Perfecting Your Normal

Many anatomical differences mean each person will need to move in a customized way that suits their body, and unless you’re ambidextrous you shouldn’t expect to move the same way with each side of your body.

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Pretty much everyone who has worked out at a gym has had the experience of getting advice (frequently unsolicited) about how to do an exercise properly. frequently, this advice comes with the intent of helping you avoid injury, maximize your efficiency, or to hit on you. However, I am about to blow your mind with a revelation. People come in all shapes and sizes. Brilliant as this view of human nature may be, it is something that is forgotten far too often in the gym. People are not machines. We are not all built the same way, move uniformly, or require the same fuel. Many anatomical differences mean each person will need to move in a customized way that suits their body, and unless you’re ambidextrous you shouldn’t expect to move the same way with each side of your body. So all that advice you’re getting on how to squat normally may be a load of crap, but I am here to explain how you can do the best with what you got to perfect your body’s normal. 
 
🚩Red Flags🚩
Don’t go running off to the gym and start using the equipment all willy nilly thinking that there is no wrong way to move. Because there is. It’s a large part of my job to make sure you don’t jack yourself up by doing something you saw on Instagram. When it comes to movement, I worry about the red flags, not the minutia. A red flag that can be revealed by a squat test might include knee valgus, or knock knees. We know this can lead to knee pain and ACL tears in athletes (1). There you have it, folks! If you’re an athlete and you have knock knees then you should work on that. Do you have back pain? Well if you hurt you back by falling down, doing a dead lift, or in a car accident, then those are red flags. But there is no magic stretch, strengthening program, or posture that are red flags or fixes for that matter. I’ve written about it before, but I’ll say it again “Neck pain is not greatly associated with neck posture (2). Sagittal (front to back) spinal curve does not relate to spinal health or back pain (3). It is highly likely that we all have disc degeneration, a bulging disk, and/or protruding disk in our back right now, and that’s normal (4). It’s not an unequal leg length that’s causing your back pain (5). Even the best athletes in the world have asymmetrical muscle size and movement patterns, and they don’t have issues caused by them (6,7).
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Why We Must Move Differently
I’ll keep this brief. We must all move differently because of our bone structure, muscle/tendon location, and injury history requires us to. We are all so different that it’s impossible to define perfect posture let alone perfect movement. As our bones grow and change, they don’t do so uniformly. Most people know that women have wider hips than men because of the birthing process. Well, there are similar genetic differences amongst everyone that can lead to the bones of the hip to stop you from moving in an “optimal” way (8). It’s also why the phrase “squat like a baby” is total crapThe image bellow gives a good visual on how the hip can be different from person to person. This is why no amount of foam rolling, stretching, or muscle activation will help with “tight hips” in some individuals. 
 
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Making It Work For You
So here’s where we get down to business. If you, or someone you know, have specific questions about pain, performance, or application of any of the following suggestions, be sure to set up a one on one session with me by replying to this email so we can get into specifics for you. 
It’s no secret that exercising can come with aches and pains. Commonly, the shoulder, back, and knee joints. What you need to know is that pain does not always mean there is tissue damage. It may simply mean you are overstressing a particular structure. Which is why switching from back squat to front squat can alleviate knee pain even though you are still putting pressure on the joint. If your knees move towards the outside of your feet too much try taking off your shoes (9). If squatting makes your back hurt, decrease the amount of weight that you use, squat deeper, and allow your knees to go in front of your toes as seen in the picture below (10). You can also adjust the depth of the squat, foot stance, and barbell location to target specific muscles which I wrote about extensively in this post.
 
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If you want to build a bigger chest, use less weight on your bench press because of the heavier the weight the more you use your shoulders and triceps (11). In fact, getting more reps in is the name of the game. Stretching before you exercise will decrease the strength and muscle gain you can achieve, and may not even be achieving anything worthwhile, to begin with (hip flexors in particular) (12). A little cheating isn’t always a bad thing if a bit of a swinging/momentum gets you to squeeze out an extra few reps (13). At the end of the day, perfecting your normal means you are experimenting with technique so you don’t feel pain/do feel the targeted muscles work, you are getting as many weighted reps in a possible, and you gradually increase your body’s ability to do more work. This may require a trained eye, but it will never require a universally true way to do things.
Resources
1. Quatman, C. E., Kiapour, A. M., Demetropoulos, C. K., Kiapour, A., Wordeman, S. C., Levine, J. W., … & Hewett, T. E. (2014). Preferential loading of the ACL compared with the MCL during landing: a novel in sim approach yields the multiplanar mechanism of dynamic valgus during ACL injuries. The American journal of sports medicine, 42(1), 177-186.
2. Grob, D., Frauenfelder, H., & Mannion, A. F. (2007). The association between cervical spine curvature and neck pain. European Spine Journal, 16(5), 669-678. doi:10.1007/s00586-006-0254-1
3. Christensen, S. T., & Hartvigsen, J. (2008). Spinal curves and health: A systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. Journal of Manipulative and Physiological Therapeutics, 31(9), 690-714. doi:10.1016/j.jmpt.2008.10.004
4. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., . . . Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American Journal of Neuroradiology, 36(4), 811-816. doi:10.3174/ajnr.A4173
5. Grundy, P. F., & Roberts, C. J. (1984). Does unequal leg length cause back pain? A case-control study. Lancet (London, England), 2(8397), 256.
6. Hides, J., Fan, T., Stanton, W., Stanton, P., McMahon, K., & Wilson, S. (2010). Psoas and quadratus lumborum muscle asymmetry among elite australian football league players. British Journal of Sports Medicine, 44(8), 563-567. doi:10.1136/bjsm.2008.048751
7. Hespanhol Junior LC, De Carvalho AC, Costa LO, Lopes AD. Lower limb alignment characteristics are not associated with running injuries in runners: Prospective cohort study. Eur J Sport Sci. 2016 Jun:1–8. PubMed #27312709.
8. Pollard, T. C. B., Villar, R. N., Norton, M. R., Fern, E. D., Williams, M. R., Murray, D. W., & Carr, A. J. (2010). Genetic influences in the aetiology of femoroacetabular impingement. Bone & Joint Journal, 92(2), 209-216.
9. Southwell, D. J., Petersen, S. A., Beach, T. A., & Graham, R. B. (2016). The effects of squatting footwear on three-dimensional lower limb and spine kinetics. Journal of Electromyography and Kinesiology, 31, 111-118.
10. Hartmann, H., Wirth, K., Mickel, C., Keiner, M., Sander, A., & Yaghobi, D. (2016). Stress for Vertebral Bodies and Intervertebral Discs with Respect to Squatting Depth. Journal of Functional Morphology and Kinesiology, 1(2), 254-268.
11. Król, H., & Golas, A. (2017). Effect of Barbell Weight on the Structure of the Flat Bench Press. The Journal of Strength & Conditioning Research, 31(5), 1321-1337.
12. Junior, R. M., Berton, R., de Souza, T. M. F., Chacon-Mikahil, M. P. T., & Cavaglieri, C. R. (2017). Effect of the flexibility training performed immediately before resistance training on muscle hypertrophy, maximum strength and flexibility. European journal of applied physiology, 1-8.
13. Arandjelović, O. (2013). Does cheating pay: the role of externally supplied momentum on muscular force in resistance exercise. European journal of applied physiology, 113(1), 135-145.

Cramp Twitch Shake: What’s Making It Happen?!

Why can’t you control your own body while trying to work out?!?!

It’s a plague, a natural disaster, and a nightmare we have all experienced. Calf cramps that hurt so bad you don’t want to move, uncontrollable twitching in the thighs after a heavy squat or an embarrassing whole body tremble while trying to hold a plank. Muscle cramps, twitches, and shakes affect us all in one way or another. But what’s going on with the body when they happen? Why can’t you control your own body while trying to work out?!?! Well, the answer, as usual, is complicated yet very simple.
Image result for muscle cramp gif
Exercise-Induced Muscle Cramps
Let’s start with a list of things that don’t help with cramping:
 x Magnesium supplements
 x Hydration status
 x Sports drinks
 x Electrolytes
 x Shoe type
Muscle cramps happen for a wide variety of reasons, but for today we will focus in on the kind you get while exercising. It may surprise you to know that cramps do not happen because of dehydration or electrolyte loss/imbalance. Losses in fluids and electrolytes, plasma, blood volume, and body weight are similar in people who experience cramps and those who do not experience cramping (1). Ever get a cramp while doing calf raises? I certainly have, and I bet if you try to do calf raises until fatigue now, you will get a cramp regardless of your hydration status. The “until fatigue” part is important because that is why muscle cramps happen. The scientific way to put it is (2):
The muscle spindle responds to length changes in the muscle. As length increases, the muscle spindle increases impulses to the agonist muscle to contract and decreases impulses to the antagonist muscle so it relaxes. The golgi tendon responds to length changes in the tendon and causes the agonist muscle to relax. Both work together to protect the muscle from over stretching. However, with fatigue, it has been noted that the muscle spindle activity increases while the golgi tendon activity decreases.
In other words, your body thinks it’s going to injure itself through overtraining/overstimulation so it shuts down activity (3). The body does this by firing the nerves up to 150 electrical discharges every second (4). Aside from intensity of exercise, some causes of cramps include a family history of cramps, muscle damage, and heat illness (5).
The best treatments include (4,6,7)
 – Static stretching of the muscle
 – Acetic acid (found in pickle juice) to increase neurotransmitter inhibition to cramping muscles
 – Maintaining safe body temperature via hydration and rest intervals
 – Increasing total body strength to delay target muscle fatigue
 – Avoiding stimulants
 
Shake Spasm and Twitch
Shakes, spasms, and twitching kind of come with the exercise territory. There are medical classifications for all of the following information; however, we will be talking about them from a benign exercise-induced standpoint. Shakes (tremors) are almost always harmless and will never be explained. They are a huge category of involuntary muscle activity, ranging from the trivial to the disastrous, from teeth chattering in the cold to the wobbles of Parkinson’s Disease. In healthy people, they are usually stress induced. So if your hands or legs are ever a bit shaky after a hard workout, it’s because our motor control systems are a bit delicate. This is why unwanted contractions are so common and yet usually meaningless. Muscle spasms are an informal, non-specific term often used to “explain” musculoskeletal pain. Back spasms specifically do not cause pain, but rather are caused by pain (8). Muscles are always turned on and active in healthy people, and there is no such thing as normal muscle tone which is why “feeling tight” really doesn’t mean too much. A “muscle spasm” is really just the body preparing for a task (9). Twitching/rippling (Myokymia) happens when your muscle gets fatigued, so the motor units of your muscle fibers, rather than firing all at once, alternate their contractions, like pistons. Essentially, there aren’t enough motor units available for smooth contraction, so muscles start to ripple and quiver with intense exertions.
A Riddle To Ponder
What’s caused by doing exercise, and what’s caused by not doing exercise? Cramps, shakes, spasms, and twitches! It all comes down to how you’re training. If you’re doing enough exercise, you will start to see these issue go away. If you increase your exercise intensity, you will see them return… temporarily. The body is a crazy mystical web of mysteries. We are still discovering a lot, but the more you learn, the more it seems like we only know the tip of the iceberg. So don’t be embarrassed if you shake like a leaf while holding a plank, it’s completely natural.
References
1. Schwellnus, M. P., Drew, N., & Collins, M. (2011). Increased running speed and previous cramps rather than dehydration or serum sodium changes predict exercise-associated muscle cramping: a prospective cohort study in 210 Ironman triathletes. British journal of sports medicine, 45(8), 650-656.
2. Miller, Kevin. The Neurological Evidence for Muscle Cramping. NATA Symposium, June 2011, New Orleans Convention Center, New Orleans, LA. Conference Presentation.
3. Nelson, N. L., & Churilla, J. R. (2016). A narrative review of exercise‐associated muscle cramps: Factors that contribute to neuromuscular fatigue and management implications. Muscle & nerve, 54(2), 177-185.
4. Miller, T. M., & Layzer, R. B. (2005). Muscle cramps. Muscle & nerve, 32(4), 431-442.
5. Shang, G., Collins, M., & Schwellnus, M. P. (2011). Factors associated with a self-reported history of exercise-associated muscle cramps in Ironman triathletes: a case–control study. Clinical Journal of Sport Medicine, 21(3), 204-210.
6. Miller, K. C., Mack, G. W., Knight, K. L., Hopkins, J. T., Draper, D. O., Fields, P. J., & Hunter, I. (2010). Reflex inhibition of electrically induced muscle cramps in hypohydrated humans. Med Sci Sports Exerc, 42(5), 953-961.
7. Casa, D. J., Armstrong, L. E., Hillman, S. K., Montain, S. J., Reiff, R. V., Rich, B. S., … & Stone, J. A. (2000). National Athletic Trainers’ Association position statement: fluid replacement for athletes. Journal of athletic training, 35(2), 212.
8. Friedmann, L. W. (1989). The myth of skeletal muscle spasm. American journal of physical medicine & rehabilitation, 68(5), 257.
9. Szeto, G. P. Y., Straker, L. M., & O’Sullivan, P. B. (2009). Neck–shoulder muscle activity in general and task-specific resting postures of symptomatic computer users with chronic neck pain. Manual Therapy, 14(3), 338-345.

Get A Sexy Back & Healthy Shoulders By Doing This

For nearly all of us, there is one muscle group that’s often ignore which can keep our backs looking good and shoulders strong.

With pool, beach, and wedding season right around the corner, most of us are thinking about the implications of showing some skin. For others, our thoughts may rest completely on the thought of keeping our body healthy and pain-free. For nearly all of us, there is one muscle group that’s often ignore which can keep our backs looking good and shoulders strong. And that muscle is….
 
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The Serratus Anterior
The serratus anterior (SA), AKA boxer’s muscle does a lot. When it’s strong, the SA holds scapula (shoulder blade) against the thoracic wall (the rib cage) and rotation of the scapula. But when the SA is weak, it can lead to a forward head posture, winging scapula, subacromial impingement, rotator cuff tears, glenohumeral inferior instability, sternoclavicular joint pain, acromioclavicular joint pain, glenohumeral osteoarthritis, frozen shoulder syndrome, scoliosis, lateral epicondylalgia, kyphosis, thoracic outlet syndrome, headaches, neck pain, and upper crossed syndrome (1,2). Aesthetically, scapular winging can lead some to avoid open back dresses or leaving the shirt on at the pool.
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The Fix
For most people, I recommend some basic thoracic spine mobility drills. If you’re in a rush, some simple thoracic spine foam rolling for about 30 seconds will do in a pinch. As for exercises, the easiest thing you can do is incorporate pushups into your workout routine! Pushups are great for building SA strength when done correctly (3). And while I could write a book on the mistakes that can be made while doing pushups, let’s focus in on how to do them correctly. Keep your hands directly under your shoulders, brace the abdomen, keep your head and neck in neutral alignment with your spine (don’t look at your toes), and emphasize the last little bit of pushing at the end of each repetition. If you are already a proficient pushup pro, there are always fun ways to spice it up a bit like using a stability ball under your feet, BOSU ball under your hands, and performing pushups on an uneven surface.  
 
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Another great exercise is the dynamic hug. In this exercise, you use a resistance band wrapped around your back to increase the resistance of moving your arms forward for a hug. When done correctly, it should look the same as when my wife hugs me after I workout and stink like an old gym sock. Of course, there are dozens of exercises that work wonders for strengthening the SA, but these two exercises are safe, easily modified, and are very effective.
Bottom Line
At the end of the day, most of us exercise for our health and/or to look good in our birthday suits. Hitting the serratus anterior on a regular basis is a great way to accomplish both at the same time. So the next time you’re in the gym if you hear a trainer say “drop down and give me 20” you know it’s for a good reason. 
Resources
1. 4Fayad, F., Roby-Brami, A., Yazbeck, C., Hanneton, S., Lefevre-Colau, M., Gautheron, V.. . Revel, M. (2008). Three-dimensional scapular kinematics and scapulohumeral rhythm in patients with glenohumeral osteoarthritis or frozen shoulder. Journal of Biomechanics, 41(2), 326-332. doi:10.1016/j.jbiomech.2007.09.004
2. Nagai, K., Tateuchi, H., Takashima, S., Miyasaka, J., Hasegawa, S., Arai, R.. . Ichihashi, N. (2013). Effects of trunk rotation on scapular kinematics and muscle activity during humeral elevation. Journal of Electromyography and Kinesiology : Official Journal of the International Society of Electrophysiological Kinesiology, 23(3), 679-687. doi:10.1016/j.jelekin.2013.01.012
3. Decker, M. J., Hintermeister, R. A., Faber, K. J., & Hawkins, R. J. (1999). Serratus anterior muscle activity during selected rehabilitation exercises. The American journal of sports medicine, 27(6), 784-791.

What Happens To The Body When We Lose Fat & Gain Muscles

How fat loss and muscle gain occur in the body.

 
Fat Loss
When it comes to fat loss, there is a lot to go over. I’ll do my best to keep it simple, short, and sweet. Let’s start with metabolism, which is the energy your body uses to stay alive. This often-used excuse for gaining fat, or as a sales tool, is almost always overstated. In reality, 96% of us will stay within 200-300 calories of the average person’s metabolic rate (2). While doing things to raise your metabolism may seem like a great way to lose fat, in reality, those efforts may largely be meaningless. This is because our body knows that when metabolism is higher, we will need to eat more to recover the calories burned. And that’s why we get hungrier after we go for a run or swim (3). This can be counteracted by having a steady and healthy diet/lifestyle, instead of “going on a diet” for a particular period of time (4).
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Fat loss and weight loss are two completely different things. To lose weight, simply go to the bathroom. To lose fat, you will need to metabolize fat. To accomplish this, an activated fatty acid is oxidized to introduce a double bond; the double bond is hydrated to introduce an oxygen; the alcohol is oxidized to a ketone; and, finally, the four carbon fragment is cleaved by coenzyme A to yield acetyl CoA and a fatty acid chain two carbons shorter (5). Yes, that’s a lot of technical terms. However, what I wanted to demonstrate is that burning fat is not just as simple as applying a magic wrap or using lasers to liquidate the fat. There are a lot of things that need to happen for your body to use stored fat. A combination of diet, training, sleep, stress management, hormones, and other lifestyle factors play an integral part in how much body fat one has (6). 
 
Muscles!!!
Most people workout, in part, to look fit. Your aesthetics are mostly determined by how long your bones are, the length relationship between muscle bellies and tendons, and insertion points. Muscle growth is essential for all sorts of things like bone health, fat loss, and looking great naked. Muscle growth occurs, in part, by resistance training-induced release of inflammatory agents, activation of satellite cells, and upregulation of the IGF-1 system, or at least setting in motion the signaling pathways that lead to hypertrophy (7). Despite what you may hear, everyone is capable of building substantial amounts of muscle (8). I have found that the people who have done the best at gaining muscle:
1. have trained with intensity (adding weight to the bar, increasing total volume, and approaching failure with their training).
2. were very consistent and made training a lifestyle (years of consistent training, not a few months here and there).
3. varied their training over time to help induce new muscle growth stimulus and avoid adaptation and injuries.
4. and were methodical in their approach, meaning they paid attention to rep schemes, tracked their progress, and aimed to improve over and over again.
 
And while I can go on for days about the nuances of exercise and resistance training, I’ll boil it all down to consistency. As long as you are weight training each muscle group at least once per week, you will see improvements. Just lift heavy things, and lift them often, because there is a dose-response relationship (9). So what I am saying is, take the “at least” advice literally and shoot for more. At the end of the day, if you want to gain muscle there are no legitimate “get ripped quick” plans. 
Resources

  1. Klein, A. V., & Kiat, H. (2015). Detox diets for toxin elimination and weight management: A critical review of the evidence. Journal of Human Nutrition and Dietetics, 28(6), 675-686. doi:10.1111/jhn.12286
  2. Donahoo, W. T., Levine, J. A., & Melanson, E. L. (2004). Variability in energy expenditure and its components. Current Opinion in Clinical Nutrition & Metabolic Care, 7(6), 599-605.
  3. Weise, C. M., Thiyyagura, P., Reiman, E. M., Chen, K., & Krakoff, J. (2015). A potential role for the midbrain in integrating fat‐free mass determined energy needs: An H215O PET study. Human brain mapping, 36(6), 2406-2415.
  4. Dulloo, A. G. (2017). Collateral fattening: When a deficit in lean body mass drives overeating. Obesity.
  5. Berg, J. M., Tymoczko, J. L., & Stryer, L. (2002). Lipids and cell membranes. Biochemistry, fifth edition. New York: WH Freeman, 1050.
  6. Müller, M. J., Enderle, J., & Bosy-Westphal, A. (2016). Changes in energy expenditure with weight gain and weight loss in humans. Current Obesity Reports, 5(4), 413-423.
  7. Schoenfeld, B. J. (2012). Does exercise-induced muscle damage play a role in skeletal muscle hypertrophy?. The Journal of Strength & Conditioning Research, 26(5), 1441-1453.
  8. Montero, D., & Lundby, C. (2017). Refuting the myth of non-response to exercise training: ‘non-responders’ do respond to higher dose of training. The Journal of Physiology, doi:10.1113/JP273480
  9. Schoenfeld, B. J., Ogborn, D., & Krieger, J. W. (2016). Dose-response relationship between weekly resistance training volume and increases in muscle mass: A systematic review and meta-analysis. Journal of Sports Sciences, 1-10.

You Don’t Know Squat?!

Training the prime movers of the squat is essential for maintaining fitness, a fine physique, and independence into old age. So we ALL need to practice/enhance this skill through exercise.

Squatting is an exercise that we must do everyday. I’m not talking about putting loads of weight on your back and squatting up and down in front of a mirror. I’m talking about the motion itself! We squat when we get in and out of the car, sit down and stand up from dinner or the couch, use the toilet, and in many other daily situations. We squat while doing tasks like picking something off of the ground, getting out of bed, dancing, picking up groceries, and almost any type of athletic movement. Training the prime movers of the squat is essential for maintaining fitness, a fine physique, and independence into old age. So we ALL need to practice/enhance this skill through exercise.
There are dozens of ways that you can squat, and there are hundreds of people who claim to know the “best way” to squat. But for all intents and purposes the squat can be broken down into two basic forms. These two forms are the front and back squat, that can be further distinguished by three basic heights: partial, parallel, and full. Proper form for squatting requires keeping your back flat, heels on the floor, and knees aligned over the feet. And when we talk about the safety of squat variations you don’t just have to consider how far back you sit, how far your trunk leans, or how far your knees travel over the toes; you also have to consider how far you shift forward or backward with the bar relative to the feet, as this influences joint torques considerably. So everything considered, squatting can be very complex. If you want to ensure proper form, it may be worthwhile to seek professional advice.
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Pros And Cons
There are many benefits from squatting in any fashion, but there can also be negative outcomes. The Back Squat is good for increasing tendon, ligament, and bone strength as well as developing speed, power, and strength in the lower back, hips, and knees. The bad news is that it can cause joint degeneration, osteoarthritis and osteochondritis, muscle strains, damage to the ACL, and knee instability.
The Front Squat may be a good alternative for those with knee pain because it is just as effective regarding overall muscle recruitment with significantly less compressive forces on the knees. However, there appears to be no difference between front squat and back squat regarding shear stress on the knee, which is actually fairly low -– a lot lower than, say, knee extensions. Squat depth has been shown to have a significant effect on muscular development at the hip and knee joints. To optimize development of the gluteus maximus (the butt muscles), squats should be carried out through their full range of motion. To target the quadriceps (the thigh muscles), a squat depth of 90 degrees appears to be optimal. Hamstring activation / development are generally unaffected by squat depth. The drawback seems to be that although deep squats seem to be safe in healthy folks, those with PCL disorders should refrain from squatting below 50 to 60 degrees, and those suffering from chondromalacia, osteoarthritis, and osteochondritis may also need to avoid deep squats. Where you place the bar can also be a factor. So after a hip injury, high-bar squats should be used at the beginning to minimize the risk of hip overload. After a knee injury, a squatting technique more similar to the low-bar technique should be preferred. Finally, research shows that box squats and powerlifting squats could be “safer” for the low back compared to traditional squats.
From Noob To Pro In No Time
In this section I will go over how to learn to squat correctly for beginners, progressively squat more for novice squatters, and how to kick it up a notch for the squat masters.
Noobies
Before you go out and throw a barbell on your back, consider learning these basic moves first if you’re a beginner.
1. The hip hinge requires flexibility of the ankles, hips, and thoracic spine and stability in the feet, knees, and lumbar spine. Therefore, hitting the foam roller, or using some preparation exercises might be required pre-hip hinge. To perform this motion, start by shifting your body backwards, place your weight through the heels, and keep a neutral spine position. Practice first with hands on the hips, then add the simultaneous movement of both arms straight forward and above shoulder height.
2. Body weight squats are next. Begin by looking at a mirror to ensure your head is in a neutral position with your gaze forward or slightly up, thoracic spine (mid back) slightly straight and mobile, lumbar spine (low back) neutral and stable, hip joints mobile and bending backward behind heels, and knees stable and in alignment with your hips and feet. Additionally, your feet should be at shoulder width, in a neutral position, with your heels are firmly on the floor. Start the squat motion by beginning with a bend in the hip joints, followed by bending knees to the desired depth while ensuring that your trunk angle (from the floor) is stable in each movement phase.
3. Functional squatting exercises are important for us all. So once mobility, stability, and strength have been developed, we can get creative! See the next section for more on this.
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The novice squatter is someone with established form and proper mobility, stability, and strength. If you’re a novice squatter, you should:
1. Begin at the top by training loaded partial squats to the desired sets and repetitions. Gradually increase your range of motion while keeping in mind that the deeper you squat, the lighter the load should be.
2. Start adding more volume by increasing the frequency you squat per week. To keep it simple, squatting 3 times per week with 3 working sets per session for a total of 9 weekly sets will be plenty for the average gym goer.
3. Gradually increasing weight will be inevitable. The general rule of thumb here is to increase your load by no more than 10% each week.
The advanced squat star (squar?) will want to change things up a bit and get jiggy with it. Shake things up by going for exercises such as single leg squatsplyometric squatssquats with a band around your kneessquat burpiespistol squatsgoblet squats, and unstable squats.

25% Of Us Have Knee Pain Due To…

Just because it’s common doesn’t mean you have to develop it or that it will last forever. So don’t stop moving!

Our knees hate us. Or at least it can seem that way when they aren’t doing what we want them to do. Creaky, achy, and wonky knees are all too common among my friends when I ask them to help me move. And while those may be excuses for them, I bet it’s a reality for most of you. The sad part is that because the knee is so complex, it is often misunderstood. When you have a bum knee, rest is almost never the answer. This is particularly true for the 25% of us who will end up having knee pain due to patellofemoral pain syndrome (PFPS) (1). Also known sometimes as runner’s knee, PFPS is a complex issue without one true solution. Let’s take a look at why the knee cap can make us feel like knee crap!
 
So What’s The Problem Again? 
As the name implies, PFPS is not a single problem but a group of signs and symptoms. Generally, the epicenter of the pain is somewhere under or around the kneecap, and will usually be mainly on the front of the knee. It can be caused by variations in strength, flexibility, patellar tracking, quadriceps angle, and patellofemoral joint (PFJ) morphology and even psychological issues such as depression, fear-avoidance, and anxiety (2). However, I like to think of PFPS as the knee leaving homeostasis. Homeostasis can be described as a zone, or “envelope of function”, where the tissue is capable of tolerating loads (3). So as you get stronger, you increase your envelope of function. And when you over-do it with your training, your knee may no longer tolerate levels of loading even during routine activities, such as descending stairs or previously well-tolerated running distances (4). In other words, when you over-do-it with your training or exercise, you may not be able to do half as much as you used to without pain.
 
How Do I Avoid/Fix The Problem?
While I would love to tell you how to screen yourself for potential red flags, there really aren’t any good predictors of injury (5). What will help you out is strengthening the quadriceps (6). By using a progressive overload scheme (aka gradually doing more over time), you can make those quads stronger and avoid pain and/or injury! Here are some exercises to try out for good quad activation and strengthening (4):
 – Knee extension with a weight attached to the ankle
 – A knee extension machine
 – Single leg squat to at least 65 degrees of knee flexion
 – Squatting between 0 and 45 degrees of knee flexion
 – Leg presses between 0 and 45 degrees of knee flexion
You can also try taping (anywhere on the front of the knee) or bracing the knee to alleviate the pain. You can pretty much tape your knee however you want because it doesn’t change the biomechanics of the knee (7). Strengthening the hip muscles will be helpful for more than just bikini season because strengthening those glutes (and other muscles of the hip) can help reduce pain and improve function (8). Similar to taping and bracing, strengthening the hips won’t improve biomechanics. Hip strengthening will, however, increase the load tolerance of the knee and supportive structures (9).
 
For Runners
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This segment is for runners, so feel free to skip it if you don’t anticipate doing a 5k anytime soon. Runners, in particular, are susceptible to having issues with their movement patterns that can lead to knee issues. Movement re-education through simple techniques can be extremely helpful for reducing knee pain. Reducing hip drop while running is a great way to help reduce knee pain. In addition to using glute strengthening techniques, mirror and verbal feedback can reduce hip drop and hip adduction (knee movement inwards) while running (10). A general increase in step rate by 5-10% can also be very beneficial for reducing knee load and pain (11). A metronome works great for achieving a faster gait pattern.
 
Summary
While knee pain may never be completely eliminated, there are some steps that can be taken to decrease pain and the likelihood of developing pain. Work toward having strong quadriceps, move with good technique and don’t advance your exercise routine too quickly. And while shock absorbing insoles and arch supports may be useless, throwing on a little tape or knee support may give you enough pain relief to build up your leg strength (12). For runners, watch yourself in the mirror and make sure you don’t have hip-drop and increase your running cadence. Just because PFPS is common doesn’t mean you have to develop it or that it will last forever. So don’t stop moving!

References

  1. Nunes, G. S., Stapait, E. L., Kirsten, M. H., de Noronha, M., & Santos, G. M. (2013). Clinical test for diagnosis of patellofemoral pain syndrome: Systematic review with meta-analysis. Physical Therapy in Sport : Official Journal of the Association of Chartered Physiotherapists in Sports Medicine, 14(1), 54-59. doi:10.1016/j.ptsp.2012.11.003
  2. Meira, E. P., & Brumitt, J. (2011). Influence of the hip on patients with patellofemoral pain syndrome: A systematic review. Sports Health: A Multidisciplinary Approach, 3(5), 455-465. doi:10.1177/1941738111415006
  3. Gabbett, T. J. (2016). The training-injury prevention paradox: Should athletes be training smarter and harder? British Journal of Sports Medicine, 50(5), 273. doi:10.1136/bjsports-2015-095788
  4. Willy, R. W., & Meira, E. P. (2016). CURRENT CONCEPTS IN BIOMECHANICAL INTERVENTIONS FOR PATELLOFEMORAL PAIN. International Journal of Sports Physical Therapy, 11(6), 877.
  5. Whittaker, J. L., Booysen, N., de la Motte, S., Dennett, L., Lewis, C. L., Wilson, D., . . . Stokes, M. (2016). Predicting sport and occupational lower extremity injury risk through movement quality screening: A systematic review. British Journal of Sports Medicine, , bjsports-2016-096760. doi:10.1136/bjsports-2016-096760
  6. Kooiker L Van De Port IG Weir A Moen MH. Effects of physical therapist-guided quadriceps-strengthening exercises for the treatment of patellofemoral pain syndrome: A systematic review. J Orthop Sports Phys Ther. 2014;44(6):391-B391.
  7. Whittingham M Palmer S Macmillan F. Effects of taping on pain and function in patellofemoral pain syndrome: A randomized controlled trial. J Orthop Sports Phys Ther. 2004;34(9):504-510.
  8. Lack, S., Barton, C., Sohan, O., Crossley, K., & Morrissey, D. (2015). Proximal muscle rehabilitation is effective for patellofemoral pain: A systematic review with meta-analysis. British Journal of Sports Medicine, 49(21), 1365-1376. doi:10.1136/bjsports-2015-094723
  9. Willy RW Davis IS. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. J Orthop Sports Phys Ther. 2011;41(9):625-632.
  10. Willy, R. W., Scholz, J. P., & Davis, I. S. (2012). Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clinical Biomechanics (Bristol, Avon), 27(10), 1045-1051. doi:10.1016/j.clinbiomech.2012.07.011
  11. LENHART, R. L., THELEN, D. G., WILLE, C. M., CHUMANOV, E. S., & HEIDERSCHEIT, B. C. (2014;2013;). Increasing running step rate reduces patellofemoral joint forces. Medicine & Science in Sports & Exercise, 46(3), 557-564. doi:10.1249/MSS.0b013e3182a78c3a
  12. Bonanno, D. R., Landorf, K. B., Munteanu, S. E., Murley, G. S., & Menz, H. B. (2016). Effectiveness of foot orthoses and shock-absorbing insoles for the prevention of injury: A systematic review and meta-analysis. British Journal of Sports Medicine, , bjsports-2016-096671. doi:10.1136/bjsports-2016-096671

Everything In Moderation

Common causes, injuries, and solutions to the problem.

This week I wanted to talk about over-training and injury. This topic is particularly important to me because, well, it’s a big part of why I went to school to be an Athletic Trainer. In High School I played a lot of sports, and as a result, sustained a lot of injuries from over-training. So today I will share common causes, injuries, and solutions to the problem.
The Problem
Over-training is a complex beast. It’s determined by an imbalance of pro- and anti-inflammatory factors, and can rear its ugly head at the worst of times. When it comes down to it, over-training occurs when the body doesn’t have enough time to recover, and can manifest in the following ways:
elevated resting heart rate and blood pressure
loss of appetite and weight loss
chronic fatigue, workouts described as draining
chronic soreness/slow recovery rates
an increase in colds or infections
a decrease in performance, or an inability to reach training goals
lack of enthusiasm, psychological staleness
Injuries
It’s important to note that while experiencing muscle pain is normal, not all pain is good pain. Make sure you know the difference before you run to the doctor with every little nagging problem, or conversely, avoid the doc when you do have an issue. 
As a result, injuries can also pile up. I commonly see injuries of the shoulder, lower back pain, and even shin splints due to over-training just to name a few. In particular, the shoulder can be fickle. From weight lifting, to swimming, or even throwing a ball around, the shoulder is the poor joint we love to overuse. Some symptoms to look out for include an obvious deformity, it gets popped out of place, difficulty lifting the arm, clicking or popping sensation deep in the shoulder, and/or pain reaching across your body. These symptoms warrant a trip to your favorite doctor, but the good news is that many shoulder injuries DON’T require being sliced and diced to fix them.
Solution
To avoid missing long stints of exercise, you will want to treat over-training by doing… well… nothing! One of my favorite sayings is “you don’t build muscles in the gym. You build them in bed.” The key here is to make sure that you are getting enough rest and proper food to support your physical activity. You should also make sure you shake things up here and there. Doing the same thing over and over again can be stressful on the body and mind, so moderation is crucial. In fact, doing a mix of cardio, weight lifting, and HIIT (join me Monday nights at 6:15 for our HIIT Grit team training) is optimal for reaching almost any goal. On that note, it’s important to remember that you will want to increase intensity carefully. You should make small steps every day toward those goals, one pound or mile at a time. Finally, you will want to take a chill pill. Everyday stress can affect our performance in the gym, so grab a stress ball (or a beer), take deep breaths, and smile more often to feel more refreshed.