How 'The Big 3' Can Decrease Low Back Pain and Make You Stronger & Faster

If you are among the estimated 50% of all athletes who experience recurrent low back pain, don’t stress, there are exercises that can help…and a couple you should probably avoid.

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Our ‘core’ is the link between our upper and lower bodies, and mastery of control here is the secret to improved strength, running efficiency, faster speed, and overall health and athleticism. In regards to back pain, our core needs to be solid to not only support a stable spine but provide for proper biomechanics when running, throwing, squatting, swimming, and even just walking.

From an anatomical perspective, our core is made up of the rectus abdominis, transversus abdominis, internal and external obliques, quadratus lumborum, glutes, and internally, the diaphragm and pelvic floor muscle. The goal of these muscles is not only to be strong but to provide a stable platform for our spine through any and all movements. Stability here has a dramatic impact on injury risk and should be a focal point in any sport and health training plan.

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Lets use the example of a runner as the majority of our patient population are runners and almost every sport requires it. A strong core, one with ample endurance, allows for proper movement through our hips, legs, and upper body without excess expenditure of energy. If we are weak here, the late stages of a long run or race become challenging injury risk increase. As the core fatigues, the hips begin to dip, causing extension through the low back, excessive strain on the hamstrings, inward rotation of the femur causing excessive rotation of the tibia that can lead to excessive strain of the ligaments of the knee. This can travel down the chain and lead to poor pronation control causing shin splints, Achilles strains and plantar foot pain…you see where we are going here. Simply put, the core needs to function properly, or the whole system fails.

Most people understand parts of this and that core strength is important, but we still find people who lie on the floor, knock out 100 crunches, call it a day and then wonder why their low back hurts the next day. For this reason, I do not recommend sit-ups or crunches. These two exercises cause undue strain on the low back through repetitive flexion that stresses the discs, joints, and muscles of the lumbar spine.

While many finds these exercises easy to perform, and a staple in their routine, I want to introduce you to a more effective core routine. One that focuses on proper back support and overall functionality as an athlete, regardless of sport. These 3 exercises, termed ‘The Big 3’ were developed by Prof. Stuart McGill, rigorously studied, and proven to protect your back and improve core endurance.

The big 3 are made up of the Modified Curl-Up, Bird Dog, and Side Bridge.

1. Modified Curl-Up

McGill Curl - Up. Low Back Pain Relief Utah.

McGill Curl - Up. Low Back Pain Relief Utah.

Lying on your back, place one leg flat on the floor with the other bent. This position allows for a neutral pelvis during the movement and puts your core muscles in control of the movement without undue strain on the low back. Place your hands under the small of your low back to ensure a normal arch is maintained during the movement. Begin by bearing down to brace your abdomen, continue a normal breathing pattern throughout. If you have difficulty maintaining the brace while breathing, this is where you start. Now, pretend your neck, upper back, and low back are locked together and cannot move independent of one another (straight line from head to pelvis), slowly, lift your shoulders blades off the floor and return to the floor in a smooth pattern, only coming off the ground a couple inches. Take note of your posture, did your chin stick out, did your shoulders round forward from memories of doing endless crunches? Work through 2–3 sets of 10–15, slow and controlled.

2. Bird Dog

Bird Dog Ex. for Low Back Pain

Bird Dog Ex. for Low Back Pain

Begin in a quadruped position with hands under shoulders and knees under hips, both about shoulder-width apart. Brace your abdominals while maintaining a neutral (straight) spine. While maintaining this posture, breath in and out, squeeze your glutes and begin moving your right arm up to a point position while also bringing your left leg to a straight position. Our goal here is to avoid rotation through the spine, maintain our posture and keeping the hips in line. Slowly return to the starting position and then perform with the opposite arm and leg. That is one repetition, perform 3 sets 10–15.

3. Side Bridge

Side Bridge - Core Stability

Side Bridge - Core Stability

Lying on your side, prop yourself up on your elbow, hinge at the hips, and stack your knees on top of each other with a 90 degree bend. Maintaining a solid shoulder directly over the elbow on the ground, lift your hips up and push them forward, bringing your spine to a neutral position. Hold for a 5 count and then slowly return to the starting position. Be aware of head posture and hip extension, maintain a straight line from the head to the pelvis. Perform 3 sets of 10–15 on each side, holding each for a 5 count at the top.

Obviously, there are numerous other exercises that provide stability for the spine while strengthening the core, this is just a starting point. Focus and repetition will bring proficiency, and proficiency will bring improved performance! If you have any questions, please ask, I’m happy to answer what I can.

Until next time, train hard, train smart, and recover well.


Source: McGill, S. (2002). Low Back Disorders: Evidence Based Prevention and Rehabilitation. (2nd Ed).

Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

7 Things You Need To Know About Dry Needling

Salt Lake City Dry Needling Chiropractor

The more we study dry needling, the more we understand its benefit and expand its use in the treatment of musculoskeletal injuries.  Addressing everything from low back pain, migraines, and sports injuries; dry needling proves beneficial in the most common muscle, tendon, ligament, and joint issues seen in a physician's office.  

As more practitioners utilize this technique, it is important to know the basics about dry needling, what to expect from treatment, and what conditions can benefit from this therapy.  Below are seven important items to understand when seeking treatment.  

1. WHAT IS DRY NEEDLING?

Dry needling is a skilled technique performed by trained Chiropractic Physicians and Physical Therapists aimed at managing neuromusculoskeletal injuries and pain while addressing movement dysfunction.  Dry Needling utilizes a thin filiform needle to penetrate the skin, fascia, and muscles to address adhesions, trigger points, and connective tissue.  This speeds healing and relieves pain by decreasing muscle hypertonicity, increasing joint range of motion, and correcting movement dysfunction through releasing a trigger point adhesion.

2. DRY NEEDLING IS NOT ACUPUNCTURE. 

Acupuncture is an ancient traditional Chinese technique that utilizes the knowledge of meridians.  This focus allows an acupuncturist to work on a person's inner balance, energy, qi, and one's life-force.  Work up and exam includes physical, tongue, and pulse examination.  Traditional acupuncture has been widely studied and practiced for thousands of years.

Dry needling relies on the practitioners expanded knowledge of skeletal and neuroanatomy.  This knowledge allows one to identify damaged and sensitive tissues, taut bands, and trigger points as well as injured and overused tissues.  Dry needle practitioners utilize an extensive examination that includes movement analysis, orthopedic evaluation, and a neurological workup that includes myotomal and dermatomal testing.

3.  WHAT IS A TRIGGER POINT?

A trigger point is a spot of muscle/fascia that is hypersensitive, painful when compressed, composed of a taut muscular/fascial bands that restrict oxygenated blood flow, and can refer pain and tenderness while causing motor dysfunction.  According to a recent article in Current Pain and Headache Reports, muscle overtraining or direct trauma to the muscle can lead to the development of trigger points. Trigger points may develop during occupational, recreational or sports activities when muscle use exceeds the muscles capacity to handle stress, disturbing normal recovery.  Dry needling differs from other types of therapy because it focuses on stimulating these trigger points and releasing the tension in order to alleviate pain.

4. WHAT IS A TWITCH RESPONSE

Utah Dry Needling Chiropractor Sports Injury Back Pain

The twitch response is a localized, reflexive response of a dysfunctional area of muscle to palpation, or in our case, a dry needle.  When needling a trigger point, this is one of our goals as it leads to a rapid release of a taut muscle band, decreasing tightness and sensitivity of the surrounding area.  A tight muscle or one with a trigger point will feel an achy discomfort with an occasional twitching or cramping sensation. This twitch response returns the muscle to a normal state by releasing inflammatory chemicals from the trigger point and restoring blood flow to the area.  According to a recent study in the Journal of Orthopaedic & Sports Physical Therapy, The twitch may be a sign that the treatment will be successful.  A local twitch response is a spinal cord reflex that creates an involuntary contraction that can be triggered by a snapping palpitation or penetration with a needle.  When the patient has an involuntary twitch response, that suggests that the needle has hit the right spot.

5. IS DRY NEEDLING THERAPY PAINFUL? 

Dry Needling utilizes a thin filiform needle to penetrate skin, fascia and muscles to address adhesions, trigger points and connective tissue to speed healing and relieve pain.  Often, patients will experience a mild, dull ache during treatment and up to 24 hours post treatment.  Some discomfort is experienced during the rapid ‘twitch response’ but this discomfort is minimal and last only a few seconds.   It is normal to have mild to moderate muscle soreness after dry needling treatment.  Drinking lots of water, stretching, moving your body and heating the sore muscles can reduce the duration of the soreness.  Side effects include mild muscle soreness and bruising in some patients.

6. CONDITIONS COMMON TREATED WITH DRY NEEDLING. 

Salt Lake City Chiropractor Dry Needling Knee and Back Pain
  • Headaches
  • Neck Pain
  • Low Back Pain
  • Knee Pain (Osteoarthritis)
  • Shoulder Dysfunction (adhesive capsulitis, impingement, rotator cuff strain)
  • Tennis & Thrower's Elbow
  • Carpal Tunnel Syndrome
  • Hip Pain
  • IT Band Syndrome
  • Patellofemoral Pain Syndrome (Runner's Knee)
  • Medial Tibial Stress Syndrome (Shin Splints)
  • Achilles Tendinopathy
  • Plantar Fasciitis
  • Ankle Sprains
  • Muscle Strains

7.  WHAT DOES CURRENT LITERATURE SAY & WHO CAN BENEFIT?

Dry Needling is an extremely effective treatment for acute and chronic pain, decreased flexibility, joint dysfunction, and recovery from physical activity and competition.  Patients who undergo dry needling therapy experience less pain quickly, with most finding relief after their first treatment. According to reports published by the Journal of Orthopaedic & Sports Physical Therapy, patient function is restored much more quickly when dry needling is incorporated as part of the care plan.

Chronic upper-quarter (neck/upper back/shoulder) headaches and spinal movement dysfunction have all been associated with myofascial pain syndrome (trigger points).  Kietrys et. al. published a meta-analysis on the effectiveness of dry needling on this syndrome.  Based on their research and findings, they recommend dry needling as an effective option for treatment of upper quarter myofascial pain syndrome.  They found that pain measures decreased for most patients immediately after treatment and at the four week follow-up meeting.  - Effectiveness of Dry Needling for Upper-Quadrant Myofascial Pain: A Systematic Review and Meta-analysis. http://www.jospt.org/doi/pdf/10.2519/jospt.2013.4668.   

A 2015 study looking at ankle sprain rehabilitation found that adding trigger point dry needling, of the lateral lower leg peroneus muscle, to a rehabilitation plan of proprioceptive/strength exercise the four weeks following an acute lateral ankle sprain, had greater improvements in function and pain than the controlled group of just exercise.  - Trigger Point Dry Needling and Proprioceptive Exercises for the Management of Chronic Ankle Instability: A Randomized Clinical Trial.  http://dx.doi.org/10.1155/2015/790209

It is normal to take several dry needling therapy sessions before the muscle is fully functional again. This is because trigger points are located under deep layers of muscles, so it typically takes several sessions for the changes to take full effect. But patients will usually notice the difference right after each treatment.

What's The Deal With Hip Internal & External Rotation?

As I near my 2 year mark in clinical practice, you start to realize trends. Sometimes these trends solidify what we already know, align greatly with what we are already practicing, and allow us to continue down the beaten path.  However, there are things we begin to see as key indicators on how an injury occurred, things that are so simple, they often get overlooked in a treatment plan.  Today I want to briefly discuss an item that falls under both of these categories.  

Hip range of motion (ROM) is often taken for granted, until that time comes where one side is severely restricted and we are unable get up off the floor without the use of our hand, or the assistance from another.   As I have progressed clinically, hip ROM started as just something to jot down in a patients notes, but has quickly become one of the first areas I look to and address for nearly all of the low back pain** and lower extremity complaint (acute and overuse) patients that come into our clinic.  

The problem we see is that the restriction is never symmetrical, causing compensatory patterns that quickly lead to injuries and confused patients. While getting you out of pain is our job, our goal is education and prevention.  Below are some great stretches and mobility movements that are not only easy to perform, but effective is restoring symmetrical movement.  Enjoy.  

Learn, Practice, Perform!  

Level 1 Hip Internal & External Rotation

Internal Rotation Hang

Setup: Lie flat on back with knees bent and feet about 6 inches wider than shoulder/hip width.

Step 1: Allow knees to ‘hang’ inward, letting gravity to do the work.  We want to sit here for 1-2 minutes.  

Step 2: If you get bored, slowly and gently, swing the legs/pelvis back and forth to induce some extra motion into internal rotation.   

External Rotation/Mobilization Stretch

Setup: Lie flat on back with the leg being treated in a flexed hip position and the non-treated leg lying flat on the floor.  

Step 1:  Pull the foot of the flexed hip leg toward the mid-line and up toward the torso, you should begin to feel this over the posterior hip in the external rotators and glutes.  

Step 2: Pull the knee toward the OPPOSITE shoulder and hold for a 3-5 count, release and repeat 10 times on each side.  

 

Level 2 Hip Internal and External Rotation

Internal Rotation with band assistance.

Setup:  Our setup is the same as the ER exercise in level one.  This time with a band wrapped around the mid-foot and tracing the outside of the leg.  

Step 1:  The band provides a mechanical advantage and when pulled over the knee and across the body, provides assisted over-pressure into hip internal rotation.  

External Rotation: Pigeon Pose

Setup:  In a modified lunge position, externally rotate the treated leg and and sit back with the non-treated leg extended behind you.  

Step 1:  Begin with the foot of the treated leg near mid-line (easier) and begin to bring your torso closer to the ground while maintaining a straight spine.  

Step 2:  As this movement becomes easier, our goal is to get the treated lower leg perpendicular to your torso and away from the pelvis. Again, push the torso down toward the ground with a straight spine.  

 

Level 3 Internal/External Rotation - 90/90 Get-up to 1/2 kneeling  

Setup:  Sitting up tall with a straight spine, the forward leg positioned in external hip rotation and the leg 'coming through' in internal hip rotation. The lead leg foot should be close to midline and near the other leg making this a closed position.  

Step 1:  Push into the ground with the outer knee of the forward leg and bring the rear leg around to the front, landing in a lunge/half kneeling position.

Step 2:  In a slow and controlled manner, return to the starting position...enjoying the eccentric phase.  

** A 2015 study out of the Shahid Beheshti University of Medical Sciences found that Asymmetrical and limited hip internal rotation ROM were a common finding in patients with LBP.  Another study from The Sahmyook University Department of Physical Therapy found that hip mobilization brings positive effects on pain, function and psychological factors for patients with chronic low back pain, causing them to strongly recommend hip mobilization as an effective treatment method in treating chronic low back pain. 

Break Up the Endurance Training With Some Strength!

Endurance athletes, especially runners, tend to shy away from strength training due to what I would consider a misunderstanding of what it can provide. After working with hundreds, probably thousands by now, of runners and triathletes over the last few years, I find very few have a regular strength plan. Some are afraid of getting hurt, some do not know how to effectively strength train, and some still have the ridiculous notion that if they lift weights they will get so bulky, the can no longer run!

Let’s address these, shall we?

STRENGTH TRAINING SAFETY

As with every sport, there is a calculated risk of injury when strength training.  What will surprise some is that it is often much lower than the risk associated with training for an endurance sport.  This can depend on whether you are single sport athlete (running only!) or have taken to the range that triathlon offers.  

More can be read about sports specialization HERE from Dr. Greg Schiable. While this article is focused on sports specialization in children, the same can be shown for adult athletes who only participate, practice, and focus on one sport….an explanation why overuse injury rates are lower in triathletes compared to strict runners.  

This morning, I read a great post from Chris Beardsley (CLICK FOR FULL ARTICLE)  discussing the relative safety of strength training, especially when compared to endurance sports.  This article launched me into, again, thinking about strength training for endurance athletes, and puts another feather in the cap of it being a great cross option to break up the often monotonous droning on that running provides.

We can show that single sport athletes are more prone to overuse injuries and burnout, as well as demonstrate the benefits strength training gives to endurance, injury prevention and movement efficiency.

An interesting point made...Beardsley writes,

In comparison to the overall rate of injury in strength sports of between 0.24 – 5.5 injuries per 1,000 hours of training, the rate of injury during long-distance running is around 2.5 – 12.1 injuries per 1,000 hours and the rate during triathlon is around 1.4 – 5.4 injuries per 1,000 hours training.

He goes on to state that many studies put running injuries on the higher side of the stated rate.  

 

GETTING SWOLE

Let’s talk about getting bulky, to the point where you start to lose speed and endurance because you are just too massive to run efficiently.  It used to be that this conversation was primarily had with female athletes, but more and more we find male runners of the same belief.  In short, this is non-sense! Why is that you ask?

GENETICS: 

Most endurance athletes are ectomorph, some mesomorph.  Both of which are genetically predisposed to find difficulty packing on lean muscle mass.  

Most endurance athletes are ectomorph, some mesomorph.  Both of which are genetically predisposed to find difficulty packing on lean muscle mass.  

As a younger male, I spend countless hours, day after day, month after month, for a number of years, trying to pack on muscle and reach the elusive 200 lb mark.  It was a stage in my life….enjoyable and very educational… I have since returned to my love of endurance training, but strength training remains a big part of what keeps me fit, injury free, and happy.  

ENERGY & FOCUS:

I never made it to that 200 lbs mark.  Mainly because I could not eat, sleep, and breath lifting weights and energy intake.  To go from a slim and trim 155 to 200 is a feat which requires a lifestyle shift and not much time for anything else.  As runners, we simply can not consume enough, or slow down enough to really pack on muscle.  To make that shift, one would have to take all the time invested in putting in the miles...almost completely stop...and replace it with lifting weights...Not going to happen!  Stop worrying about getting bulky and think of what a 10-20% increase in strength could do for you during those last miles of a long run or how you can conserve energy by moving more efficiently.

 

BUT GYMS ARE SCARY

Many endurance athletes just don’t know what to do when they end up in a gym.  Fortunately, popular running sites and magazines have jumped aboard the strength train (locomotive type), and there are countless exercises and routines available if one simply does a Google search.  

My personal advice is to first master your body weight, which allows you to more comfortably perform exercise at home or on a track after a run.  Begin with push-ups, pull-ups, squats, lunge variations and jumps.  Once you reach a point where sets of 10, 20 or even 50 feel ‘easy’, it may be time to add in some weighted movements like kettlebell swings (my #2), deadlifts (my #1), and overhead press and pull variations.  

 

If you feel like you have been in a rut this summer or have had more than your share of injuries lately, maybe it is time to try something new?  Change up the routine a little...it is likely that you will enjoy the change and be surprised by the outcome.  

Help…I Don’t Know What To Do With My Hands!

Every runner has been through this, and most of us have tried more styles than Tiger Woods has swings, but seriously…what the heck do I do with my hands when I am running?

Lets get something straight from the start, when we are on our long run or are racing, wasted energy is just pure evil. With that, being relaxed up top while running is the name of the game. There should be no clinched fists, shoulders floating up around your ears, violent rotation from side to side or veins popping out of your face and neck like you are trying to pass a block of cheese. Everything above your waist should be relaxed and fluid…like a breeze blowing through a meadow (I don’t know…it sounds relaxing, just go with it).

If you find you are always having side stitches, cramps in you upper back, headaches, numbness in your hands and fingers or are just uncomfortable when you run, here are a few easy tips for your next run. Try them out, you really have nothing to lose.

Step 1: Shoulders down and back, head up with ears over shoulders looking ahead. Until you get this, your arm swing is lost and so is a ton of energy.

Step 2: Keep your elbows bent somewhere between 45–90 degrees. As you run, work on lightly driving your elbows back, letting gravity bring them back forward.

Step 3: Keep those hands loose. Pretend you are holding something delicate in your hands (a flower, really small animal, whatever) and the last thing you want to do is squeeze it too tight.

Step 4: About every 100–200 steps, shake your arms and hands out. Allow your shoulders to relax if they went back up to visit your ears, pick your eyes up from the ground, reset and push forward.

Finding what works for you, as I have outlined what works for me, can allow you to run more comfortable….allowing you to run further and faster!