Pain in hip flexor

Stretch It Out: The Hip Flexors

Imagine not being able to climb stairs, bend over, or even walkChanges in hip joint muscle-tendon lengths with mode of locomotion. Riley, P.O., Franz, J., Dicharry, J., et al. Center for Applied Biomechanics, University of Virginia, Charlottesville, VA. Gait & Posture, 2010 Feb; 31 (2): 279-83.. All pretty essential if you ask us! But that’s what our bodies would be like without our hip flexor muscles. Never heard of ‘em? It’s about time we share why they’re so important, how your desk job might be making them weaker (ah!), and the best ways to stretch them out.

Hips Don’t Lie — The Need-to-Know

Located deep in the front of the hip and connecting the leg, pelvis, and abdomen, the hip flexors— surprise, surprise— flex the hip. But despite being some of the most powerful muscles in our bodies (with a clearly important role), it’s easy to neglect our poor hip flexors— often without even knowing it. It turns out just working at a desk all day (guilty!) can really weaken hip flexors since they tend to shorten up while in a seated position. This tightness disrupts good posture and is a common cause of lower back pain. Weakened hip flexors can also increase the risk of foot, ankle, and knee injuries (especially among runners)Hip muscle weakness and overuse injuries in recreational runners. Niemuth, P.E., Johnson, R.J., Myers, M.J., et al. Rocky Mountain University of Health Professions, Provo, VT. Clinical Journal of Sport Medicine, 2005 Jan; 15 (1): 14-21.. So be sure to get up, stand up every hour or so! And giving the hip flexors some extra attention is not just about injury prevention. Adding power to workouts, working toward greater flexibility, and getting speedier while running is also, as they say, all in the hipsThe effect of walking speed on muscle function and mechanical energetics. Neptune, R.R., Sasaki, K., and Kautz, S.A. Department of Mechanical Engineering, The University of Texas, Austin, TX. Gait & Posture, 2008 Jul; 28 (1): 135-43..

Get Loose — Your Action Plan

While leg lifts, certain ab exercises, and even hula hooping can all help work the hips, the hip flexors can still be a tricky part of the body to stretchKinetics of hula hooping: An inverse dynamics analysis. Cluff, T., Robertson, D.G., and Balasubramaniam, R. School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada. Human Movement Science, 2008 Aug; 27 (4): 622-35.. To get them even stronger and more flexible, try these five simple hip flexor stretches:

1. Take a knee.For the kneeling hip flexor stretch, kneel on the right knee with toes down and left foot in front (knee bent and aligned with the ankle at 90-degrees). Place hands on left thigh and press hips forward until there’s tension in the front right hip. Hold for 30 seconds and switch legs.

2. Prepare for liftoff. The glute bridge stretch could score you a six-pack and tight buns, too! Lie on back with knees bent and feet flat on the floor, hip-width apart. Contract abs to flatten lower back to the floor. Exhale and lift hips off the floor (press heels to floor for added stability). Inhale, lower to starting position, and repeat.

3. Hug it out. Start the supine hip flexor stretch the same as the glute bridge, but keep the right leg relaxed on the floor. Pull shoulder blades down and back to lift hips. Grab the back thigh of the left leg and pull the knee toward the chest. Keep the right leg straight and push its heel into the floor (to feel it in the butt). Hold for 30-45 seconds and switch legs.

4. Just swing it. For the front-to-back hip swing stretch, lie on the left side with hips stacked, propped up on the left elbow. Bend the left leg to a 90-degree angle and raise the right leg to hip level with toes pointed. Keep abs tight and swing the right leg all the way in front, then swing it all the way to the back, squeezing the booty along the way. Switch sides.

5. Feel free as a bird. Open up those hips with yoga’s pigeon pose! Start on all fours with hands below the shoulders and knees below the hips. Bring the right knee forward until it touches the right hand and place the leg flat on the ground across the body (the right foot is now on the left side of the body, parallel to the front of the mat). Drop left leg to the ground, and extend it back with toes turned under. Keep the hips level, inhale, and walk hands forward. Exhale, and fold the torso over, lowering elbows to the floor. Stay in this position for 5-10 breaths before coming back up to switch sides.

Did we forget any of your hip flexor stretches? Tell us about ’em here! Photo by Justin Singh

Groin Pain When Walking or Running

What Can you do about Groin Pain?

A groin strain is an overstretch or tearing injury to the muscles of the inner thigh or front of the hip. Groin strains make walking, lifting the knee, or moving the leg away from or toward the body difficult and painful. Groin strains can occur from overuse of the muscles, or from a sudden contraction of the muscles. Pain can range from a dull ache to sharp pain. The pain will often be worse when walking or moving the leg. A person may also experience spasms in the inner thigh muscles. Weak adductors, poor off-season conditioning and inadequate warm up or stretching increase the risk of an adductor strain.

Symptoms

  • Sudden pain in the groin or medial leg sometimes associated with a pop.
  • Pain on palpation of the muscle with possible swelling and bruising.
  • Loss of motion at the hip joint
  • Weakness of the adductor muscles
  • Difficulty putting weight on the affected leg. Crutches may be necessary to move around.
  • If not cared for properly this may become a more chronic situation.

Groin strains are graded with numbers 1 to 3, depending on how serious the injury is:

  • Grade 1 causes some pain and tenderness, but the stretch or muscle tear is minor.
  • Grade 2 causes pain, tenderness, weakness, and sometimes bruising.
  • Grade 3 is a severe tear of the muscle, causing bruising and a lot of pain.

Treatment of groin pain will depend on the severity of the condition. When treating the principles of RICE (rest, ice, compression and elevation) should be initiated.

  • Rest: avoid the activities that produce the pain (jumping, running, going up or down stairs, kneeling and squatting.)
  • Ice: apply ice to the tendon or area of inflammation. It is one of the fastest ways to reduce swelling, pain and inflammation. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply ice directly to the skin.
  • Compression: such as an ace bandage to help take stress off the injured muscle may be useful. When using ice, apply light compression. This is especially helpful if swelling is present.
  • Elevation: elevate the area to help reduce swelling.

How can Physical Therapy Help??

Your physical therapist will perform a thorough evaluation to assess and determine the following:

  • Tendon: a series of tests will be performed to determine which tendon is involved.
  • Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances
  • Flexibility: tight muscles can contribute to poor mechanics and weakness creating imbalances and making the hip more susceptible to tendinitis.
  • Technique: Often it is the way we perform motions (run, jump, cycle or row) that may cause a problem. Discuss and observe the activities you participate in, that may have started the problem to improve technique.
  • Training: review your training program and any sudden changes that may have precipitated or caused the present condition.
  • Alignment or footwear: a physical therapist will assess your leg lengths, foot mechanics and alignment to see if there are any imbalances. Checking for appropriate footwear is a crucial part of balancing the stresses applied to your legs and body.

Physical therapy for a groin pain must remain conservative at the onset to avoid aggravating the condition. Emphasis will be on rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has been reduced, a program of stretching and strengthening will be initiated to restore flexibility to the muscles involved and improve strength to reduce stress on the tendons and the hip. Taping or strapping to rest and reduce the stress placed on the tendon and promote healing may be necessary. Your therapist is trained in these specific taping techniques.

Common Physical Therapy interventions include:

  • Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the knee and hip. Use of mobilization techniques also help to modulate pain.
  • Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the knee and lower extremity to support, stabilize and decrease the stresses place on the burse and tendons of the hip joint.
  • Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, kneeling, squatting and jumping) of the involved lower extremity to reduce stress on the burse and tendons in daily activities. Taping, strapping or bracing may be useful to rest the tendon and promote healing.
  • Modalities including the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation of the involved tendon and bursa.
  • A home exercise program that includes strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.

In general patients respond well to conservative treatment of a groin pain. It is important that once the pain and inflammation is reduced, and motion and strength are restored, the patient gradually returns to full activities. Instruction in daily activities or sport performance is helpful for reducing a reoccurrence of tendinitis. In most cases, full return to activity will take from 2-6 weeks depending on the severity

Resources:

Groin Pain Articles

  • Pulling Your Groin Falling On The Ice
  • Groin Pain When Walking or Running
  • What causes pain in the groin and hip area?

Understanding Hip Flexor Strain

Rest

It’s important to rest the affected muscles if you have hip flexor strain. One thing you can do is change up your normal activities to avoid overstretching the muscle. For example, you could try swimming instead of riding a bicycle.

Home remedies

Most instances of hip flexor strain can be treated at home without the need for prescription medications or more invasive treatments. Here are some home remedies that can help relieve the pain of hip flexor strain:

1. Apply a cloth-covered ice pack to the affected area for 10- to 15-minute time increments.

Keep reading: How to make a cold compress “

2. Alternate ice packs with moist heat applications starting at about 72 hours after the initial injury. These include heat patches, moist heating pads, or a warm, wet washcloth. A hot shower can have a similar effect in reducing muscle tightness.

3. Take an over-the-counter pain reliever. Any of the following can help:

  • acetaminophen (Tylenol)
  • ibuprofen (Advil, Motrin)
  • naproxen sodium (Aleve)

However, unless directed by your doctor, you shouldn’t take these medicines for longer than 10 days due to risks for stomach bleeding.

4. Rest and avoid activities that will overuse your hip flexors for 10 to 14 days after injury (or longer if directed by your doctor).

Exercises

Gentle stretching exercises can help reduce hip flexor muscle tension as well as reduce the likelihood for future injury. Try these hip flexor stretches, but make sure you don’t push too hard — these stretches should be gentle.

It can help to reduce the risk for hip flexor strain if you apply moist heat and warm up your muscles with a gentle walk for about three minutes before stretching.

In severe cases

If your hip flexor strain is so severe that it results in a large muscle tear, your doctor may recommend seeing a physical therapist. On occasion, surgery to repair the ruptured muscle may be recommended. However, this is a very rare occurrence.

Have had lower back pain for 6 weeks now, which doesn’t seem to be getting any better. Taking painkillers and inflammatory tablets but these don’t seem to be working. When I am sitting on the couch with my legs out straight I find it painful. When I just lift my leg up slightly I get sharp pains, not really in my lower back, but I would say more at my buttocks than anywhere else.

It sounds as if you may have trapped a nerve and it may be worth asking the doctor or a physio if this is the case.

Most soft tissue injuries would have cleared up within the six weeks you have been in pain.

There is one joint that can be particularly troublesome over several weeks though, the sacroiliac joint, which is located either side of the base of the spine.

It’s a little hard to explain but if you lie down on your back and clench/lift each buttock up and down, followed by some movements where you ‘drop’ the hips towards the feet on either side, you may find some relief.

In either case though, do consider applying some Atrogel® to complement the medicines you are taking.

If you don’t get some relief in the first week after trying these exercises and applying the gel then it will have been nearly two months and I would spend £30 on a local physiotherapist. They will usually visit your home if needs be.

Best wishes

Earle

PMC

A 73-year-old woman presented to the Saint Marys Hospital emergency department for anterior thigh pain. This pain began 2 weeks before presentation when she noticed difficulty lifting her right leg into her car. She noticed progressive worsening of these symptoms such that she could not put on her socks and shoes. On the day of presentation, while attempting to raise her right leg into bed, she developed severe burning pain in the anterior aspect of her thigh. The severity of the pain, 10 on a 10-point scale, prompted her to seek evaluation in the emergency department. She denied trauma, change in activity level, back pain, bladder or bowel dysfunction, and saddle anesthesia. Her medical history was notable for coronary artery disease with placement of a drug-eluting stent in the distal circumflex coronary artery 6 months previously via the right radial artery, paroxysmal atrial fibrillation, diabetes mellitus with a recent glycated hemoglobin concentration of 6.0%, and chronic lower extremity lymphedema. Her medications included aspirin, clopidogrel, diltiazem, lisinopril, simvastatin, metoprolol, warfarin, and glyburide. She had no recent changes in medications, was receiving a stable warfarin dose, and her international normalized ratio (INR) was within normal limits. She denied tobacco, ethanol, and intravenous drug use. In the emergency department, radiography of the femur and lumbar spine were performed, showing no evidence of fracture.

On admission, her vital signs were as follows: temperature, normal; pulse, 72 beats/min; and blood pressure, 126/68 mm Hg. Findings on cardiac and pulmonary examinations were within normal limits. Her abdomen was soft, obese, and nontender; no masses were palpable. Both lower extremities were warm and well perfused; dorsalis pedis and posterior tibial pulses were palpable. Musculoskeletal examination revealed intact internal and external rotation of her right hip. She was unable to do a straight leg raise or flexion/extension of both the hip and knee because of the severe pain. The spine and sacroiliac joints were not tender to palpation, but she did have tenderness to palpation over the greater trochanter of the right leg. She was able to perform transfers, but her ability to do so was limited by severe pain. During sensory testing, the patient noted a subjective difference in fine touch of the right vs the left anterior thigh.

  1. On the basis of this patient’s description of her sensory deficit, which one of the following nerves is most likely involved?

    1. Obturator nerve

    2. Femoral nerve

    3. Saphenous nerve

    4. Medial sural nerve

    5. Ilioinguinal nerve

    The obturator nerve provides cutaneous innervation to the medial aspect of the thigh. Injury to the obturator nerve can result in paresthesias of the medial aspect of the thigh and weakness of adduction that results in gait instability. This patient’s fine touch sensation alteration does not correspond with this distribution. In contrast, injury to the femoral nerve will result in weakness of the quadriceps, with associated knee extension weakness and paresthesias of the anterior aspect of the thigh. Given the patient’s physical examination findings, the femoral nerve is the most likely to be involved. Damage to the saphenous nerve, a branch of the femoral nerve that can be injured during procedures such as knee arthroscopy, knee arthrocentesis, and cut-down of the saphenous vein, results in paresthesias of the medial aspect of the leg distal to the knee. This patient described no distal leg involvement. The sural nerve innervates the posterior leg distal to the knee and lateral foot. The patient’s description of anterior thigh pain does not correlate with the sural nerve innervation pattern. Originating from the lumbar plexus, the ilioinguinal nerve innervates the skin overlying the medial femoral triangle, which is bounded by the inguinal ligament, the adductor longus, and the sartorius.1 Injury to this nerve would not explain the large area of involvement experienced by this patient. Her description of pain and paresthesias and her denial of any history of trauma were consistent with spontaneous femoral neuropathy.

    Because of the substantial tenderness over the greater trochanter of the right leg, a trochanteric bursa injection was performed. The area of maximal tenderness was identified and injected with methylprednisolone and lidocaine. After 15 minutes, the local tenderness had resolved, but her anterior thigh pain remained unchanged. On evaluation of her gait, an important finding was made.

  2. Given this patient’s presentation, which one of the following would be her expected gait?

    1. Trendelenburg gait

    2. Steppage gait

    3. Festinating gait

    4. Scissor gait

    5. Knee “buckling”

    The Trendelenburg gait describes the result of weakness of the gluteal muscles often associated with muscular dystrophy, L5 radiculopathy, and myopathies. The pelvis drops on the opposite side, making the opposite leg “too long,” resulting in leaning toward the affected side to clear the opposite foot. This gait is not associated with femoral neuropathy because the femoral nerve does not innervate the gluteal muscles. The steppage gait is associated with foot drop that requires flexion at the hip to raise the leg higher than with a normal gait in order to “clear” the foot. This is classically associated with L5 radiculopathy or peroneal nerve damage. In the case of injury to the L5 root, this gait can occur in conjunction with a Trendelenburg gait. A festinating gait (ie, a Parkinsonian gait) is usually characterized by short, shuffling steps and increasing step acceleration, resulting in a high risk of falls. The scissor gait refers to thigh adduction during leg swing that can result in legs crossing each other. The increased tone leads to decreased motion of the hip and knee joints during the gait cycle, resulting in a stiff gait. Such a gait can be seen in association with upper motor neuron lesions in patients with cerebral palsy and multiple sclerosis.2 Femoral neuropathy can result in quadriceps muscle weakness and the sensation of the knee buckling during the loading response, making knee buckling the correct response.3

    During ambulation, the patient required the support of a walker and described feeling “unsteady” while walking with the feeling that her knee would “give out.” Physical therapy was consulted for assistance with her ambulation, and pain control was attempted with oral oxycodone. She continued to have difficulty with her gait and had ongoing pain despite physical therapy and oral narcotics. Because of the unknown etiology of her femoral neuropathy, further investigation was necessary.

  3. At this stage, which one of the following laboratory investigations would be most helpful?

    1. Serum glucose levels

    2. Ionized calcium levels

    3. INR

    4. Thyroid-stimulating hormone levels

    5. Vitamin B12

    Hypoglycemia can result in a sensation of generalized weakness; however, this patient’s most prominent symptom was pain. Although diabetes mellitus is most commonly associated with a distal symmetric neuropathy affecting sensory and autonomic fibers in the classic stocking/glove distribution, it can also cause mononeuropathies, including the femoral nerve and diabetic lumbosacral radiculoplexus neuropathy (DLRPN).4,5 Initially, DLRPN can present as an asymmetric lower extremity pain that is often followed by weakness and often occurs in the setting of weight loss. Although DLRPN may explain her symptoms, a single glucose measurement would provide little insight into the etiology of pain, particularly when DLRPN can occur in patients with well-controlled diabetes.5 Hypocalcemia can cause generalized paresthesias, classically in a perioral distribution; a femoral nerve distribution would be less likely. Hypercalcemia can result in weakness but does not explain the patient’s predominant symptoms of pain and paresthesias. Because the patient was taking warfarin for paroxysmal atrial fibrillation, checking an INR would be appropriate. One adverse event that can be associated with anticoagulation is spontaneous bleeding, which includes bleeding in the retroperitoneal space that results in a the sudden onset of femoral neuropathy.6 On rare occasion, hypothyroidism results in meralgia paresthetica, causing pain and paresthesias in the anterolateral thigh.7 However, this patient did not describe any of the other symptoms associated with hypothyroidism. Vitamin B12 deficiency can result in paresthesias and varied neurologic symptoms in addition to hematologic effects; however, it would classically present over a longer time course than did this patient’s symptoms and would not explain her pain.8

    On the morning of the patient’s admission, her INR was 3.0, and her hemoglobin concentration was 13.3 g/dL (reference ranges provide parenthetically) (13.5-17.5 g/dL). However, approximately 24 hours later her hemoglobin concentration decreased to 10.2 g/dL. She remained hemodynamically stable without orthostatic hypotension. Her platelet count remained within normal limits at 139 × 109/L (150-450 × 109/L). She denied melena, hematochezia, epistaxis, and hemoptysis.

  4. Which one of the following imaging studies would be least helpful in identifying the etiology of this patient’s symptoms and laboratory findings?

    1. Indium In 111–labeled white blood cell scan

    2. Plain radiography

    3. Ultrasonography

    4. Computed tomography

    5. Magnetic resonance imaging

    An indium In 111–labeled white blood cell scan would be the least helpful. Although it can provide information about infection and inflammation, it is unlikely to reveal the cause of her pain and paresthesias. Also, this test has the disadvantage of taking up to 24 hours to complete. Plain radiography can provide diverse information about underlying pathology, including fractures. Further, asymmetry of the psoas muscle can be present in the setting of retroperitoneal hemorrhage; however, this can also occur in other pathologies as well as normal variants.6 Ultrasonography can be used to evaluate the abdomen, including retroperitoneal structures, and to rapidly visualize retroperitoneal hemorrhage with little risk to the patient. However, success can be limited by the patient’s particular anatomy, including body habitus.6,9 Computed tomography is an excellent imaging modality for evaluating retroperitoneal hemorrhage, which can be recognized by increased density areas that are typically asymmetric. Magnetic resonance imaging also provides very exact anatomic information about the extent of involvement of retroperitoneal hemorrhage. Further, it can provide information about nerve compression.6,9

    Magnetic resonance imaging showed rounded foci of slightly increased T1 and T2 signals within the right iliacus and inferior psoas muscle consistent with intramuscular hematomas.

  5. Which one of the following interventions would be most appropriate?

    1. Continue warfarin at a lower dose

    2. Discontinue warfarin until the INR has normalized

    3. Discontinue warfarin and give oral vitamin K

    4. Discontinue warfarin and give intravenous vitamin K and fresh-frozen plasma (FFP)

    5. Discontinue warfarin and start low-molecular-weight heparin therapy

    In the setting of severe bleeding, continuing warfarin even at a lower dose would place the patient at severe risk of adverse outcomes from bleeding. Although withholding warfarin without giving vitamin K is recommended in the setting of a minimally elevated INR without substantial bleeding, this patient has signs of substantial bleeding and should be treated more aggressively. Per American College of Chest Physicians recommendations, withholding warfarin and giving oral vitamin K would be sufficient for substantially elevated INR without evidence of bleeding.10 For substantial or life-threatening bleeding, regardless of INR level, the recommendation is to use intravenous vitamin K for INR reversal along with FFP or recombinant vitamin factor VIIa. The clinical status of the patient is what dictates whether FFP or recombinant factor VIIa is necessary. Low-molecular-weight heparin would not be recommended in the setting of active bleeding. Further, low-molecular-weight heparin is not readily reversible and thus poses an additional risk in the setting of bleeding.10

    Careful risk-benefit analysis was considered for this patient with “triple” anticoagulant therapy, including warfarin, aspirin, and clopidogrel in the setting of atrial fibrillation and a drug-eluting stent. Warfarin and aspirin were discontinued. Fresh-frozen plasma and 10 mg of vitamin K were given intravenously. Clopidogrel was continued because guidelines recommend clopidogrel continuation for 1 year to prevent in-stent thrombosis.11 The patient’s pain was controlled with opioid therapy. Physical therapy assisted throughout the hospitalization, and at dismissal she was able to ambulate with the aid of a walker. She was discharged to a skilled nursing facility for further work with physical therapy; 2 weeks later, she returned home with no requirement for pain medications.

Testing for Herniated Discs: Straight Leg Raise

Question: I just read an article about the straight leg raise test, but I still don’t get it. How does raising my leg help the doctor know if I have a herniated disc? Could you please explain that?
—Walpole, NH
Answer: Yes, your doctor may use a straight leg raise test to determine whether your low back and/or leg pain is due to a lumbar herniated disc.

The test is easy to perform. In most cases, you will lie down on a table (sitting is a less common variation), and your doctor will lift your straightened leg into the air.

If you feel pain that travels down your leg when it’s lifted to the 30° to 70° range, then the straight leg raise test is considered positive. That pain should replicate what you would describe as your typical leg pain. The radiating leg pain you feel is called sciatica, among the most common and painful symptoms of a lumbar herniated disc.

A straight leg raise test is used to help diagnose a lumbar herniated disc because the simple act of raising your leg stretches your spinal nerve root; doctors call this stretching excursion of the nerve. If you have a lumbar herniated disc, it should press on the stretched nerve root as your leg is raised above 30°.

If your doctor does a straight leg raise test and you have pain before your leg is at 30°, then it probably isn’t a herniated disc pressing on the nerve. Before 30°, the nerve root isn’t stretched, and it’s the nerve root stretching in the straight leg raise test that brings the nerve closer to the herniated disc (if you have one). Therefore, pain before 30° means that there is something else besides a herniated disc pressing on your nerve.

A physical exam, which may include a straight leg raise test, is usually quite simple and is an important part of figuring out what is causing your back and leg pain.

Bad Discs and Sciatica: How To Fix Them Yourself

Back Pain Is Not Mysterious

People do an astonishing number of things every day to strain, weaken, and pressure their backs. You know you shouldn’t lift wrong, but you do — all day, every day — picking up socks, petting the dog, for laundry, trash, making the bed, looking in the refrigerator, and all the dozens of times you bend over things. You work bent over your desk or bench. You drive bent forward.

If you go to the gym, you probably lift weights bent over, stretch by touching your toes, do yoga by bending over at the waist, then bend over to pick up your gym bag to go home. No wonder your back hurts. Most people know that bending wrong will injure your back. But they stand, bend, sit, and lift wrong many dozens of times a day, day after day, then compound the problem with holding muscles tightly, and doing bad exercises. They may do special “back exercises,” but not be aware that strong muscles will not automatically give you good posture, make you bend and lift properly, or make up for all the things you do the rest of the day to hurt your back. They wonder why they still get pain even though they take their medicine and “do their exercises.

“Many wind up in back surgery, or long term or recurring pain, not understanding why their physical therapy, pills, or yoga “didn’t work.”

What Are Discs?

Discs are little fibrous cushions between each of your vertebrae (back bones). You have discs in your neck, the middle of your back, and your low back. You also have two discs in each knee. A knee disc is commonly called a meniscus. You even have a little disc between your lower and upper jaw bone at your temporo-mandibular joint (TMJ). Discs are living parts of your body.

They do many things like absorb shock, and keep your bones from grinding against each other. When you abuse them by bad habits, they can break down.

How Discs Herniate

Years of forward rounding, squashes your discs and pushes them out toward the back. The discs eventually break down (degenerate) and push outward (herniate). Think of a water balloon.

When you squeeze the front, it bulges toward the back. The resulting herniation can press on nearby nerves, sending sciatic pain down your leg. Or if you squash and push the discs in your neck with a forward head posture – letting your head tilt “chin-forward” instead of holding it up straight, the disc in your neck may herniate and press on nerves, sending pain down your arm. Tight muscles from years of poor positioning and short resting muscle length can also press on the same nerves mimicking sciatica. Chronic forward bending (flexion) also overstretches the muscles and long ligament down the back, which weakens the back, and pushes vertebral discs posteriorly. The pressure of your own body weight on your muscles and discs over years of poor sitting, standing, and bending habits is enough to injure your back as badly as a single accident.

Think of braces on your teeth. After years of pushing, things eventually move. An unfortunate situation is that someone with a slipping or degenerating disc is often told they have “degenerative disc disease” or “disc disease.” But it is not a disease. The condition was misnamed. A hurt disc is a simple, mechanical injury that can heal, if you just stop grinding it and physically pushing it out of place with terrible habits.

Forward bending gradually pushes discs out to the back. Lift and bend properly to avoid pushing your discs out of place. Sitting with lower back rounded can eventually push low back discs out.

Not a Disease

An unfortunate situation is that someone with a slipping or degenerating disc is often told they have “degenerative disc disease” or “disc disease.” But it is not a disease. The condition is misnamed. A hurt disc is a simple, mechanical injury that can heal, if you just stop grinding it and physically pushing it out of place. It will heal and stop pressing on nerves. The disc pain and sciatica will go away.

It is simple, and depends a great deal on how you hold your body when sitting, bending, and exercising.

Discs Can Heal

Disc injury is not a life sentence. Disc degeneration or slippage (herniation) can heal and stop hurting- if you let it – no differently than a sprained ankle. Stop damaging your discs with bad bending, standing, and sitting habits and your discs can heal. It takes years to herniate a disc, and only days to weeks to let it heal it by stopping bad habits.

When Pain Isn’t From Discs Often

A person may be in great pain from simple damaging bending and movement habits. They may go for an x-ray or MRI, and the scans show a degenerating or herniated disc. The pain may not be from the disc, but from the strained, tired muscles from bad habits. Just like car tires that are mid-life, but perfectly good, some wear may show on exam — but may be unrelated to the pain. Pain is falsely ascribed to the disc. Pain continues, but from the poor mechanics. This is no mystery.

Change the bad habits to change the pain. Sometimes, people go for surgery for the “bad disc.” But their pain persists or returns— because they never corrected the bad mechanics that caused the pain. Or they may herniate another disc for the same reasons they herniated the first one — bad sitting and lifting and all the other bad habits that they did not easily change.

What To Do Every Day To Stop Ruining Your Discs

First thing in the morning, don’t sit on the edge of the bed. Instead of sitting and rounding your back, turn over and lie face down. Prop gently on elbows, but not so high that it strains. It should feel good and help you start your day with straighter positioning. Get out of bed without sitting.

  • Sit without rounding. Don’t be ramrod straight or hold your muscles tightly. Just hold a comfortable, natural, straight position.
  • Stand and carry loads without forward head, or rounding your low back. (Don’t lean backward either, to “balance” the weight — that causes problems of its own.
  • Just use your muscles to stand straight.
  • Count how many times you bend each day. For most people, it will be several hundreds of times a day. Imagine the injury to your back by bending wrong that many times each day.
  • Lift using the lunge or squat, not bending over.
  • Don’t use bad knees as an excuse to wreck your back. Bending properly will strengthen your knees as well. Or you can use “the Golfer’s pickup” where you raise the back leg and rest your arm on the front leg.
  • Raise computer monitor off the desk – use a low shelf or phone books. – Move your TV up higher. Stop curling downward and forward to watch.
  • Move desk and car seats closer to sit back not forward (don’t worry about having to keep feet on floor or “flat thighs”).
  • Move keyboard off “below desk” tray, and back up on the desk.
  • Use a lumbar roll (jacket or towel will do) to pad the backward-rounding space in most chair backs. Sit up and lean slightly back. Don’t round against the lumbar roll. More about this later.
  • Use your muscles, not joints to hold you up. It’s free exercise.
  • Don’t do bad exercises (described below)—Use good exercises to retrain bending habits and how to position your body in healthy ways when moving around (described below).

Don’t Exercise in Ways that Damage Your Back

Many people hurt from excessive forward bending. Unfortunately, many exercises they do for their back often involves more forward bending: toe touches, knee to chest, and crunches.

It is important to strengthen the muscles that pull the back the other way. These are the extension exercises (to follow). Bend properly for everything, even the water fountain, to pick things up from the floor, to look in the refrigerator, or take things out of the dishwasher.

Keep your torso upright and bend your knees. Keep your knees over your feet, not slumping forward, which is hard on the knees. Don’t stretch by bending over at the waist without supporting your body weight on your hands. Many people are surprised to find that they injure their back doing forward yoga stretches. You wouldn’t pick up a package that way.

Ineffective Exercising

Strengthening and stretching are crucial, but alone will not change posture or lifting habits, and so cannot “cure” back pain or posture problems.

Many contribute to the original problem of over rounding and bad posture. Back exercises are supposed to be used to retrain you how you hold your body all the time. Doing exercises for back pain is not like getting a shot of penicillin or going to confession. It does not “fix” bad habits the rest of the time.

One common example is doing “pelvic tilts,” then walking away, letting your back flop into any old bad posture, instead of keeping the proper tilt you just practiced. Back exercises are supposed to be used to retrain your thinking and habits when you get back up off the floor. This does not happen automatically.

This is where many people have missed the point of back exercises. Strengthening has no effect on posture if you don’t apply the strength the rest of the day to control joint angles for all activities.

Exercises to Strengthen and Retrain Muscles

Back pain exercises are misunderstood. People often injure their back all day then hope to fix it with a few exercises.

They don’t understand when this does not work. They lie on the floor to do exercises, then stand up and walk away with no use of the positioning or strength they just practiced. It is like eating butter and sugar all day, then doing 10 minutes of exercises and wondering why it doesn’t “work.” The key is what you do all day.

Try a small number of these exercises slowly. See how you feel the next day, then increase. Use these back exercises to retrain how to stand, sit and move all day.

Lunge. You know not to bend wrong to pick things up, but you do it. Every day. Hundreds of times a day. Instead, bend your knees. You already know that. But most people don’t do it because their legs are too weak.

The lunge exercise retrains bending habits and gives you free leg and back exercise at the same time: Bend properly using the lunge for all the many dozens of times you bend every day. Keep front knee over ankle (left) not forward (right).

Keep front knee over ankle (left) not forward (right). Stand up, feet apart. Slide one foot comfortably back, keeping foot straight not turned out. Tuck your hip under to reduce the arch in your back, and to stretch back hip.

Don’t lean back. Bend your knees to dip to the floor without touching the floor.
If you can’t dip all the way down, at least dip a few inches. Don’t let your front knee come forward. Keep front knee over ankle. Don’t arch your back. Tip your hip under to prevent arching and straighten your posture.

Don’t lean back. This is a great exercise to strengthen your legs and practice proper bending and lifting posture. You already know you should use your legs like this to bend and lift. Now you will be strong enough to do it. – Upper back extension. Most people stretch their back by forward rounding but never strengthen the back muscles that hold the back upright.

Upper back extension is an important exercise to strengthen at the same time that you practice moving your back in the other direction. Lie face down on the floor, hands and arms off the floor. Gently lift upper body without hands. Don’t force. Don’t crane your neck, keep it straight, just lift using upper body muscles. Upper back extension

Lower back extension. This is another important exercise to strengthen the back and practice extending the hip. Lie face down, hands under your chin or wherever comfortable. Gently lift both legs upward, knees straight. Don’t yank or force. Don’t pinch the low back, just use lower body muscles.

Lower back extension – Isometric abs. A major purpose of your abs is to hold your back in position when you are standing up. But many people allow their back to sway or arch too much. They may do “exercises” for this by lying on the floor or standing against the wall and pressing the low back (pelvic tilt) to reduce the curve. But that does not change your positioning the rest of the time, and so, does not heal the back pain. You are supposed to use the tilt when standing to keep your back in position – preventing arching. This exercise strengthens your abs and back at the same time you retrain how to hold your back without arching.

Learn to use your abs to control the posture of your back:

  • Keep your low back from arching even against moving resistance, simulating real life activity when standing up.
  • Lie face up, arms overhead on floor, biceps by your ears. – Press your low back toward the floor to remove the arch. You will feel your abdominal muscles working to prevent your back from arching.
  • Hold hand weights an inch above the floor, without arching your back. Keep your low back against the floor by using ab muscles to straighten your spine.
  • As you get better at this, gradually straighten your legs so that you can practice posture the way you need it for standing up – spine held at healthy position without bending knees. This is how your abs should work all the time, when standing up, to prevent too much arching.

Use this exercise to practice using your abs to control the posture of your back, even against moving resistance, simulating real life activity when standing up. Notice that you don’t need to tighten your abs to do this. Just use ab muscles, like any other muscles, to move your body to healthy position.

Hold a push-up position. In a push-up position (hands and toes, not on knees) tuck your hips under so that your back doesn’t arch. You will immediately feel your abs working when you do this. You will also immediately feel the pressure in your back disappear, that was caused by arching. The purpose of this exercise is to train your abs at the same time you relearn how to hold your back when you are standing up. Keep your back straight, not letting it sag into an arch like a hammock.

Tuck hips as if you were starting a crunch, but don’t hike your behind up in the air or drop your head. Make your posture as straight as if you were standing up. Use a mirror, if available, to see yourself and learn what healthy position feels like. Use this new healthy position all the time, particularly when you stand and reach overhead. Don’t let your back arch to reach overhead. Use the principle of this tuck exercise.

Tuck your hips under to remove the low back arch. You will immediately feel your abs working and pressure gone from your back.

How to Stretch Your Hamstrings Without Ruining Your Discs

Tight hamstrings are commonly accepted to contribute to back pain. The irony is that many hamstring stretches are done in ways that round and strain the back and squash discs.

Leaning over at the waist for toe-touches does stretch your back and hamstrings, and may feel good, but it is terrible for your back. This is true even for yoga stretches where you bend over at the waist without supporting on your hands. You know never to bend over like that to pick things up.

It doesn’t magically become good for you by calling it a stretch. Lie on your back and hold one leg in the air, keeping shoulders, head, and hip flat on the floor and back straight. Keep your other leg straight and flat against the floor too.

If the front of your hip is too tight, your bottom leg may rise along with your top leg. To fix this common problem, stretch the front of your hip using the lunge.

When Walking and Exercising – Walk with feet parallel, not turned in or out. Weight on sole, not arches. – Walk, move, exercise and sit down with shock absorption.

Avoid Bad Exercises

For more on how to avoid bad exercises that contribute to back pain, click here Summary A herniated or degenerating disc is not a mysterious “condition” or a disease. People spend their day sitting, working, walking, and driving in the very hunched posture that pushes discs out the back. They hunch over the computer, lifting and bending wrong all day, walking heavily, and slouching all day, and then exercise in ways that strain and pressure discs and muscles. They do yoga and Pilates exercises that forcibly pressure discs.

They try remedies that do not address the cause of the problem, do physical therapy in ways that exacerbates the original problem, give up favorite activities, have surgery then return to previous injurious habits, then everyone is astonished that they “tried everything and nothing seemed to work.” It’s like eating butter and sugar all day, then waving your hands in the air for 5 minutes and saying “I don’t understands why I don’t lose weight, I do my exercises.” How is your body positioning right now? Use your muscles to stand and bend properly for all daily tasks. Bonus: It burns calories, strengthens, and is a free workout.

You Don’t Have To Live With Pain (Homework!)

Watch other people’s posture, gait, and movement habits. Notice injurious postures doing “fitness and health” moves featured in fitness magazines. Notice your own habits. Use principles learned in this article to identify and eliminate the cause of your own pain.

Articles

To learn to stretch the way you really need, learn why stretches can harm, and to feel better about stretching, read this stretching article.

Books The Ab Revolution™ No More Crunches! No More Back Pain! by Dr. Jolie Bookspan. Expanded second edition. Revolutionary core training method that involves no crunches. Combines sports medicine with fun exercise to get a workout at the same time that you retrain your muscles for healthy movement for ordinary daily activities. Burn more calories and get incredible abs. Used by military, law enforcement, and the nation’s top spine docs.

Hip Flexor Strain During the Lacrosse Season? The Fastest Way to Get Back on the Field

Here is the information any lacrosse player suffering from a hip flexor strain needs to know.

Any athlete who has experienced a hip flexor strain knows the frustration of this type of injury. The injury may happen suddenly, but often pain and tension build gradually and persistently from overuse. The familiar twinge and tightness in the hip are dreaded by athletes of all types. Lacrosse players can be particularly susceptible to this injury as a result of the high intensity running and pivoting movements associated with the sport that put particular strain on the hip joint.

When an athlete experiences an injury, the top priority is to facilitate complete recovery as quickly as possible so they can return to participation. At Rothman Orthopaedic Institute we understand how important this is for athletes–not just to make a complete recovery, but as quickly and effectively as possible. Let’s take a look at what you can expect from a hip flexor injury and the most effective way to get you back on the field.

Hip Flexor Strain Signs and Symptoms

The hip flexors are a group of muscles that run across the front of your hip and allow the knee to bend and the hip to flex. A hip flexor strain occurs when one or more of these muscles becomes stretched or torn.

Risk Factors Include:

  • Weak muscles

  • Failure to warm up properly

  • Stiffness in muscles

  • Trauma or falls

Symptoms (vary depending on severity)

  • Pain and a “pulling” feeling in the front of the hip

  • Cramping and sharp pain

  • Hip flexor pain when walking way make it difficult to walk without a limp

  • Severe pain and spasms

  • Bruising

  • Swelling

  • Bulging in front of thigh muscle

If you are experiencing some or all of these symptoms, then you may have sustained a hip flexor strain. The temptation for any athlete may be to push through the pain and ignore the symptoms in a hope that they will go away or, at least not worsen. While this is understandable, it is the worst course of action to choose. A very slight or mild strain may easily be injured further. This result can keep you off the field even longer.

Treatment Options

  • Rest: This may be hard to hear, but you need to cease any activity that causes pain. You may be able to cross-train using other activities that do not put stress on the muscles. Biking and swimming are both possible options.

  • Ice: Icing will help reduce swelling in the joint. Apply ice for 20 minutes every 3 to 4 hours for 2 to 3 days.

  • Anti-inflammatory meds: Medications like ibuprofen, naproxen, or acetaminophen can be used to manage pain and inflammation. Do not use the medication to push through the pain and continue activity.

  • Stretch and Strengthen: Utilize stretches and exercises that target the hip flexor muscles and surrounding muscles to strengthen the hip joint.

  • Heat therapy: At least 72 hours after the injury occurred heat therapy can be employed to reduce pain and improve motion.

  • Physical therapy: If pain persists after a few weeks of rest and strengthening, physical therapy may be advised to further facilitate rehabilitation.

  • Surgery: Surgery is only likely to be recommended if the muscle fibers have been completely torn. The torn pieces will be stitched back together to allow healing.

To ensure the quickest recovery, you may want to consider speaking with the orthopaedic experts at Rothman Orthopaedic Institute. An evaluation will determine the exact extent of the damage done to the hip flexor muscles and a plan can be made for the most efficient and effective form of treatment to get you back on the field. A hip flexor strain can be very frustrating, but the experts at Rothman Orthopaedic Institute can help you to make a successful recovery and return to your sport stronger than ever. For more information, visit us hereor contact us at 1-800-321-9999.

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