Superior Performance Physical Therapy

What is a Diastasis Recti?

A Diastasis Recti occurs when the re**us abdominis (six-pack abs) separate allowing the fascia and muscles in the deeper layers of the abdomen to bulge out. This is common in pregnancy and post-partum, but also can be seen in men and other women who have never been pregnant. Typically in these cases, it is a result of overly developed 6-pack muscle and underdeveloped deep core (transverse abdominis), often along with some fascial or visceral adhesions or restrictions.

To tell if you have a diastasis, lay on your back and look down at your belly when you lift your head. Do you see a little canyon between two ridges of muscle at the midline either above or below your belly button? We can measure this by how many fingers fit into that little canyon--one, two, three, or more?

If you identify a diastasis, it is not the end of the world, they can be fixed! It is important to focus on DEEP core strength (TA) and performing your core exercises without this canyon from forming so that you give the re**us abdominis time to heal back together.

This week's Friday Fitness Challenge will show you some exercises to progress to as you begin to develop that deep core strength and the re**us has begun to heal back together.

We all have four layers of abdominal muscles.

Oftentimes when we think of abdominal muscles and strengthening our core, we get tunnel-vision and think just about our six-pack (or lack thereof). While a six-pack may look good in all your IG posts, that's about all it's good for if the muscles deep to it are not strong as well.

The deepest layer is called the Transverse Abdominis (TA) and is the primary stabilizer of your spine and pelvis. The TA is to your body as a foundation is to a house. If the foundation is not solid, then no matter how good the stucco and the siding look, eventually it will all crumble away because the foundation just couldn't hold it up. Our primary objective when it comes to ab strength and stabilizing your spine is to build automatic engagement and strength of THIS muscle!

The internal obliques sit on top of the TA, and then the external obliques are next. These muscles are well-known for helping with rotation and side-bending movements of the spine. But they also play very important roles in breathing and maintaining intra-abdominal pressure that helps protect and support the functioning of our internal organs.

Finally, the outermost layer we come to the Re**us Abdominis, or the six-pack muscle. While there is nothing wrong with building this muscle, it is important to recognize that having a six-pack says little about your ability to actually stabilize and protect your spine.

Navicular drop test -

Try this test to determine if you have a dropped navicular that may be causing your "flat-feet", and if you might benefit from getting some work done on your feet and strengthening the muscles that support your arch.

Step 1 - Make a mark on your navicular with a pen - this is on the inside of your foot, the pointy bone that sticks out above the arch of your foot.

Step 2 - In sitting, have your feet planted solidly on the ground. Try to have even pressure into both feet. Have a friend take a piece of paper, line up the bottom along the floor and make a mark on the paper even with the mark on your foot. (Make sure to do this on a hard surface floor!)

Step 3 - Stand up without changing the position or angle of your feet, and have your friend mark the same piece of paper even with the mark on your foot.

If you find that the mark from standing is lower than the mark from sitting, you have some degree of navicular drop.

Are you really flat-footed?

There is a misconception that being "flat-footed" is quite common. What we generally consider flat-footed is usually the result of stiffness in the joints of your foot in combination with some muscle weakness. There are 26 bones and 30 joints in your foot and there should be some natural splay or separation between them all when you bear weight. This splay may be limited from constantly wearing tight or uncomfortable footwear or maybe a compensation from past injuries.

To feel grounded and balanced on your feet it is very important to have your big toe able to plant firmly to the ground. If many of the smaller joints in your foot are restricted, then in order to get that big toe down to the ground, we must allow the arch to collapse and a bone called the navicular to drop. This is what makes the foot appear to be "flat". It is not often an actual structural issue, but a functional one that can be addressed through manual treatment and exercise.

While maintaining good alignment is a goal we should have throughout all of our movements and exercise routines, placing constant focus on your form is not only impractical but it can be dangerous!

Initially in your rehab journey, focusing on alignment by watching yourself in the mirror can be very beneficial. But using visual aids like a mirror can also become a crutch that you begin to rely on, and will hold you back from full recovery and optimal performance.

For Friday's fitness challenge, I will post some fun ways to help you make this shift from reliance on visual feedback and conscious control of your position and movements, to more automatic subconscious control so that you can free up your brain power to pay attention to the things that you should be watching out for…

…like knowing where the obstacles are for one…

What is a Q-Angle?

The Q-angle (aka Quadriceps Angle) is the angle formed between quadriceps muscles and the kneecap. Typically females have a larger Q angle than males due to naturally wider structure of their pelvis. Some angulation is normal and expected, but too small or too great of an angle can:
1. Indicate dysfunction at, above, or below the knee
2. Contribute to causing (more) damage at the knee…and possibly also above/below

When doing lower body strengthening exercises we will often hear our instructors or coaches talk about "maintaining alignment" with knee tracking directly over your second toe. A common error is letting the knees knock in together, effectively increasing the Q-angle which can put the knee in a vulnerable position and at greater risk of injury.

Sometimes we are limited by mechanical dysfunctions that we need to address with manual therapy or other direct treatment. Other times, we may be limited by strength and/or motor planning deficits to maintain this alignment.

If you have pain in your knees with squatting motions or maybe going up or down stairs, check out your alignment. If you find that you are unable to keep your knees aligned with your second toe when squatting (did you try it with single leg squat as well???), you probably have some work ahead of you!

The proprioceptive system is located in our muscles and joints and provides us with a sense of where we are in space, detects and controls our movements. Our proprioceptors make split second decisions to help protect our bodies from getting into bad positions, before our brain even gets any indication that something may be amiss.

Proprioception around the shoulder is critical in providing stability of the joint. Pain and damage to the surrounding structures can get in the way of the system functioning properly, putting the shoulder at further risk for injury. Whether you have shoulder pain or not, incorporating some dynamic stabilization exercises into your routine will help keep this system working as it should to protect you.

This week’s Friday's fitness challenge will take you through some fun shoulder stability exercises you can do at home!

A true frozen shoulder is a very specific diagnosis but many patients complain of a frozen shoulder. If you’re limited in mobility of the shoulder joint there can be many different causes. Just to name a few:

- Injured joint capsule
- Referred pain from the neck
- Referred pain from the thoracic spine
- Increased neural tension
- Rotator cuff injury

Make sure if you get that diagnosis, you know what the health care provider means. They are very different treatment strategies for each example. Be your own advocate and ask questions!

Shoulder Impingement Syndrome:
Shoulder impingement can cause pain in the shoulder with motion, often the result of repetitive micro-traumas to one of the rotator cuff tendons from rubbing between the top of your humerus (arm bone) and the glenoid (its socket). Most commonly this presents as pain in the top of the shoulder as you move your arm over head.

The shoulder is a relatively shallow and incongruous joint so it relies heavily on the surrounding structures for stability. Picture a golf ball sitting on a tee, this is what your shoulder joint looks like. In order for that ball to not fall off of the tee while you are moving your arms, the structures around it (muscles, tendons, ligaments, fascia) must work together to hold it in place.

But we get into trouble as soon as the structures around the joint stop working together--they could become any combination of too tight, too loose, too strong or too weak--and this is what leads to impingement. Shoulder impingement is an indication that things are not balanced within the shoulder joint and the sooner we can catch and correct this the better to avoid long-term damage. This is why proper strength and mobility of the shoulder complex is so important, even if we are not yet exhibiting symptoms.

Pain isn’t always what it seems! Pain can be a referral from somewhere else in the body. It’s important to know the different referral patterns, especially if your musculoskeletal pain doesn’t seem to follow a pattern with movement or pressure. The organs can refer to many different areas as seen above.

Could your pain be from Thoracolumbar Junction Dysfunction?

The thoracolumbar junction (TLJ) is the transition between the thoracic (mid-back) and lumbar (low-back) spine. The mid-back moves most in rotation, and the low-back moves most in forward flexion and backward extension. It is the TLJ's job to attenuate the forces from above and below and support this change in available motion from thoracic to lumbar spine. This is a big job and makes the TLJ particularly vulnerable to injury or damage.

The TLJ is often a silent source of pain, and is commonly overlooked as the driver of dysfunction. Particularly sciatica-like symptoms can be present but stem from TLJ rather than the sacroiliac region (SI). Referred pain from the TLJ is common in the flank, hip, outer thigh, and groin--this follows the distribution of the cluneal nerve, which is the primary nerve affected by TLJ dysfunction.

TLJ Syndrome (also called Maigne's Syndrome) often presents as pain in only one side of the low back, hip, groin, ge****ls, lower abdomen, or SI region; rarely is there complaint of pain at the TLJ itself, however pain can sometimes be provoked at the TLJ by palpating on the facets of these vertebral segments. Oftentimes, persistent standing and/or walking can aggravate symptoms as well which can often be mistaken for lumbar stenosis.

If you have been dealing with chronic sciatica-like symptoms but have not found relief through treatment of the low-back and sacrum, perhaps the issue stems from a little bit higher up.

Mobility and stability are important to maintain a healthy TLJ. This week's "Friday Fitness Challenge" will work your core to help you build strength and endurance to properly stabilize your spine, with focus on the TLJ.

The "lordotic" and "kyphotic" curves of our spines are a uniquely human trait and are what allow us to maintain an upright position on two feet instead of four. The change in directions of the curves are unique for energy distribution in relation to locomotion, and they offset each other for better righting abilities as we move throughout life.

But this means that if we have an injury or mechanical issue occur at one point along the curve, we need to be aware that consequences may be felt elsewhere down or up the line. With chronic pain, it can be easy to point to the site of pain as the problem area. In reality, the site of pain is often the result of a compensatory dysfunction and not the primary one. Getting treatment in this area may offer some temporary relief, but it will never actually fix the problem.

If you have been dealing with chronic pain anywhere in your body, and have had it treated over and over again with minimal lasting change, find a physical therapist who will take the time to zoom out and evaluate where the issue is actually coming from.

If you had a leak in your ceiling, would you want someone who just patched up the ceiling tile but didn't actually stop the leak? Or would you rather find someone who took a little more time to actually find and fix the leaky pipe and stop the leak altogether? Advocate for yourself and find someone who can help you stop the leak!

Why are we focusing on the pericardial ligaments with our post Covid patients?

The heart is vital for the body to survive… seems pretty common sense, right? Well if the suspensory system of the heart is impacted, it will effect how the rest of the body will function. It’s not just the obvious pulmonary and cardiac issues that we are treating the ligaments for. We’re finding dysfunctions all over the body because of the rest of the body will go into compensatory positions to avoid effecting the heart.

The pelvic floor is greatly effected when the diaphragm isn’t working. We are seeing patients with pelvic floor pain, pressure and digestive changes.

Neck and head pain are also common because some ligaments go up to the mid cervical spine or neck. The tension will pull on the neck and cause pain and also headaches. We’ve also seen numbness and pain down the arms because of these restrictions.

Anxiety is also a commonly described issue our patients are having. The vagus nerves which regulate the heart rate, among many other functions of the body, are your major rest and digest regulator. It keeps your fight or flight response at bay but when there are restrictions of those nerves they can’t work as well. This can lead to increases in anxiety.

Have you noticed any of these symptoms after having Covid? Tell us if you’re seeing any changes occurring in your body, especially if they start occurring > 6 weeks after you’ve had Covid.

The COVID-19 Virus (SARS-CoV-2) targets something called the ACE2 receptor and causes a dominos-type reaction of inflammation throughout the body. This protein is abundant not only in the lungs, but in the heart, vessels, and most other organs as well, which means the virus can attack any of these areas.

While respiratory symptoms seem to be the most widely recognized effects of COVID-19, inflammation of the heart is not uncommon and the effects can last for months after recovering, possibly longer.

This inflammation can lead to restrictions of the pericardial ligaments that limit mobility of the ribcage, and may cause other issues elsewhere in the body. If you have had COVID, be sure to take the time to get this checked out!

The study referenced can be found at:
https://jamanetwork.com/journals/jamacardiology/fullarticle/276891

Why is it best to get treated within the first 6 weeks after you’ve recovered from covid?

The natural inflammatory process takes 6-8 weeks to complete. With this process, there are cells called fibrin that surround the area and will eventually solidify into new fibers. It’s during this time that we can have an effect on how those fibers align and their extensibility.

We are seeing time and time again that regardless of what the patients’ symptoms were, even if they are asymptomatic, they are getting restrictions around their heart in the pericardial ligaments. These will inhibit mobility in the rib cage and thus impact the rest of the body.

Seeing someone in the first 6 weeks will allow for quicker healing and hopefully stave off the other more significant dysfunctions. Now that isn’t to say it’s pointless after 6 weeks, but it will just take a little longer. Be proactive and look into finding a therapist that can treat your pericardial ligaments.

"Text Neck" is no joke!

Studies have shown a significant positive correlation to time spent on mobile devices and the duration and severity of neck (and shoulder) pain.

In an ideal world, we could all limit time spent on our mobile devices--but this isn't always realistic. If you cannot limit your time, adjust your position! Hold your device closer to eye level rather than down at your chest or abdomen--your body will thank you!

Did you know the hip also has a “rotator cuff”? It’s not just the shoulder that has this built in muscular stability. The hip’s deep internal and external rotators help to stabilize the ball in the socket. They need to be trained in order to keep the hip in an efficient alignment for all the other demands you want to put on it!

The Gluteus Medius muscle is one of the most important muscles that stabilize your pelvis, especially when you move side to side (like making a ski turn, or cutting moves in sports like soccer or basketball). Weakness of this muscle can lead to compensations that may bring on back or hip pain, or even contribute to knee or ankle pain.

Check back in with us on Friday for a fun challenge to work this muscle and feel the burn!

Working out is great for your body in many different ways! It can help kickstart your immune system, improve your mood, get you a better nights sleep and doesn’t have to be boring!

Check out our latest blog entry to learn about ski injury prevention through proper selection of equipment and ski conditioning.

Dr. Tina Roberts takes you through a detailed look at how your equipment can either contribute to potential injury or help you perform at a higher level. She breaks down the different components of skis, boots, and bindings, offering simple explanations of the different options that are available and then provides general guidelines on what qualities to look for in your gear based on the type of skier you are. Tina then dives into some of the key components of a good ski conditioning program, highlighting specific muscle groups to target and even provides guided instruction of some of her favorite ski-prep exercises.

View the presentation at https://www.superiorperformancept.com/preventing-injury-and-optimizing-performance-in-skiing/

Thank you to everyone who has served our country to keep us safe! We thank you and your families for your sacrifice.