An often overlooked muscle group when it comes to stabilization exercises for the pelvis and low back are the pelvic floor muscles (the levator ani and coccygeus). This is a group of muscles that connect from the front of the pubic bone to the tailbone. They create a hammock between the legs and assist in stabilizing the pelvis as well as supporting the abdominal organs, particularly the bladder and bowels.

Weakness in the pelvic floor muscles can contribute to back pain, sacroiliac joint pain, pubic symphysis pain, as well as incontinence (leakage of urine) when you cough or sneeze. Dysfunction in the pelvic floor muscles can be due to trauma, as a result of childbirth, or due to poor posture with associated muscle imbalances.

To exercise the pelvic floor muscles, try to envision pulling the muscles of the saddle area up and in towards your abdominal cavity. You should not feel your buttocks, thighs, or abdominals tightening as you do this. One of the simplest ways to learn to contract the pelvic floor is to stop the flow of urine while you are on the toilet. You can try this technique to verify which muscles to isolate, but avoid doing this often, as it can cause urinary tract infections.

This type of pelvic floor contraction is also known as Kegel exercises. Though it can be difficult to learn how to isolate these muscles, they are an important component of a lumbosacral rehabilitation program. (They’re also very important to do throughout pregnancy and immediately following birth in order to prevent and manage incontinence.) If you are not certain that you are performing these with the correct technique, discuss it with your health care provider or physical therapist.

When I was in college I had my fair share of running injuries…mostly because I didn’t stretch enough. I developed Achilles tendinitis, which is an inflammation of the Achilles tendon, the thick, fibrous tendon that travels from the calf muscles along the back of the ankle.

When the Achilles becomes inflamed, there is less space within the connective tissue sheath that surrounds it. It can feel squishy, or even like it gets stuck as you try to flex and point the foot, due to adhesions that develop. These prevent the tendon from gliding smoothly. The pain can be mild or severe, and is worse during the push off phase of walking or running, or any time you point the foot and toes downward.

Often, there is associated weakness in the Achilles and possibly weakness in the anterior muscles of the shin, with tightness in the calf and Achilles. Both stretching and contracting of the calf muscles may reproduce pain.

Managing this type of injury requires frequent icing to reduce inflammation. Rest is also key. High impact activities, particularly any sports that involve running or jumping should be avoided. Cross friction massage is also very beneficial to improve circulation and reduce adhesions and promote optimal alignment of collagen fibers. It may be that flat feet or high arches contributed to the problem, and orthotics may be helpful in restoring better alignment to the foot and ankle. There are also braces and night splints available for more severe cases that allow the calf muscle to rest and have a gentle sustained stretch. Frequent active stretching of the gastracnemius and soleus, the 2 muscles that form the Achilles tendon, is also essential.

Seeking treatment early will help prevent a chronic inflammation from developing. Physical therapy can be very helpful in correcting any muscles imbalances, retraining the joint receptors, and helping to reduce inflammation with various modalities (such as ultrasound, iontophoresis, and electric stimulation). A PT can also help develop a sports specific rehab program to help get you back to your sport safely and as quickly as possible, teaching you ways to avoid the same condition in the future.

My friend’s mom is newly diagnosed with spinal stenosis. She began to experience back pain a couple of months ago and her primary doctor referred her to physical therapy with a diagnosis of a bulging disc based upon her symptom: back pain that radiated down her leg.

Based upon her diagnosis, her therapists had her working on spinal extension exercises based upon the McKenzie method. These exercises encourage back bending of the spine and are designed to encourage the disc to migrate back into position, thereby relieving pressure on neighboring nerve roots. She did not improve, and in fact she experienced an increase in pain and further loss of function. Everyday walking and going to her gardening club became impossible.

She was then referred to a specialist who ordered an MRI. The results revealed that she has significant spinal stenosis. This condition also causes pressure on nerve roots due to arthritic changes around the spinal column which result in crowding of the canal.

In general, people with spinal stenosis respond well to flexion, or forward bending exercises, which help to open up the stiff, crowded joint spaces in the spine. This is quite the opposite of what she experienced in her first go around with physical therapy.

As a result of her negative experience, she opted to try acupuncture and steroid injections into her spine. I have tried to encourage her to resume some exercise, such as stationary cycling, or gentle water exercise. Walking, which naturally promotes spinal extension, truly aggravates her symptoms, but doing no exercise will only exacerbate the stiffness and mobility limitations within her spine. She is still reluctant, and rightfully so given her current pain level and her prior PT treatments…which were unfortunately for the incorrect diagnosis.

I don’t think her primary doctor is to blame here. Doctors must make their best educated diagnosis based upon a patient’s presenting symptoms and in these days of managed care, do try to avoid ordering expensive tests, such as an MRI until necessary. Many of my patients with back pain come to physical therapy before MRIs are performed, and many do in fact get better without having a confirmed diagnosis. In this instance, however, an earlier MRI may have resulted in a better outcome. Earlier access to the appropriate form of physical therapy or other treatment may have provided more rapid relief of pain and prevented a decline in her function and activity level.

Over the years when I worked in hospitals, I occasionally saw patients who were admitted with chest pain. A heart attack wasn’t the culprit (but of course had to be ruled out), but after many tests and doctor examinations, it was determined that the source of pain was due to inflammation at the joint where the ribs meet the sternum, or breastbone. This condition is known as costochondritis.

The joints where the ribs attach to the sternum do not allow a great amount of motion, but they do glide and can become inflamed or irritated. In many cases, the problem stems from poor posture. When the shoulders and upper back round forward, the chest caves in and the joints at the breastbone get compressed. The pain associated with this often increases with coughing, sneezing, sudden movements, slouching, or stretching the chest.

If you experience any chest pain, it’s essential to seek care from a physician immediately in case it is of cardiac origin (early access to care is the best indicator for positive outcome with coronary events). If they determine that you have costochondritis, you may be prescribed anti-inflammatories and rest or referred to an orthopedist, physical therapist, or chiropractor.

I recommend being very aware and careful with your posture and avoid slouching at all. Use a lumbar support cushion to help maintain upright sitting posture with ease. Deep breathing, gentle chest stretching (as long as it doesn’t increase your pain) and icing the area are also helpful to facilitate healing.

Growing up I loved the Wizard of Oz. The combination of the music, costumes, and the absurdness of it was really so entertaining. In my work, I often think of the poor Tin Man, who was so stiff and constantly needed to oil his joints to keep mobile. That’s really not too far off from our bodies in a way. We have special lubricating fluid in our joints that helps the joints move smoothly.

The joints in the body bend and straighten, but they also glide in multiple directions. For example, the knee bends and straightens, but as it bends, the tibia (shin bone) glides backwards on the femur (thigh bone). And at the same time, the knee cap glides down. There’s a lot of complexity to that really, and if any part of the bending or gliding is limited, pain can occur.

I’m going to stay with the knee as an example because it’s an easier joint to explain. If you sit with your legs straight out in front of you and relax your thigh muscles, you can use your hands to gently wiggle your kneecap up and down and side to side. If the joint capsule (which is essentially like saran wrap around the joint) here becomes tight due to a new or old injury, a disease process, or disuse, knee dysfunction could occur. In addition, tight muscles can restrict the kneecap’s ability to glide. For example, a tight IT Band will tend to pull the knee cap out to the side, decreasing it’s ability to glide inward and altering the resting and functional alignment of the kneecap. This can cause wearing on the underside of the kneecap which would inflame the joint. Injuries to the knee such as chondromalacia patella, IT Band syndrome, patella dislocation, and patella tenndinitis can all be related to a disruption in the gliding mechanism of the kneecap.

So sometimes when you stretch on your own and don’t see an improvement in flexibility, it may be because the joint isn’t gliding correctly and that is what is limiting your motion and progress. The only way to restore normal flexibility in that case is by mobilizing the joint and stretching the joint capsule. This could be done by a chiropractor or physical therapist. There are also self mobilization straps and wedges you can be instructed to use for mobilizing the neck and back. It’s important to maintain the flexibility of both muscles and joints in order to keep from getting stiff and creaky like my friend the Tin Man.

Over the years, I’ve learned to very easily distinguish between the pain I feel when I injure a joint versus a muscle. And I’ve had my share of injuries… plantar fasciitis, Achilles tendinitis, chondromalacia patella, ITB syndrome, SI sprain, thoracic/rib sprain, rotator cuff strain, cervical sprain, and I’m probably leaving out a few.

Though I’m not into extreme sports and I exercise regularly, I have some structural skeltal abnormalities that have predisposed me to these many injuries just with somewhat normal activity (especially running…which I love but my body doesn’t share the sentiment.)

The pain from the joint injuries or sprains is quite distinct from muscular injuries. Joint pain is often felt or described as being:

1. Sharp

2. Localized

3. Worse with specific movement patterns

For example, when I sprained my wrist, I could pinpoint the exact joints/ligaments that were affected, and it only hurt in the one spot when I extended my wrist back. When I sprained my SI joint, the pain was again, very specific to the SI joint, and it hurt when I brought my leg out to the side and extended my spine as if into a backbend.

A muscle injury, or strain is usually experienced differently. The pain tends to be:

1. Along the length of the muscle or tendons

2. Worse when the muscle contracts and stretches

3. More difficult to pinpoint to just one spot

4. Tenderness to the touch with or without muscle spasm

When I strained my rotator cuff, it hurt to both reach my arm up (as it contracted) and reach my arm around my back (as it stretched). When I pressed on the tendon it was very sore to touch, and the pain seemed to travel all around my shoulder.

The treatment for both types of acute injuries is the same: rest, ice, compression, and elevation. In terms of rehabilitation, it’s important to consult with a doctor regarding the best form of treatment for your specific injury. You may find that for joint injuries, a chiropractor or physical therapist may offer the most relief. Muscular injuries may respond well to massage and/or physical therapy. Again, I can’t stress the importance of early access to evaluation and treatment to prevent a chronic condition from developing.

I was talking with a nurse the other day and she said to me, “You’ll appreciate this…my husband just ruptured his Achilles Tendon.” The look of dread on her face was apparent, and she went on to share with me that he had ruptured his other one only a few years before. They knew exactly what lie ahead.

The Achilles tendon is the thick, long band of tendon that runs vertically along the back of your ankle. It’s where tendons of the calf muscles (gastracnemius and soleus) come together, and it functions when you push your foot down. Actions like pushing off to run, jumping, and other high impact sports all require the Achilles tendon to be strong and pliable.

A more common injury in men, Achilles tendon ruptures are often seen in weekend warriors, though can also occur in seasoned athletes. When a person experiences a complete rupture of the Achilles, he may hear or feel a snap or pop, but with complete ruptures there usually isn’t a lot of pain since the nerve endings are no longer intact. The tendon may then ball up, like a roller shade would retract up, and a lump can be seen and felt in the calf. This type of injury requires surgery to reconnect the Achilles tendon in order to regain a normal walking pattern and daily function.

Following surgery, the rehabilitation course is a long, extensive process. For the first month or more, weight bearing is restricted and a walking cast is required. Physical therapy often begins with gentle non-weight bearing range of motion exercises to start getting the calf and Achilles used to movement again. This is in addition to modalities such as ultrasound, heat, and soft tissue mobilization and scar massage which help to increase circulation to the tissues, promote healing, and help reduce scar tissue and adhesions.

Over the next month, usually the walking cast is still required for all weight bearing in order to protect the Achilles, but additional stretches and strengthening are begun. The boot cast may be taken off (depending on the individual surgeon and case) during therapy sessions at this point. Eventually, and it can seem like forever with this injury, you’re told the walking cast can be removed and walking without it attempted. People are often surprised at how unable to walk they are, since the calf hasn’t had to work to push the foot off the ground. Many have to re-learn how to walk in a more normal fashion without a limp.

It is now that weight bearing strengthening and balance retraining begin for most individuals. Rising up on the tiptoes, using a balance board to shift weight, and progressing to other uneven surfaces, balancing on one leg, and more dynamic stretching of the Achilles are performed.

Return to sports and hobbies can take up to a couple of months more if running or jumping are required. (Maybe a good time to focus on your golf swing?) It is so important to gently warm-up and stretch before, during, and after play, to keep the Achilles soft, flexible, and less susceptible to re-injury.

Just don’t forget to stretch both sides!

So we decided for the first time this year to forgo the flu shot. I’ve done it in years past when I worked in hospitals and then with young children we always opted for it. My kids are 4 and 5 this year and out of the high risk age range, so we skipped it since we’re generally healthy and I was feeling optimistic.

Well, live and learn. We got the flu (and I say this diagnosis with confidence because the pediatrician did a nasal swab on my daughter to confirm that it was in fact the flu) not once, but twice. Yes, we got two different strains of the virus this year, and it hit hard. High fevers, stomach upset, and a cough that was unlike any I’ve ever experienced. And this is how my injury came to be.

From my frequent, violent, coughing fits, I managed to send my entire neck into painful spasm, to the point where I couldn’t even turn my head. It was so excruciating and every time I coughed I had to brace myself and support my neck in anticipation of the pain.

Now, I’m an advocate of early access to treatment, so after unsuccessfully trying to treat myself (and actually making myself worse by trying to stretch the joints and muscles of my neck and upper back), I went to see a chiropractor and then a massage therapist. My pain gradually decreased as my motion also improved. I have regained almost full motion, and only have pain when I cough (which has lasted over 2 weeks now) and at the extremes of motion. Had I not sought immediate treatment, I don’t believe I would be feeling as well as I am today.

I can’t stress enough the importance of early access to treatment for any type of musculoskeletal pain. It helps to restore function and prevent secondary effects from stiffness and immobilization. Although waiting it out to see what happens is sometimes OK, in many cases, you will speed your recovery time and healing process by seeking out professional care from a doctor, chiropractor, physical therapist, and/or massage therapist within the first three days.

Within physical therapy and among physical therapists there is a a lot of variation in treatments that can be implemented. I’ve worked in hospitals and private clinics, and I have yet to meet 2 physical therapists who would approach a patient with low back pain in exactly the same way. A lot depends on the therapists level of experience, continuing education, and clinical training.

When I graduated with my master’s 10 years ago, I could treat a patient with low back pain in a very basic way. I had done one of my clinical rotations at an outpatient clinic in rural Iowa, and I learned entry-level techniques, without a lot of emphasis on manual therapy for the spine. With my low back patients, I would do some stretching, strengthening, modalities (like ultrasound and electric stimulation), and basic soft tissue and joint mobilization. The lower back was certainly not the area I was most comfortable treating.

Then I attended a seminar where I learned muscle energy techniques, and it changed my approach to back pain (and how quickly my patients felt better). A year or so later I learned another type of joint mobilization and again my experience, approach, and effectiveness improved. I also learned myofascial release, a type of soft tissue mobilization, which added another hands on tool for me to utilize. I wonder had I not taken these particular courses, would I still dread evaluating and treating lower back pain.

I recently read an article that talked about how the approach to care for low back pain patients varies greatly. Some practitioners take a very gentle approach to working with these patients, doing aquatic exercise, gentle stretching, heat, ultrasound, and ice. Others use McKenzie exercises, which encourage a lot of back bending type exercises. Some prefer to do all spinal stabilization. Some therapists use only hands on techniques to restore alignment and muscle balance. This is in high contrast to others, such as the New England Baptist Spine Program which takes a very aggressive approach to strengthening and does not use any modalities or hands on treatment (which has very good clinical results for decreasing pain and improving function for patients with chronic back pain.).

I feel very strongly that each patient is unique and their experience of pain must be looked at very individually. My experience has shown that a combination of some manual therapy, stretching, strengthening, and pain management modalities (all specific to the patient’s body and needs) if necessary provides relief for most patients. If you are working with a therapist and not seeing results, it may be that a different approach to your condition may be what you need. If you notice you are only doing exercises and the therapist doesn’t do any hands on work, you may need some specific joint stretching done. If your therapist is only doing hands on work and modalities, you probably need to do exercises to maintain the changes that their hands are invoking. It’s perfectly okay and appropriate to let your PT know that you are concerned about a lack of progress. You can also ask for a second opinion. You may not feel comfortable telling your provider that you want a different PT to see you, but a good therapist should be open to at least getting a colleague’s opinion and suggestions if you aren’t improving. You can always seek treatment at a different facility as well. If you take that route, be sure to communicate with your new therapist about the specifics of prior treatment that weren’t effective so you can start in the right direction. (You will also need to talk with your insurance company as they may not pay for a second evaluation and you may have partially exhausted your benefit.)

There are many options for back pain treatment within and aside from physical therapy. The same treatment doesn’t work for everybody; if it did, there wouldn’t be anybody living with chronic pain. If you can be open to trying new things, be consistent with the requirements of the treatment (if you don’t do any of your exercises and aren’t getting better, that may be the problem), and be proactive in finding the best solution for yourself, over time you should find relief from your pain.

This is a question I hear often from patients, friends, and family. It’s so interesting the way the body responds to an injury, and how a specific injury or problem can cascade into other areas of the body.

Here’s a great example…many patients with lower back pain present with restricted movement in their neck or upper back. Although these areas may not be painful or uncomfortable (and many would not think they are related) I would bet that in most cases they are a huge part of the problem at the lower back. You see, the body is an amazing structure, and it compensates in many ways so it can still function fully. So if the upper back is stiff, the lower back may overstretch in efforts to reach or twist, creating an imbalance there. This over stretching can create a condition of excess mobility in the lower back, which may become a source of pain before the root of the problem (the neck or upper back) ever speaks up. And for some, the neck or upper back area may start to become bothersome after the lower back is inflamed, painful, and weak. Here comes the feeling of falling apart…

So what can you do to prevent this? Stay as healthy as possible. This includes eating a well balanced diet, and getting enough exercise, sleep, and relaxation time. Regular physical exams are important as are some regular pampering sessions. You may choose quarterly massages, chiropractic treatments, working with a physical therapist or trainer, acupuncture, Reiki, Reflexology, or any number of other alternative forms of body work or healing practices. Getting prompt treatment and care when you feel pain or discomfort is also of huge importance so any imbalances get addressed immediately and secondary problems can be avoided.