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An Individualized Approach to Pain & Dysfunction

Fear mongering is can be found in all areas of fitness and health. With such a low barrier of entry to become a “qualified professional” (do you have a few hundred bucks and a weekend to spare?) it becomes easier to be a problem finder than a problem solver. I’ve worked with professional problem finders. They are great salesmen

because they convince you how much you need the service they are selling and what will happen to you if you don’t let them “fix” you. The result? A lot of people walk around feeling broken because some salesman or blog post convinced them they are on their way to back surgery or joint replacement.

Important note: There are also a lot of truly great coaches and healthcare professionals out there. Some of them may inform you of very real issues that need urgent attention. I do not wish to instill distrust. Rather, to inspire some deeper thought.

A while back I took a class on movement and posture. A big part of that class was its lab component. In the labs we would get in small groups and do various types of postural analysis for all parts of the body. While it was interesting to add so many assessment tools to my toolbox, it actually brought a much greater lesson.

One week we were measuring pelvic tilt by marking the ASIS and PSIS then measuring angle of tilt with digital software. It is an imperfect measurement, but it can provide insight into the amount of anterior pelvic tilt a person may have. Large anterior pelvic tilt correlates to more lumbar lordosis (arch in your lower back), which is what gives it its ties to back pain. This test was stirring up a lot of excitement in one of my lab partners. He kept talking about how he has such an extreme anterior pelvic tilt and therefore, lumbar curve. He had been working very hard to strengthen and stretch the appropriate muscles around the hips to correct this

When it came time to perform the measurement the results where a huge eye-opener for him. For context, a “normal” range is loosely defined to be 4-7 degrees in men and 7-10 degrees in women. I measured my partner at 2 degrees of anterior pelvic tilt. In a mission to “fix” his anterior pelvic tilt he worked himself into the opposite extreme. I actually couldn’t even see any tilt visually. He pelvic looked perfectly horizontal and his lower back looked perfectly flat, lacking its normal curve.

This is what happens all too often. A “problem” is found, all our energy redirects towards fixing it, and a new problem arises from over-correction or neglection of other important factors. The solution is found in context. We can find context in individual consideration and movement assessments.

Individual Consideration

Individual consideration is easy but often neglected. It’s as simple as asking questions of yourself or your client about how a particular deficiency effects their life. For example, you’re experiencing back pain that limits you from doing your job or playing with your children. If we determine that an unstable foot-ankle complex is causing dysfunction up the chain to your hip, and the dysfunctional hip is a likely cause for your back pain, you better believe we are going to work on correcting dysfunction in your foot (… and hip… and back… and still train the rest of the body, if that needs saying.).

As an alternate example, if you have the exact same foot/ankle “issue” but your hips and back are healthy, you don’t feel pain, and your lifestyle isn’t impacted then we aren’t going to make your foot the goal. Chasing a fictional functional perfection probably isn’t as important as, say, losing weight. Before I get coaches jumping down my throat, remember that a good training program for any goal is going to result in a stronger foot and a stronger everything else even if it’s just a by-product. So, let’s not get consumed with fake problems and keep the goal the goal.

“The man who chases two rabbits, catches neither.” Confucius

Movement Assessments

Movement, on the other hand, takes a skillful coach to assess. This is an important aspect because posture is dynamic. Analyzing how we stand in place is a very small piece of the puzzle. To get a true look at posture you have to look at the biomechanics of various movement patterns. The main ones being squat, hinge, lunge, push, pull, twist, flex/extend, and gait (walking/running).

It’s not enough to be able to hold good posture when sitting or standing if you are unable to get in good positions in any of the above movement patterns. These are the movement patterns we spend most of our time in, and we will spend much more time doing those movements than being static in one position.

If we suspect a weak foot-ankle complex we can make assumptions about what harm that may cause, but until we see actual movement we are simply guessing. It is possible that what looks like a flat foot when you sit or stand becomes a strong, functional foot when you lunge or stand on one leg. Once we determine the movement context we can return back to individual consideration. Is dysfunction found in movements that are vital in daily living? Are there other movement options available (hinge vs squat)? And so on.

When it comes to the actual training process it becomes very simple. Train the basic movement patterns (squat, hinge, lunge, push, pull, twist, flex/extend, and gait) in a fashion appropriate for the goal (athletic performance, weight loss, muscle gain, etc.) while performing corrective exercises that will target the missing links needed to perform the movement patterns properly.

I like to add correctives in the movement preparation phase of the warm-up. You’ve got to warm-up anyway, and it only makes sense that the warm-up will include exercises that help you perform the upcoming movements better. This set up allows frequency of exposure (every single workout), while serving a duel purpose (warming up and creating functional movement).

Real-World Example

Let’s use an example that hits close to home for me, squatting and butt wink. It’s a great representation of dynamic posture. You can probably get your pelvis and spine to a neutral position (slight inward curve at the low back and neck with a slight outward curve of the upper back), but getting down into a squat is a whole different story. The image below demonstrates what butt wink looks like at the skeletal level. The pelvis tucks under and the low back has a slight rounding (this may not even be easily visible in reality).

Let’s go through the process outlined above with myself. I know I can get about as low as a 90 degree knee bend before I go into butt wink and lose my neutral spine. Why might I want to improve this? The larger range of motion you can take a muscle through during an exercise the better training effect you will get, so if I enhance my ability to squat deeper I will actually get better results from my squat without compromising my back. Also, I know that I will probably lose that neutral spine anytime I’m picking anything up off the floor, which is obviously relevant to daily living but also exercises like deadlifts. For me, these are great reasons to improve my abilities here, but I do have other movement options. A split squat trains similar muscle groups and allows me to use a much larger range of motion, and when I pick lighter things up I will often use a “golfer’s lift” which is essentially just a single leg deadlift. As a quick summary, we’ve determined that it’s important for me to improve this movement pattern, but I also have options that allow me to navigate training and life in the meantime. An important but non-urgent task.

As for movement assessments, I have a huge restriction in my hamstring flexibility, hip flexor strength (particularly at end-range, when my hip is bent), and ankle mobility. Remember to keep the context in mind here. I can wrap my hands around my feet with my knees locked out. Would this tell you that I have ample hamstring flexibility? The problem with such a simple assessment is you don’t know how much of that reach is coming from my hips tilting (lengthening the hamstring) or from my low back bending (shortening the hamstring). This can be visualized in the butt wink image above. When the pelvis tucks under the hamstrings shorten and relax. It turns out I have very little ability to bend while maintaining knee lock out and a neutral spine.

So now we’ve gone through the process of determining the potential dysfunction, the individual importance of fixing the dysfunction, and the root causes of the dysfunction. Click here for a complete breakdown of how I structure a warm-up. Here’s some simple correctives I might add into my warm-up to target my specific issue:

· Dynamic ankle dorsiflexion stretch

· Ankle dorsiflexion active stretching

· Hamstring scoop with neutral spine

· Hip flexor end-range holds

· Mini band hip flexor

· Squat grooving

As a client or patient I hope you can be a little more critical and have ownership over your individual journey. You're entitled to be lead towards your goals, and it's the coach's job to take necessary detours (correctives) if it ultimately serves you. Don't be afraid to ask why a lot, too. Good coaches love this question. If you ever feel like your coach has taken a detour going the wrong way (you're not getting closer to your goal), ask why. Your coach may be thinking big picture and be able to explain how this serves you, or maybe (hopefully not) they had their own agenda for you.

I hope as a coach you rethink how you assess and correct dysfunctions. People do not come to you to be "fixed." They're not broken. If they come to you believing to be broken, prove them wrong. Show them what they are capable of because he human body can do amazing things with the right energy and direction. Map out the direction and help add energy when it's low.

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