Snap, Crack, Pop: What Joint Sounds Really Mean

It’s harmless to be a crack addict (e.g. cracking your knuckles), the hazards of trusting others to crack you, and what those other sounds your joints make actually mean.

I cracked my knuckles while at work the other day and a patron looks at me like a mother scolding her toddler and says “You know cracking your knuckles causes arthritis. You wouldn’t want to deal with that down the road now would you?” Being the nice young man that I am, I just smiled and nodded. But I really wanted to explain to her that cracking your own joints is harmless! That’s why I am going to talk about how it’s harmless to be a crack addict (e.g. cracking your knuckles), the hazards of trusting others to crack you, and what those other sounds your joints make actually mean. So prepare yourself for some snappy puns, and let’s get started on this poppin post!
Tribonucleation is the formation of tiny bubbles between two submerged surfaces when those surfaces are suddenly pulled apart (A.K.A. knuckle cracking). What this means is that during a the cracking process the opposing knuckle joint surfaces resist separation until a critical point where they then separate rapidly creating sustained gas cavities. We know this, due to a very cool study where a person cracked their knuckles during an MRI showing that the cracking is due to cavity inception rather than collapse of a pre-existing bubble (1). In other words, if you want to get your crack on you must generate enough force to overcome tension within the joints (synovial) fluid that keeps the joint tight (not within the soft tissues). This means that you are disrupting the tension forces that keep the joint surfaces together that adds stability to the joint itself (2). This is why you feel nice and loose after a good popping. 
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When it comes to the safety/potential for harm, we know that there is no reason to fret. The old wives’ tale of knuckle cracking causing joint arthritis stems from the thought that the joint collapses during and/or after the force is applied (3). However, we now know for sure that the resting joint orientation is not changed by the cracking event. Furthermore, there is some pretty good research out there showing that cracking your knuckles won’t cause harm (4)… unless it annoys those around you enough for them to cut your fingers off.
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What About My Back?!?!
Cracking backs is a practice used by Doctors of Osteopathy, Physical Therapist, and of course Chiropractors. Although the latter of the professions may suggest otherwise, what happens during a back crack is cavitation of a spinal facet joint… same as with the knuckles (5). And what does this “treatment” do? Well it can relieve back pain by taking pressure off sensitive nerves or tissue, increase range of motion, restoring blood flow, reducing muscle tension, and, like more active exercise, promote the release of endorphins within the body to act as natural painkillers. Of course these effects last for about 5 minutes, so a spinal manipulation should be considered one part of a therapy, and not THE therapy (6). Anyone who says otherwise is either lying, or selling you something (The Princess Bride shout out).
The Neck
Here’s where things get serious. First of all, we know that cracking the neck is not super beneficial for resolving pain compared to medication (7). Second, we know that neck manipulations come with a rare, but serious, side effects such Cervical Artery Dissection, stroke, and even death (8). I’ll end this brief segment by saying that the risks simply do not justify the reward.
Clicking, Crunching, Snapping & The Others
You may notice that not all joints make the same noises. In fact, there are lot’s of sounds that your joints can make, and they can often mean different things. Some common places to experience snapping, clicking, popping, or crunching include the chestshoulderforearmhips, and knees. Of these, the knee is the most common area to experience some form joint sound. Crepitus is the formal term for popping or cracking under the patella (kneecap) and can mean different things depending on where you experience it or feel pain. For instance, a grinding sensation can indicate arthritis, a popping sensation can mean you have loose tissue (plica) getting caught, and a catching feeling could indicate you have a meniscus disorder. Check out this brief video to learn a bit more about what to lookout for if you have questions on how to determine what your knee issue is.
Finally, I would say that the most important factor in deciding what to do about your joint noises is to ask yourself “is this stopping me from doing the things I want to do?” If the answer is NO, then the issue may resolve on its own in time. If the answer is YES, you should seriously consider seeing your Doctor or a Physical Therapist about it.
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1. Kawchuk, G. N., Fryer, J., Jaremko, J. L., Zeng, H., Rowe, L., & Thompson, R. (2015). Real-time visualization of joint cavitation: E0119470. PLoS One, 10(4) doi:10.1371/journal.pone.0119470
2. ROSTON, J. B., & HAINES, R. W. (1947). Cracking in the metacarpo-phalangeal joint. Journal of Anatomy, 81(Pt 2), 165.
3. Unsworth, A., Dowson, D., & Wright, V. (1971). ‘cracking joints’. A bioengineering study of cavitation in the metacarpophalangeal joint. Annals of the Rheumatic Diseases, 30(4), 348-358. doi:10.1136/ard.30.4.348
4. Deweber, K., Olszewski, M., & Ortolano, R. (2011). Knuckle cracking and hand osteoarthritis. Journal of the American Board of Family Medicine : JABFM, 24(2), 169.
5. Patient positioning and spinal locking for lumbar spine rotation manipulation. (2001). Journal of Osteopathic Medicine, 4(2), 65-65. doi:10.1016/S1443-8461(01)80005-8
6. Hegedus, E. J., Goode, A., Butler, R. J., & Slaven, E. (2011). The neurophysiological effects of a single session of spinal joint mobilization: Does the effect last? The Journal of Manual & Manipulative Therapy, 19(3), 143-151. doi:10.1179/2042618611Y.0000000003
7. Gross, A., Langevin, P., Burnie, S. J., Bédard-Brochu, M., Empey, B., Dugas, E.. . LeBlanc, F. (2015). Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. The Cochrane Database of Systematic Reviews, (9), CD004249.
8. Thomas, L. C., Rivett, D. A., Attia, J. R., & Levi, C. (2015). Risk factors and clinical presentation of cervical arterial dissection: Preliminary results of a prospective case-control study. The Journal of Orthopaedic and Sports Physical Therapy, 45(7), 503.

Shaking Things Up: A Guide To Periodization (AKA Muscle Confusion)

If you do the same workout all the time, you shouldn’t expect to reach greater exercise outcomes.

Today I wanted to go over workout periodization. This used to be known as muscle confusion, but I really hate that term. That’s because our muscles don’t have brains, and as research rock star Brad Schoenfeld puts it “Periodization is a concept, not a defined training model. It’s simply a way to manipulate training variables (load, volume, frequency, etc) over time to optimize a given fitness outcome while reducing the potential for plateau/overtraining. As such, there are an almost endless number of ways to structure a periodized routine to achieve individual goals.” This means if you do the same workout all the time, you shouldn’t expect to reach greater exercise outcomes. So let’s dive into how to shake things up!
One of the first steps that you can take is knowing different exercises. This means growing your toolbox of exercises! If you just go to the gym and hop on the same machines all the time, you can expect to only get better at what those machines offer. I have written about how to structure a basic exercise routine, and there are plenty of great resources online describing how to exercise. But the bottom line here is that you need to branch out and explore the gym for new ways to get strong.
Basic Breakdown
As mentioned before, shaking things up means changing the load (weight lifted), volume (weight x reps), and frequency (how often you target a muscle group). Whether you know it or not, your goal in shaking things up is to build more muscle. More muscle means more strength, more stability, greater sports performance, and general life performance. In the end this means by shaking things up through proper periodization you are enhancing your longevity. You won’t become huge by lifting weights (unless you put a LOT of effort in), but muscle growth is the ultimate goal for everyone in one way or another!
Perfecting Your Periodization
Depending on what your exact goals are, training experience, and current fitness levels, your periodization scheme will vary somewhat. However, here are some recommendations that everyone should follow (1):
All muscle groups should be worked out, including legs, back, abs, chest, shoulders and arms.
Do one set of 8-12 reps for each exercise.
2 hours and 30 minutes each week (total of 150 minutes) of moderate-intensity aerobic activity. That’s the 30 minutes a day Monday through Friday recommendation we’re all so familiar with.
Or, 1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity. That’s about 20 minutes of exercise 3-4 times a week.
Or, a combination of the above that gives you an equivalent result. For example, you can walk briskly for 30 min twice during the week and then jog for 20 min on two other days.
Boring recommendations, but they are a minimum for a reason. If you really want to see improvements, you should try a few different strategies. One great way to see a performance boost is to change up your rep ranges. For instance, lift near-max weight for two to four reps on the first workout day, moderate weight for 8 to 12 reps on the second day, and lightweight for 20 to 30 reps on the third day. By training in this alternating fashion you can see greater strength and muscle growth benefits (2)! To make your workouts easier to track, you can also alternate weights on a weekly or even monthly basis to see similar benefits.
Timing Is Everything
Changing things up is necessary, but there is more to consider. Two big factors are when to change, and when to rest! Rest is important because there is a benefit to instituting regular deload period, where a week of reduced frequency, volume, and/or intensity every month or so to facilitate recuperation and regeneration. But we do know that training a minimum of 2 days a week is needed to maximize muscle growth (3). Check out the table below for a great example of how to schedule your workouts (4).
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Changing your sets, reps, and frequency schemes will bring you results. So if you haven’t figured it out yet, tracking your workouts is extremely important. None of this information will be very useful if you don’t know how much volume you’re lifting per muscle group. So get yourself an exercise journal, or create an Excel spreadsheet to see the gains and avoid injury. Because even though you may have the secret to the building big arms, you won’t be able to know if you’re doing it right unless you write it down!

A Healthy Body Begins With Happy Feet

The foot and ankle complex provides a base of support for all of our upright movement, so why don’t more people do exercises to strengthen such an important part of their body?!?!

Today I wanted to address how your feet influence the movements of your entire body. Your feet play a critical role in many movements beyond just walking, running, and jumping. The foot and ankle complex (FAC) provides a base of support for all of our upright movement, and if the muscles within the FAC become imbalanced it can set off a chain of negative reactions. So why don’t more people do exercises to strengthen such an important part of their body?!?! Well, today I am going to lay out what what the FAC is good for, and how to best go about achieving arch strength and happy feet.
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FAC Facts and FAQs
The FAC is extremely complex because there are dozens of bones and hundreds of muscles, tendons, fascial components, and ligaments at play. All of these components come together within the FAC to provide stationary support while standing and dynamic spring while moving. So I will do my best to keep it simple, but please forgive me if my inner nerd comes out and I use too much technical jargon. When it comes to movement of the FAC, one major concern is the interaction between the arch of the foot and dorsiflexion of the foot (taking your foot off the gas motion). A lack of dorsiflexion in the ankle can be the caused by several factors, but frequently involves decreased strength of the tibialis anterior muscle (1). The decrease in shin muscle strength can then lead to flat feet, increased plantar flexion (pressing the foot down on the gas) during squatting motions and gait (walking). All in all, the arch can be placed under great amount of stress during the load acceptance phase of gate, if your foot is weak and there is limited dorsi flexion. That’s because during this phase of the walking/running cycle the shin and ankle muscles assist the arch in energy absorption (2). If the ankle is unable to properly dorsiflex, a huge amount of stress will be placed on the foots spring ligament, plantar fascia, and intrinsic muscles which can lower the arch. This lowered arch in turn causes tibial (shin) rotation, hip internal rotation, slight hip flexion, and hip adduction creating a valgus (knock knee) stress (3,4). So what does this mean for you? Well to sum it all up, when we don’t pay attention to the FAC we are more likely to have stiff hips, lower back paintight calves, weak feet, weak ankles, altered gait, plantar fasciitishallux valgus (a.k.a. bunions), patellofemoral pain, increased susceptibility to medial collateral ligament (MCL) injuries, and an increased likelihood of anterior cruciate ligament (ACL) tears.
There are also some other surprising aspects of foot strength that I’m betting most of you didn’t even think about. Having proper FAC strength means you have developed some proprioception (foot eye coordination in this case). In turn, this means you know where your body is at in space. This is extremely important if you think about it because it’s the same as knowing where my fingers are as I type each letter of this post. I don’t need to look down for each letter, I just know how to move my hands. So, if you practice strengthening your FAC you will know where your lower body is during each step you take. This leads to better performance for athletesenhancements in the standing and walking positions, and the ever crucial prevention of falls for seniors (5).
Foot Fitness
So I’m going to start this section by being a negative Nancy. To have healthy feet you SHOULD NOT use arch supports or supportive shoes. No, this does not mean you should take out those stinky old things you have put in your shoes for years and start walking around. What I mean is that the arch support is to the feet, what the weight lifting belt is to the back. Yes they are both supportive, but if you don’t let those underlying muscles develop you will end up with some limp noodles for muscles. So instead of opting for the all or nothing path, star weaning yourself off of the arch support and into regular shoes. Or if you’re ready for it, start weaning yourself onto more minimalist shoes. It’s really all about a gradual progression into a more barefoot environment… unless your feet stink like mine ;). You wouldn’t go from lifting 10 lbs dumbbells to benching  225 lbs, so don’t jump too quickly on the minimalist bandwagon especially if you have high arches to begin with (6).  
Okay, I know that if you have read this far you might be a little frightened of your weak feet. But I promise you that you don’t have to do that much to whip them into shape! This is because even though you use them all day long, the interaction between your nerves and your muscles may be the real underlying issue. So to re-learn your own feet, there are a few simple steps you need to take. Use your time wisely by standing on one foot as often as you can. This can be done while you wash dishes, make phone calls, eat Ramen noodles, or other things that people who aren’t poor college students do. You can also practice flexing your toes while you’re sitting down. This can be done by simple scrunching your toes together while at your desk, or by picking up objects and putting them into a container while you’re seated (7). Additional exercises include standing on one foot, bunny hops, walk heel to toemedial (inside) calf raises, resisted ankle inversion exercises, single-leg kettlebell swap, foam rolling the biceps femoris (outside hamstring) and plantar fascia, and walking in a straight line with one foot in front of the other. Finally, you should take care of your hips. The interaction between the hips and the ankles goes both ways. So stiff hips can mean stiff ankles and visa versa.
1. Chizewski M., & Chiu L. Contribution of calcaneal and leg segment rotations to ankle joint dorsiflexion in a weight-bearing task. Gait & Posture, 3685-89. doi:10.1016/j.gaitpost.2012.01.007
2. Spaich, E. G., Andersen, O. K., & Arendt-Nielsen, L. (2004). Tibialis Anterior and Soleus Withdrawal Reflexes Elicited by Electrical Stimulation of the Sole of the Foot during Gait. Neuromodulation, 7(2), 126-132. doi:10.1111/j.1094-7159.2004.04016.x
3. Hollman, J. H., Kolbeck, K. E., Hitchcock, J. L., Koverman, J. W., & Krause, D. A. (2006). Correlations Between Hip Strength and Static Foot and Knee Posture. Journal Of Sport Rehabilitation, 15(1), 12.
4. Simon, L., Christian, B., Peter, M., Richard, T., Roger, W., & Dylan, M. (n.d). The effect of anti-pronation foot orthoses on hip and knee kinematics and muscle activity during a functional step-up task in healthy individuals: A laboratory study. Clinical Biomechanics, doi:10.1016/j.clinbiomech.2013.11.015
5. Hashimoto T, Sakuraba K. Strength Training for the Intrinsic Flexor Muscles of the Foot: Effects on Muscle Strength, the Foot Arch, and Dynamic Parameters Before and After the Training. Journal of Physical Therapy Science. 2014;26(3):373-376. doi:10.1589/jpts.26.373.
6. McKeon, P. O., Hertel, J., Bramble, D., & Davis, I. (2014). The foot core system: a new paradigm for understanding intrinsic foot muscle function. British journal of sports medicine, bjsports-2013.
7.Siddiqi A., Kumar D., Arjunan S. Age-related motor unit remodeling in the Tibialis Anterior Proceedings of the Annual International Conference of the IEEE Engineering in Medicine and Biology Society, EMBS, Volumes 2015-November, 4 November 2015, Pages 6090-6093

Take Control of you LBProbems

From young athletes, to chair bound adults, to golden year seniors, almost everyone will experience lower back pain at some point in their life. For this reason I decided to break down LBP into what it is and what to do about it!

Today I am talking about the dreaded lower back pain (LBP). From young athletes, to chair bound adults, to golden year seniors, almost everyone will experience lower back pain at some point in their life. For this reason I decided to break down LBP into what it is and what to do about it!
The Major Malfunctions
There are dozens of reasons why someone would have LBP. Even different illnesses can cause it. So to avoid writing a whole book I’m going to cover the biggies. 
In young athletes, the problem is often in the bones of the spine. In fact 47% will have a spondylolysis fracture with only 11% of LBP being caused by disc issue in this population. This differs from the adult population where 48% of LBP is disc related. So in young athletes the problem is often caused by repetitive extension and torsion of the spine, where as in adults the issue is typically due to sitting posture. Take a look at the picture bellow to see how changing your body position affects the load on you spine
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So clearly much of the problem has to do with… well… you! Do you sit too long? Do you sit with crap posture? Do you move well? All of these questions are important ones to ask yourself. But the good news is that you’re in control!
What To Do About It
Before I go into detail about exercises and stretches to help, I will tell you that you need to see a doctor if you experience any of the following issues:
Do you feel any tingling or numbness?
● Do you have any loss of sensation?
● Do you have any loss of motor control, such as an inability to raise your arm over your head?
● Do you have or have you ever had a loss of bowel or bladder function?
● Do you have severe immobility or an inability to walk?
Answered no to all of the above? wonderful, please read on at your leisure. In fact stand up, walk around, then sit back down and read on. Because Tip 1 is to start by sitting for no more than 30 minutes at a time. It’s the most simple and easiest way to help control that back pain. Now that you’re sitting Tip 2 is to now get into a proper sitting posture. So feet flat, chest up, core contracted, and eyes straight ahead. And finally Tip 3 breath from your belly. Not only will this help relieve stress (another cause of LBP) but it will engage that protective core musculature.
The Exercises
Here’s the problem with recommending exercises. Everyone has different needs!!!! Not everyone is going to be weak in the same areas. Not everyone is going to need stretching of the same muscles. For instance, if your back rounds out like a turtle when you sit down, you may need to stretch your hamstrings. However, if your back arches when you do a squat or sit down then that’s the opposite of what you want to do! So please come see me if you want some specifics on what to do to help correct your posture. In the meantime, you can try some of these exercises which are generally safe and effective for most people.
1. The Glute bridge. A simple and easy exercise that you can do anywhere. It activates the tooshie as well as the wonderful core muscles.

2. The hip flexor stretch. A wonderful pairing to the glute bridge is a stretch of the hip flexors. This stretch will allow the butts and guts do their jobs.

3. The plank. Abdominal bracing is all the rage this fall. So make the plank a part of your workout wardrobe.

4. Leg swings. This will help mobilize the hips so you can use your booty!

5. The fire hydrant. This exercise uses your mobilized hips to further strengthen them glutes.
When it comes to back health there is a lot to take into account.To be honest I have barely scratched the surface on this topic, but I feel like this post has gone on long enough as it is. So sit up straight, work on glute and core strength, and get out of that chair! 

Pain In The Neck

The neck is really designed to balance the 10- to 14-pound pumpkin that sits on top of it. The problem arises when your head starts to drift forward.

One thing I take pride in, and greatly enjoy, about my job, is my ability to see dysfunction postures and movement pasterns. So this week I wanted to discus an issue that I see far too often these days. This issue is the forward head posture. So while you read this weeks post, make sure you sit up straight!
The Issue
The Cervical spine, the neck, can bend forwards, backwards, to the side, and rotates. It’s made out of seven vertebrae and dozens of muscles, both large and small. Some of these muscles never rest when you’re upright, otherwise your head would fall to your chest! The neck is really designed to balance the 10- to 14-pound pumpkin that sits on top of it. The problem arises when your head starts to drift forward. This is because for every inch the head juts forward, the neck takes on a load equal to roughly 10 additional pounds. In turn this can lead to neck pain, stiffness, cervical muscle strains, headaches, dizziness, early onset arthritis, decreased lung capacity, and pain or weakness in parts of the body that lie below the cervical spine.Yikes!
How Did I Get This Way 😥
By now I assume you’re all sitting up straight in your chair like Hermione Granger in class. But in reality, this posture develops over a long period of time. Most commonly, people who work long hours at a computer, professional drivers, cyclists, runners, baseball players, cell phone addicts, musicians, chefs, surgeons, dentists, and other people who lean over their work are likely to develop a forward head posture.
What To Do About It
So by now you should be able to tell that this issue doesn’t just develop over night. So don’t be a Goober and think simply sitting up straight more often will fix it. You spend your whole life getting into the posture that your in, so you will need to take a few more steps to overcome the postural dysfunction. The first step is to see a doctor if you’re experiencing numbness, pain that radiates toward the shoulder or arm, or a loss of strength in the arms or hands. If you don’t have any of these medical concerns then you can try stretching and foam rolling the thoracic spine, sternocleidomastoid, levator scapulae, and upper trapezius to start. Next, you need to be mindful of the muscles that are working during your exercise. If you’re doing a shoulder raise, but feel the muscles in the upper traps firing up, you will need to make adjustments to what you’re doing.