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.

This is the time of year when many of my patients express frustration at not being ableto enjoy gardening because of pain or an injury. Personally, I look forward to making changes to my perennial garden and planning our vegetable and herb garden each spring. And though I’m careful and try to be safe, there are evenings where I find myself sore from a day’s worth of digging and planting.

The back, neck, knees, and shoulders are often taxed with the various motions and positions assumed while tending to a garden. Kneeling, for example can be hard put a lot of pressure on the knee joint and bursa. Squatting repeatedly or for sustained periods can be aggravating to the knees, low back, pelvis, and hips. Raking, weed pulling, and digging require the neck and shoudlers to do a lot of work. So what’s a gardener to do?

I always promote the use of proper body mechanics, however I am realistic too. It’s often difficult to keep the joints in neutral alignment whn working in the garden. In situations where the body is under stress or working in a less than ideal alignment, the following tips may help prevent soreness and injury:

1. Vary your position every 5-10 minutes. Alternate between half kneeling on one knee, kneeling on both knees, and squatting when working low to the ground. It’s also a good idea to vary between standing and squatting to minimize the likelihood of strain to the joints and overuse type injuries.
2. Stretch often. Every 10-15 minutes, do a few simple stretches. Since a lot of positions I find myself in when gardening involve bending forward, I try to do stretches where I bend backward. Placing the hands on the lower back and gently arching back while standing is a nice way to stretch the front of the body. You can also do various stretches for the neck, chest, hip, and hamstring. This gives the muscles a well deserved break, allows better circulation to reach the tissues, and helps restore symmetry and balance to the body.
3. Don’t overdo it. (This is where I often go wrong.) I sometimes get on such a roll and can be in the garden for hours working. Try to limit the length of time you spend to perhaps one hour, maybe more or less, each day.
4. Sit back and enjoy. Allow yourself time to relax and take in the sights and sounds in your garden, even if you aren’t finished.

The wrists are very complex anatomically, with lots of little bones, ligaments, muscles, and nerves running through it. It is also subject to a lot of use, particularly in our age of technology. I remeber from the old Jetson’s cartoons George Jetson used to get a big swollen finger from all the button pressing, and we’ve seen that really happening..well not so much with fingers, but more often with wrists.

If due to trauma or overuse you begin to experience acute wrist pain, it’s important to follow the RICE protocol.

Rest: try to limit motion at he involved wrist. This may be best accomplished by wearing a wrist splint, which will immobilize and protect the wrist as it heals.

Ice: Using an ice pack or performing ice massage to the affected area using ice cubes will help to reduce both pain and swelling.

Compress: compression helps to provide warmth, comfort, and protection to the wrist and limits swelling. Some neoprene splints provide compression. You may also use an ace bandage or the self adhesive ace wraps available at most drug stores.

Elevate: If there is very significant swelling, such as from a fracture, it’s important to elevate the wrist and hand above the level of the heart (after emergency medical treatment and care are administered). This will help prevent complications during healing and speed up the recovery process.

If possible, try to prevent wrist injuries by keeping the wrists in a neutral position, using good posture, and taking frequent breaks to stretch the muscles of the wrist and elbow.

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.

Sitting on the floor may be something you do often, or for some it may be a position they never assume. Personally, I never felt comfortable sitting on the floor, but when I had children, I found myself constantly on the floor with them. I would vary my position between sitting cross legged, kneeling, lying on my side, or propped up on my elbows while on my stomach. These frequent position changes helped my stave off stiffness and soreness, but it still wasn’t ideal to change my posture every few minutes.

As my yoga practice deepened, I began doing more spine and hip opening postures which certainly helped in terms of flexibility for being able to maintain these seated on the floor positions. The other technique I applied at home was to sit on a bolster pillow or folded blanket to help lift my hips up a little. By lifting the hips higher than my knees, the pressure on the muscles along the spine is reduced, and I am able to maintain these seated positions for longer periods and feel much more comfortable doing so. With my hips elevated, I can vary between sitting with my legs crossed, with my legs straight out in front of me, or with my legs out to the sides. It has helped me to gain better strength through sitting with an upright spine, and also improved the flexibility of my hamstrings and thighs.

You can experiment with sitting on a firm, folded blanket or a firm pillow. Allow your “sit bones” (the bony prominences within the flesh of the buttocks also known as the ischial tuberosities) to rest at the front edge of the blanket, so the pelvis starts to spill forward slightly, bringing the lower spine into it’s natural curve. This alignment through the lower spine translates to better posture through the ribcage, upper back, shoulders, and neck. If you find this to be particularly helpful, I recommend investing in a yoga bolster. They are made specifically to aid with seated postures on the floor and are the right size and firmness for doing this.

As always, listen to and respect your body. If something doesn’t feel right to you (stiffness, aching, throbbing, or other pain/discomfort), immediately bring awareness to your body, change your position, and eliminate the strain on your body. This will help reduce the likelihood of and assist in recovery from musculoskeletal injuries.

Back pain during the childbearing year affects up to 80% of women as a result of the vast changes happening in the body as the baby grows. During pregnancy, the joints throughout the body become more mobile due to the production of several hormones. The spine is therefore more easily sprained or pulled into sub-optimal alignment. This can result in muscle spasm, inflammation, pain, and a decrease in functional and recreational activities. In addition, women gain on average 25-35 pounds over a short period of time, with the majority of that weight distributed at the abdomen and breasts. This change in her shape shifts the woman’s center of gravity forward and upward, resulting in changes in her posture. She tends to stand with an excess arch in her lower back and her upper back rounded forward. These postural changes place stress on the muscles and ligaments surrounding the spine which can also lead to pain and functional limitations. Although back pain during pregnancy is a common problem, it often goes untreated as it is often perceived as an inevitable side effect of pregnancy.

Research findings suggest that the majority of cases of pregnancy-related back pain go unreported, with only a third of women discussing the problem with their maternity providers. Within that group, only 25% of their providers recommended a specific form of treatment.1 Women do not, however, have to suffer through their pregnancies with back pain. There are several safe, effective treatments that can help them manage their pain and optimize their well-being throughout pregnancy and into the postpartum period. A description of each follows, as well as some pros and cons.

Independent Exercise Program

Exercise is beneficial in preventing back pain, as well as helping to manage and reduce existing pain. In fact, research findings suggest that regular exercise during pregnancy can result in a significant reduction in the intensity of back pain. 2,3 Achieving a good balance between the strength and flexibility of the muscles surrounding the spine and pelvis can help provide stability and decrease the risk of injuries. In particular, the abdominal, back, and pelvic floor muscles should be targeted, as they are often most impacted by the physical changes that occur during pregnancy. Prenatal fitness classes offer a nice way for women to improve their cardiovascular fitness, strength, and flexibility, with the added benefit of socializing with other women. Prenatal yoga and Pilates are nice options as they target the spinal stabilizing muscles while focusing on alignment and posture. If such classes are not accessible or affordable, there are numerous book and video resources that can help women design their own programs.

Pros:

• May help prevent pain
• Can do exercise when it’s convenient
• Inexpensive
• Can use as an adjunct to individualized treatments for optimal results

Cons:

• If exercises are done incorrectly, pain and injury could result
• If lacking motivation, women may not be consistent with an exercise program
• Exercise may not be suitable for women with high risk pregnancies

If attempts to exercise independently are unsuccessful or pain initially prohibits exercise, individualized treatment by one of the following professionals could be beneficial.

Physical Therapy

A physical therapist experienced in treating pregnant women can evaluate the woman’s posture, spinal and pelvic alignment, joint mobility, muscle flexibility, strength, and tone. The physical therapist can perform safe, gentle techniques to re-align joints, improve joint motion, and reduce muscle spasm. In addition, a physical therapist can design an exercise program specific to the client’s needs in terms of muscle strength and flexibility, as well as teaching her how to move, position herself during sleep, and optimize her posture during daily activities. The treatment modalities physical therapists commonly use, including ultrasound and electrical stimulation, are for the most part contraindicated during pregnancy, but moist heat or cold packs could be used to help reduce pain and spasm.

Pros:

• Postural re-training will help during pregnancy and throughout motherhood to decrease stress to the spine, thereby decreasing risk of injury
• The pregnant woman can stop seeing the physical therapist and continue independently with her individually designed exercise program once she is ready
• Most health insurance covers the cost of physical therapy minus a co-payment

Cons:

• Depending on the facility, patients may not receive one on one treatment
• Not all therapists are experienced in treating pregnant women, so it is advised to inquire with local facilities to find an experienced provider

Massage Therapy

A massage therapist trained in prenatal massage will evaluate the client’s muscle tone and address any areas of tightness or restriction. The pregnant woman may be treated on her side, and some massage therapists use special pillows with a cutout for the abdomen so the woman can lie on her belly. Using various techniques, the massage therapist can help improve the circulation to the muscles, reduce stress, and promote relaxation, which can in turn improve posture. One study also found that pregnant women receiving massage therapy for 20 minutes twice a week experienced less anxiety, improved mood, better sleep, and a reduction in back pain.4

Pros:

• Improves circulation to muscles in pain or spasm
• Promotes relaxation and improved posture
• Gives the pregnant women an opportunity to rest and unwind, which is often much needed

Cons:

• Can be costly, even if subsidized by insurance
• Without exercise to help address muscle weakness and inflexibility, relief may be temporary
• As with physical therapists, one should find a massage therapist trained in prenatal massage

Chiropractor

A chiropractor experienced in treating pregnant women will assess the client’s posture, alignment, muscle tone, and mobility for regions of restricted movement or mal-alignment which would contribute to swelling, pain, and muscle spasm. S/he will then use various techniques to adjust, manipulate, or realign the joints. This restoration of joint positioning helps to reduce pain and improve movement and function. Some chiropractors will also recommend appropriate stretching and strengthening exercises to help maintain the corrections in alignment. In addition, one study found that women with back pain who were treated with spinal manipulation experienced less back pain during labor. 5

Pros:

• An effective way to correct an alignment problem
• Can sometimes provide immediate relief
• Effective if done in conjunction with the appropriate stretching and stabilization exercises

Cons:

• Can be costly depending on insurance
• Manipulating joints that are already more mobile (as a result of hormonal changes) could result in pain and injury if done incorrectly, so it is important to work with a chiropractor experienced in treating pregnant women
• If done without incorporating exercise, relief may be temporary

Acupuncture

Acupuncture, an ancient form of Chinese medicine, continues to gain popularity as a treatment for back pain in the general population. Recent studies have found that acupuncture helps improve function and reduce the intensity of back pain during pregnancy.6 An acupuncturist will perform a comprehensive exam including an evaluation of the client’s appearance, color, speech, pulses, tongue, and physical condition to determine where the flow of energy is obstructed. The treatment consists of fine needles (generally painless) being inserted into specific points throughout the body to help open the energy channels, thereby restoring balance, reducing pain and muscle spasm, and improving mobility. Acupuncture is safe during pregnancy, with the exception of specific points around the ankle that may stimulate the uterus.

Pros:

• A safe alternative treatment for back pain and restoring good flow of energy
• May also help reduce morning sickness in early pregnancy

Cons:

• Can be costly depending on insurance
• Patients need to be open and receptive to a alternative medicine
• People who fear needles may be intimidated by it

It is important to discuss with your OB/GYN or midwife to determine what type of treatment is best suited for you.

1 Wang, S et al. Low back pain during pregnancy: Prevalence, risk factors, and outcomes. Obstet Gynecol 2004 Jul;104(1):65-70.

2 Garshasbi, A, et al. The effect of exercise on the intensity of low back pain in pregnant women. Int J Gynaecol Obstet. 2005 Mar;88(3):271-5.

3 Kihlstrand, M et al. Water-gymnastics reduced the intensity of back/low back pain in pregnant women. Acta Obstet Gynecol Scand Mar 1999;78(3):180-185.

4 Field, T et al. J Pregnant women benefit from massage therapy. J Psychosom Obstet Gynaecol. 1999 Mar;20(1)31-8.

5 Diakow, PR et al. Back pain during pregnancy and labor. J Manipulative Physio Ther. Feb 1991;14(2)116-8.

6 Guerreiro da Silva, JB et al. Acupuncture for low back pain in pregnancy. Acupuncture in Medicine. 2004 Jun;22(2):60-7.

I was reading a Scooby Doo mystery with my kids this morning and one of the villains was walking with a cane in his right hand and a cast on his right foot. The first thing that struck me about the illustration was that the character was holding the cane in the wrong hand. (The other thing was that he appeared to be walking without bearing weight on his right foot, which can’t actually be accomplished with a cane…he’d need crutches or a walker for that. But it’s just pretend, so I guess it’s OK.)

Although it may seem intuitive to use a cane on the injured side, it actually should be carried in the opposite hand. It’s a long physics equation basically, but when you hold the cane on the same side you are able to take much less weight off the involved leg than when you carry it in the opposite hand.

So if you go out and buy a cane for yourself because of an aching hip, knee, or foot, be sure to hold it on the opposite side from where you feel pain. You will get the most benefit and relief this way.

Sitting with the legs crossed is something many people do. If you have any back, hip, or knee problems, it may be best for you to try to break this habit and there’s a few reasons why.

1. It creates an imbalance in the pelvis. When you sit with let’s say the right leg crossed over the left, the right side of the pelvis shifts higher than the left. This creates an uneven alignment throughout the lower spine that translates all the way up to the neck. Anatomical imbalances such as these, particularly when prolonged or sustained, can eventually contribute to dysfunctional posture and pain. Sciatica, sacroiliac instability, and low back pain can be caused or exacerbated by this way of sitting.

2. You probably always cross the same leg on top. The majority of people always cross the same leg on top. It’s a habit, the body gets used to it, and the muscles around the hips, knees, and pelvis change in response to this. This also applies to when you sit cross legged on the floor. If you sit down on the floor without thinking about it, then change which leg is positioned in front, it will most likely be a very obvious difference in how comfortable you are. (I always have students in my yoga classes switch which leg is in front to create better balance in the body.)

3. Crossing the legs places strain on the knees. When the leg that’s crossed is positioned with the top knee out to the side and the ankle resting on the opposite knee, the ligaments on the knee can be stressed. There can be compression of the cartilage within the knee which can also be damaging over time.

4. Circulation is compromised when the legs are crossed. The compression that occurs from the legs being crossed makes it more difficult for the veins to return blood from the legs back to the heart. This is why the legs can sometimes be felt to “fall asleep” if the legs are crossed for prolonged periods.This can be problematic especially for individuals with vascular disease, diabetes, and other problems with circulation.

So if you find that you cross your legs and you’re having a hard time breaking the habit, be aware of your body and switch which way you cross periodically to restore symmetry and reduce your likelihood of pain or injury.

A bad hip, knee, or ankle can make climbing up and down stairs difficult and at times unbearable. The weight bearing, changes in range of motion and strength required to coordinate the shifts in balance are demanding on the joints and muscles, and an injury can greatly affect the ability to perform this everyday task.

If climbing stairs is a problem, try this: go up leading with the good foot, and down leading with the bad foot. By doing a “step to step” gait pattern (as opposed to step over step), the amount of weight carried by the injured leg can be reduced, thereby reducing pain.

I was working with a patient who started to describe to me the back pain she felt mostly at night. It started when lying on her stomach, so she adapted to sleep on her back or side. Then lying on her back was uncomfortable too, causing stiffness and pressure in the low back. These were recent problems, and did not coincide with activity, injury, or pain during the day. When I questioned the age of the mattress she slept on, she had to think about it…at least 10 years old she thought.

An older mattress may be less supportive, uneven, or sag, thereby not providing adequate support and cushioning for the body while sleeping. The life of a mattress is usually about 10-15 years, but may vary depending on the type of mattress and other factors (like how often the kids jump on it!) You will know it’s time if your mattress sags, you wake up sore, and have trouble getting comfortable and getting a good night’s sleep.

Since a mattress is an investment, it’s important to find a mattress you are comfortable with. There are so many different types, some even adjustable firmness now, and I recommend you find a store where you can trial mattresses and have the ability to return within 30 days if not satisfied. In the New England area, there is a large furniture store with a sleep lab and sleep technicians who help guide you towards the best fit for you.

If you do suffer from back pain it may be helpful to know this: a study of over 300 people found that a medium-firm mattress reduced pain and disability among people with chronic, non-specific low back pain.1

1 Kovacs, et. al. “Effect of firmness of mattress on chronic non-specific low back pain:randomised, double blind, controlled, multicentre trial.” Lancet,2003 Nov 15;362(9396):1599-604.