and can create imbalances throughout the spine, predisposing a person to degenerative changes (bone loss) or injury.
• Sitting posture is also critically important to maintaining a healthy spine.  Read this article for more information on sitting postures and ways to improve ergonomics! And because our muscles heal during deep sleep, sleep posture is critical as well.  Keep in mind what we discussed above under Positioning, and read this article for more information on sleep posture!

4. Appropriate Movement: Decrease strain in your low back by following these tips

• Avoid aggravating activities: If a particular movement or activity causes pain and discomfort, avoid that movement or activity temporarily until the pain subsides.  If it is impossible to avoid because of your job or lifestyle, at least consider ways in which you can modify an activity to decrease strain on your low back.
• Hip hinge: A hip hinge involves leaning forward with your upper body while maintaining a neutral spine.  During activities such as shaving (for guys)/putting on makeup (for women), brushing your teeth, or washing dishes  we tend to lean over the counter by bending in the low back.  This creates tremendous strain in the structures of the spine, particularly the discs and facets.  Instead of bending from the low back, keep the spine neutral and allow yourself to bend forward from the hips.  This also comes in handy when standing up from a chair.
• Use your legs: This is cliche advice, but it is rarely followed to its intended extent, partially because many of us are not strong enough in our legs.  Working on lower body strength will help decrease strain in your low back, if you are using good mechanics.  But “using your legs” means more than just having strong legs.  To decrease strain in your low back it is essential that you learn to accept weight into your legs.  A good example of this involves sitting.  If you can easily lift your legs off the floor while sitting, then you are not accepting enough weight into your legs.  And if you aren’t accepting weight into your legs, much more pressure is placed on your lumbar spine.  Another way to use this information, and an alternative version of the hip hinge, would be to stand in a stride stance while washing dishes or performing one of the aforementioned activities.  Keeping a neutral spine, allow yourself to bend forward (from the hips), and feel how much weight you have accepted into your front leg.
• Lift wisely: When lifting objects (not just heavy objects), keep these tips in mind:

1. Use a wide base of support: keep your feet at least shoulder width apart
2. Keep the object as close to you as possible
3. Keep the lumbar spine in a neutral position: think of the hip hinge
4. Brace by contracting your deep abdominal muscles
5. Do not twist or rotate while lifting objects

5. Exercise: The best treatment for low back pain

• Exercise helps to decrease pain and increase function.  In 2008 The Spine Journal published information compiled from many different individual research journals.  They determined that exercise is more effective in the management of LBP than spinal injections, spine surgeries, medications, and physical modalities and traction.  Perhaps most interesting, they concluded that a general exercise program is just as beneficial in the management of low back pain as core stabilization exercises.  Lifting technique is critical!
• That being said, when suffering from acute, irritable LBP, “general exercise” may not be possible due to pain and symptoms. Here are five low intensity exercises that can be performed gradually when recovering from LBP.  The purpose of these exercises is to increase strength, range of motion, and coordination in the low back, as well as to decrease the fear of movement.  They can also be performed as a warmup for anyone!

1. Feldenkrais pelvic clocks: Lie on your back with your knees up and feet flat on the floor.  Imagine that your pelvis is a bowl and slowly tilt your pelvis down towards your feet (12 O’clock), and up towards your head (6 O’clock).  As you move towards 12 O’clock there should be a subtle extension/arching of the low back.  This is good, but the emphasis of the exercise is not to extend the low back.  The emphasis of this exercise is to move from the pelvis.  When moving your pelvis towards 6 O’clock there will be a subtle flexion/flattening of the low back.  Using these two points as a reference, begin to explore other points on the clock, from 1 O’clock to 11 O’clock, and every point in between.  Take this exercise slowly and make sure that you are not straining your back to perform these movements.  If you are, then decrease the size of your movements.
2. Bridging: Lie on your back with your knees up and feet flat on the floor.  Keep your spine in a neutral position as you use your hamstrings and glutes to push your pelvis up towards the ceiling. Don’t go too far and don’t extend your spine!  Begin with a small range of motion and let your symptoms guide you.  If it is easy, push yourself a little harder.  If it is difficult, back off a little bit.  Try to do 10 repetitions 2-3 times, with a 1 minute rest in between.
3. McKenzie prone press-ups: Lie on your stomach with your elbows positioned directly beneathyour shoulders and your hands flat on the ground in front of you.  Gently push your chest off of the ground.  There should be no active contraction of your low back extensors, and there should be no pain in your low back. Allow your arms to do all of the work.  Hold this position for about 30 seconds and then relax for 30 seconds.  Repeat 2-3 times.
4. Child’s pose with arms outstretched: In kneeling, spread your knees apart slightly, keeping your feet together.  Then shift your weight back and sit on your feet, keeping your arms outstretched in front of you.  Relax into the stretch while reaching out with your arms.  While holding the stretch walk your fingertips to either side, and feel how the stretch increases on the opposite side.  Breath deeply and relax.  Hold each stretch for about 30 seconds and repeat 2-3 times.  If flexing your low back (bending forward) is painful, you can perform a similar stretch with your low back in extension (the position your back was in for MecKenzie prone press-ups).  Simply shift your weight forward, bringing your hips off of your ankles.  Slide your hands forward as your chest drops towards the floor, causing your back to sag downwards.  When you feel a good stretch in your low back and your arms, hold for about 30 seconds.  As with the other exercises, start with gently, slow, small movements, and let your symptoms guide you.  Do not stretch to the point of pain.
5. Cat/Camel Stretch in quadruped: Many people with LBP are familiar with this exercise.  Begin on all fours with your hands directly under your shoulders and your knees under your hips.  Gently arch your back (A) and hold for 5-10 seconds.  Then allow your back to sag down, bringing your stomach towards the floor (B).  Again, hold this for 5-10 seconds.  Alternate these movements to enhance motion throughout your spine.  A more advanced version of this exercise involves shifting your weight forward and back while holding each of these positions (cat/camel).  As you shift your weight forward and back you will notice the stretch targeting different parts of your spine, like a wave of increased tension.  Make sure that all movements are slow and prolonged, and again, let your symptoms be your guide.

• Maintaining flexibility through the hips and lower extremities is also critical in the management of LBP.  It is important to begin with gentle flexibility exercises that do not increase strain in your lumbar spine.  For a simple introduction to six low intensity yoga postures, read this article!

Much of this information has been modified from principles and concepts developed by The Institute of Physical Art (IPA), continuing education providers for physical therapists.  For more information on IPA, click here!

There is somewhere around 640 skeletal muscles in the human body.  Skeletal muscle is a complex network of muscle fibers, connective tissue, nervous tissue, and blood vessels.  The connective tissue forms a framework of support by surrounding individual muscle fibers, bundles of muscle fibers (called fascicles), and finally the individual muscles that are made up of these fascicles.  Another type of connective tissue, called fascia, plays an integral role in how muscle functions.  Deep fascia separates neighboring muscles from one another and allows for these muscles to glide smoothly past one another as they contract.  Superficial fascia separates muscle from the overlying skin, and also allows for smooth movement of contracting muscle.  Dysfunctional fascia can increase the likelihood of suffering a muscle strain.

Each muscle fiber  is composed of many sarcomeres, which are the contractile units of the muscle.  When a muscle contracts, tension is created in these sarcomeres and this tension is controlled by the Central Nervous System. Muscle strength is affected by the number of sarcomeres present in a muscle, as well as by neural recruitment of muscle cells.  Muscle length is also a byproduct of the number of sarcomeres, with an increased number of sarcomeres in alignment corresponding to increased muscle length.  Muscle strength and length imbalances can increase the likelihood of suffering a muscle strain.

Factors That Increase the Likelihood of  Suffering a Muscle Strain

A muscle strain is defined as damage to some part of the contractile unit caused by overuse (chronic injury) or overstress (acute injury).  Strains can be graded as mild, moderate, or severe.  Several factors contributing to muscle strains were mentioned under The Anatomy above.  Here is a list of the aforementioned and some additional causes:

• Dysfunctional joints above or below the injured area: if motion is limited in one area, the body will compensate and increase the demand on adjacent structures and tissues
• Dysfunctional fascia: if the fascia does not allow for smooth sliding and gliding between neighboring muscles and other structures, adhesions and scar tissue can develop
• Poor flexibility: this can be due to muscle length or fascial adhesions (scar tissue)
• Overstretching: stretching a muscle beyond its ability to recoil and return to its resting length
• Muscle strength imbalances: strength differences between muscles or muscle groups that are meant to oppose and control one another’s movement

There are other factors that can contribute to or increase the likelihood of a muscle strain, but we will focus on these five as we discuss both the rehabilitation and prevention of muscle strains.

Signs and Symptoms of a Muscle Strain

Common signs and symptoms of a muscle strain include:

• Sometimes an audible ‘POP’ is heard
• Localized pain at the site of the tear
• Stiffness
• Pain with stretching of the injured muscle
• Pain with contraction of the injured muscle
• Swelling
• Bruising

Rehabilitation Guidelines

If you have suffered a muscle strain, the general R.I.C.E. rules apply:

• Rest: take it easy
• Ice: ice no more than 15-20 minutes with at least an hour between applications
• Compression: use an ACE wrap or compression sleeve; don’t compress too tightly
• Elevation: keep the injured muscle above heart level

There are 3 phases of healing, each with different goals for rehabilitation:

Inflammatory Phase (Acute): This phase can last from 0-5 days, but generally inflammation begins to decrease after 48-72 hours post-injury.  Follow these guidelines:

• R.I.C.E.
• Range of Motion: perform gentle movements, but not to the point to pain
• Gentle stretching: not to the point of pain
• Decrease physical or recreational activity: to prevent further injury

Subacute Phase: This phase generally lasts between 5-21 days post-injury, but is variable depending on the severity of the injury.  During this phase muscle fibers are regenerating and being laid down randomly within the muscle.  It is important to gradually resume activity during this phase to help realign the new muscle fibers into an efficient position.  Follow these guildelines:

• Stretching, with increased intensity:  perform 3 sets of 30 second holds when stretching
• Massage: helps to realign new muscle fibers and free up fascial adhesions
• Gradually resume resistance training: this will also help to realign muscle fibers, as well as increase strength
• See a Physical Therapist: they can help address factors that may have contributed to the strain, such as spine mobility, pelvis mobility, inefficient muscle recruitment patterns, etc…

Maturation Phase (Recovery): This phase can last up to 6 months post-injury for the most severe cases.  This phase should consist of the following components:

• Resistance training with increase intensity: increase intensity slow and steady
• Endurance training: emphasize muscle strength and endurance
• Aerobic/Cardiovascular conditioning: don’t forget this!
• Balance and Proprioceptive training: this could be another reason why the strain occurred in the first place
• Agility training: quick movements and plyometrics.  This should be towards the end of rehabilitation

For resistance training and aerobic training guidelines, read this article!

Muscle Strain Prevention:

Based upon the predisposing factors and the rehabilitation guidelines we can formulate some key concepts to help prevent muscle strains from occurring.  Follow these five guidelines:

• Increase flexibility: Stretching all major muscle groups before and after a workout is a great idea.  Hold all stretches for 30 seconds.  Don’t stretch to the point of pain.  Beginning a Yoga program would be a great idea, but start easy and take it slow.
• Increase soft tissue mobility: This is a fancy way of saying, “get rid of the scar tissue and adhesions in and between your muscles”.  Remember the fascia that we’ve talked a little bit about?  Sometimes stretching isn’t enough.  A good physical therapist or masseuse can help you here!
• Correct strength imbalances: don’t ignore muscle groups.  For example, work your quads and your hamstrings, your triceps and your biceps, your low back and your abs, etc…  Strength imbalance not only can predispose you to a muscle strain, but possible worse!
• Work concentric and eccentric contractions: A concentric contraction means that the muscle is shortening as it is contracting.  An eccentric contraction is the opposite; the muscle lengthens as it contracts.  The easiest example to visualize this is a biceps curl.  As the weight comes up the biceps is contracting and shortening (concentric contraction).  As the weight is relaxed to its resting position, the muscle is still contracting as it is lengthening (eccentric contraction).  MOST MUSCLE STRAINS OCCUR DURING ECCENTRIC CONTRACTIONS!  You can integrate eccentric training into every exercise.  For example, when you squat, squat slowly down to your end position (controlling the eccentric contraction) and then push up.  When you bench press, lower the bar slowly (controlling the eccentric contraction) and then push up.
• See a good physical therapist, chiropractor or osteopath: they can make sure that you are moving efficiently, and eliminating extra, unnecessary demands on your muscles.

History and Symptoms

Posterior (back) view

• Usually not traumatic, although impingement can occur secondary to other shoulder injuries
• Usually a gradual onset; pain may have been present off-and-on for months or years
• Less commonly new activities can cause onset of pain
• Associated with prolonged overhead activities
• Pain in the front and the outside of the shoulder (sometimes pain may radiate down the arm)
• Pain with lying on the shoulder
• Pain with moving the arm up, out the side, or reaching behind (usually there is a painful arc of motion between ~80-120 degrees)
• Pain is usually sharp in nature and relieved upon cessation of activity

Conservative Treatment

• Ice: icing post-activity helps decrease inflammation and pain
• NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): such as Advil or Aleve.  Always check with your physician before using medication
• Rest/Activity Modification: rest is a critical component of treatment in order to decrease the inflammation incurred through repetitive, exacerbating motions (such as overhead activity).  However, rest in isolation will not solve the structural or biomechanical issues causing the impingement.  These will…
• Transverse Friction Massage: transverse friction massage increases blood flow to the (otherwise hypovascular) rotator cuff tendons, and also increases the mobility and integrity of the tendons.
  
• Rotator Cuff Strengthening: because of pain and/or disuse, the rotator cuff muscles often become inhibited and weak.  This perpetuates the impingement process.

1. Standing Shoulder Internal Rotation: Attach an elastic band to a doorknob (like a Theraband).  Hold one end in your hand.  Stand with your elbow tucked against your side,  your elbow bent to 90 degrees, and your hand facing straight ahead.  Slowly rotate your forearm to your stomach.  Relax and slowly return to the starting position.  External rotation can also be performed using an elastic band.
2. Side-lying Shoulder External Rotation: Lie on your side with your top elbow tucked against your side and your elbow bent to 90 degrees. Slowly rotate your forearm up towards the ceiling, keeping your elbow firmly against your side.  Lower slowly back to the starting position.  Progress to using light dumbells (less than 5 lbs.)
3. Shoulder Scaption: Begin by gently squeezing your shoulder blades together.  This is called “setting your scapulas”.  Holding your shoulder blades together (gently), raise your arm to shoulder height with your thumb facing up.  Make sure your elbows are straight. The angle of this motion should be about 30 degrees to the outside of straight ahead.  This exercise can also be progressed using light dumbells.

• Physical Therapy: A good PT can address posture, muscle strength/coordination, shoulder joint mobility, and other factors related to shoulder impingement that you may not be able to address on your own.

Tendonitis of the knee refers to inflammation of the tendons that surround the knee joint. In general, the patellar tendon, or the tendon that connects your patella (knee cap) to your tibia (shin bone) can become irritated when asked to meet the high demands of physical stresses and loads. The patellar tendon is necessary for knee and lower leg extension during activities such as walking, running, kicking a ball, pushing the pedals on a bike or jumping. Commonly associated with athletes or other sports related overuse injury, this condition can be associated with pain, swelling and redness. People who endure increased levels of jumping, running and impact may experience symptoms of activity that expresses itself in the knees or anywhere up the kinetic chain. There are many different types of knee tendonitis, conventional breeds you may have heard of are patellar tendonitis, also referred to as “jumper’s knee”, quadriceps tendonitis, or iliotibial band friction syndrome or IT band syndrome.

What if you have these symptoms?

There are a few proven techniques that will help you on your road to recovery, and the first thing to do is to reduce your symptoms.RICE: Rest, Ice, Compression, and Elevation after activity is recommended to calm the swelling and reduce pain. As noted, REST is the first and single most beneficial thing you can do for your knee once it is inflamed. Studies have shown that symptoms of tendonitis tend to disappear on a scale of weeks with rest, although elderly people and people who continued to ignore symptoms in their affected area did not heal as quickly and were more likely to progress to a chronic condition.

Taking anti-inflammatory drugs or pain relievers may also be an option to alleviate acute pain and symptoms of swelling/inflammation. In some cases people have found relief from coritsone or local anesthetic injections which tend to last up to 24 to 72 hours. In even more rare cases, surgery may be required to attend to damaged or frayed tendons.

Stretching is also suggested for specific muscle groups such as the quads, and IT band.

Cross-friction self massage or use of ointments that increase the temperature and circulation to the tissue area may also be helpful. The increase in blood flow will help speed the tissue healing and recovery time. Small vigorous semi-circular motions over the tendon and sweeping motions up towards the heart are good for increasing blood flow and encouraging lymph drainage.

Strengthening exercises such as mini-squats, wall slides or using an exercise ball against the wall can improve the strength of your quadricep muscles and help with overall balance and the alignment of forces through the knee. Exercises should be done in moderation and should not cause pain. If possible, make sure to perform exercises in a mirror and to watch yourself as you squat down that the plane of your knees does not exceed the plane of your toes, and your legs are coming down in a straight line, and not caving in towards one another.

Add support by wearing a knee brace or taping your knee may also help with painful symptoms during activity.

Overuse injuries tend to be chronic in nature and thus will most likely not disappear overnight. It is always a good idea to see a doctor or physical therapist to have them give you an individualized exercise prescription and answer any other questions you may have.