I’m Not A Doctor, And I Don’t Play One At The Gym!

Doctor's Diagnosis

 

When people hear that I am a strength coach and a personal trainer, they love to tell me about their injuries and ask me how they can resolve them. Let me make this clear, I am not a doctor, and I’ll never make a diagnosis. That’s what medical professionals are for. If you want to learn some basic exercises to improve mobility and master good technique when it comes to lifting heavy things, I’m your man. If you have acute or chronic pain, find a medical professional. It is not within my scope of practice to diagnose injuries or health conditions. I recently watched a DVD series titled Spinal Health and Core Strength. A chiropractor named Jeff Cubos had an interesting slide during his presentation titled, “Assessment and Injury Prevention.” The slide showed a table titled, “How The Emergency Physician Considers The Differential Diagnosis Of Back Pain.” The following is a list of all the possible causes of low back pain, and while some may be highly unlikely, they are all possibilities.

Pulmonary Embolism

Thoracic Aortic Dissection

Myocardial Infarction

Tumor

Hematoma

Abscess

Disc Herniation

Endocarditis

Pyelonephritis

Infected Kidney Stone

Renal Artery Dissection

Perforated Ulcer

Unstable Vertebral Fracture

Abruptio Placenta

Osteomyelitis

Pott’s Disease (tuberculosis of Spine)

Vertebral Tumor

Stable Vertebral Fracture

Spondylolisthesis

Herniated Disc

Discitis

Ankylosing Spondylitis

Pancreatitis

PID

Ureteral Colic

Pregnancy

Endometriosis

Ovarian Conditions

Dysmenorrhea

Lumbosacral Strain

Varicella Zoster

I don’t know about you, but to me, that’s one huge list of possible causes, and this is just the potential causes for back pain. Back pain is one of the most common types of pain that people suffer from. We can assume that there is another long list of causes for shoulder pain, and knee pain, and just about any pain. I think you get my point. I don’t have the education, medical license, or technology to tell you what the problem is. If you have pain, especially if it hasn’t resolved or improved over time, see a medical professional. If you see a doctor or a physical therapist, and your condition has improved or is verified as nothing serious, then there are some things that might be helpful in the gym. I am going to address the three most common issues I see as a personal trainer. Low back, knee, and shoulder dysfunction.

According to the research stated in the ACE Advanced Health & Fitness Specialist Manual, 80% of people will experience at least one episode of back pain during their life time. Low back pain (LBP) is by far, one of the most common ailments that people seem to suffer from. As I mentioned earlier, there can be a long list of different causes for that pain. However, if you have visited a medical professional and have been cleared to exercise, there are a few things I have found to be beneficial in training. Scrap the crunches and focus on core stability. Front planks, side planks, dead-bugs, and bird dogs should be some of your go to exercises for the core. However, before you progress to those exercises, make sure you can breath and brace. Some people have a hard time breathing into their belly and fully utilizing their diaphragm. They breathe into their chest which can bring tightness to the upper back and neck. The second thing that some people don’t do, is fully exhale. If we don’t fully exhale, it can leave us in a state of hyperventilation. We may suffer from rapid heart beat, feeling lightheaded, shortness of breath, muscle tightness, and chest soreness. Practice some deep belly breathing and then try a few full exhales, almost to the point of discomfort, and you will probably feel your deep abdominal muscles activate, along with a stretch in your diaphragm. The next step is to learn how to brace the abdomen. Practice consciously engaging your core muscles around the whole midsection, it should feel as if you are wearing a belt around your abdomen. In most cases, when someone has LBP, they are loose in the midsection and there appears to be a disconnect between their upper and lower body. This usually results in their hips dipping down and their low back hinging. I most often see this when they perform a front plank or a push-up. There are three steps you should be concerned with when you are performing a core stability exercise.

  1. Find neutral with your pelvis and low back
  2. Brace by actively engaging all the muscles around your mid section (360 degrees)
  3. Breathe

Often times, clients come to me with the goal of building a strong core. Unfortunately, people have it in their head that they should be doing all kinds of fancy spinal flexion (think v-ups) and extension exercises (think supermans), instead of working on these basic core stability moves. Many people don’t find these basic exercises sexy and assume they are useless because their core doesn’t feel extreme soreness the next day. It is unfortunate because many times people don’t perform the basics right in the first place. I believe I must credit Kelly Starrett of Mobility WOD for the following concept. If you have specific problem area, it is helpful to look upstream and downstream from the problem, and not just directly at the problem. Improving mobility in the hips and thoracic spine can be helpful in the case of LBP. If these areas are limited in movement, the low back is often used as a substitute for the movement. Ultimately, the low back should be stable. When I see people who are stiff in their hips or upper back, I see them hinge in their low back when they perform a movement such as a toe touch. Learn to stabilize your core and often people see good results.

It seems like just about everyone has had a bum knee at some time in their life. A few possible causes of knee pain can be illiotibial band friction syndrome, patellofemoral pain syndrome, meniscal injuries, and knee ligament injuries. An orthopedic doctor will be your best bet for a diagnosis and a plan for recovery. Sometimes for people who complain of knee pain in the gym, it just comes down to them performing a lower body exercise with poor form. I have a client that I have worked with for years, and initially they complained of knee pain when exercising. They felt it had started from incorrectly performing a move in one of those high intensity at home workout programs, such as P90X. With a few tweaks to their form, they could perform squats, lunges, and step-ups. I had them working on keeping a more vertical shin and sitting back into their heels. This helped limit the forward movement of the knees and kept them off their toes, thus reducing the shear force on their knees. If we subscribe to the upstream and downstream theory, then we would work on ankle and hip mobility. Limited range of motion in the ankle is often a factor in poor performance of squats and lunges. Check out this post by physical therapist, Mike Reinhold, on assessing ankle mobility and drills to improve it. If the hips are locked up, and it’s difficult for a person to hinge from the hips, there could be more chance that they will drive their knees forward in a squat and come up on their toes. Here are four hip mobility drills from Kevin Carr, to improve your squat. Of course, I need to mention that core stability plays an important role in maintaining proper exercise positioning. If the core is unstable, there is risk of valgus knee collapse (inward rotation of the tibia) while exercising or during athletic competition, which can grind away the meniscus or instigate an ACL tear. So core stability exercises can make a difference for your knees and hips too.

While low back pain is probably the most popular complaint I hear, shoulder pain and dysfunction is quickly catching up. I think it’s pretty easy to identify poor posture as the main culprit in this rise of  this dysfunction. In a majority of people I see over the age of 40, overhead lifting is not recommended until this issue of mobility and dysfunction is addressed. Yet, many popular exercise regimens throw overhead lifting right into the mix from day one, and it doesn’t matter how much you reduce the weight and/or limit the volume, it’s just not good for them at this point (if ever). We can have acromioclavicular joint injuries, instability of the joint, or rotator cuff pathologies. Generally, we train for stability in the scapula, and mobility in the thoracic spine and shoulders. Often times, people will arch through their low back to compensate for poor overhead shoulder mobility. This can lead to issues in the low back. Try laying on your back and raising your arms overhead as you perform a full exhale. This will help you keep the ribs down and you will feel more of the stretch in your lats and chest, instead of just cheating with your low back. Whenever you are performing any overhead lifting, it’s important to keep the ribs down, and the back neutral. Eric Cressey is a strength coach and expert on the upper body, working with numerous baseball players. Here are some great drills from Cressey for shoulder mobility, scapular upward rotation, thoracic spine extension, and anterior core stability. And there you go, we are once again revisiting the importance of core stability and proper breathing. It all ties together. Most clients do well to start with cable chops and kettlebell lifts as they work on improving their shoulder strength and mobility.

We have a lot of great medical professionals in the Rogue Valley, and you probably have great ones wherever you reside. I can think of many medical professionals that definitely can help. As a physical therapist that I know pointed out, differential diagnosis of musculo-skeletal injuries are included in the entry level scope of practice for orthopedic surgeons and physical therapists. Rehabilitation of musculo-skeletal injuries is also covered under the entry level scope of practice for physical therapists. If you are having joint and muscle pain that limits you, especially if it has become chronic and it hasn’t resolved, you really should see one of these people. As I mentioned above, there can be many different possibilities for your pain and dysfunction.  In my opinion, chiropractors, osteopaths, and massage therapists can provide services that can help support the recovery process and keep healthy individuals functioning at a high level.  However, for pain/dysfunction, it’s best to get that diagnosis first! I am an ACE Advanced Health and Fitness Specialist, which was developed to enable fitness professionals to collaborate with the healthcare community to support a client. If you come to me with undiagnosed pain, I will punt the ball to the appropriate healthcare provider. Then, with your permission of course, they can relay the appropriate information to me, to make your training correct. From there, I can help you with the mobility and stability you need, along with teaching you how to lift heavy things. If you are unsure about whether you need a medical intervention, a good trainer should be able to help you answer that question when they do an initial screen. If I run a person through the Functional Movement Screen and a fitness assessment, it usually becomes clear if an issue is beyond me. Then I can help refer the client to the appropriate medical intervention. So just to be clear once more, I’m not a doctor, and no, I have never played one on television or in a gym. There are well educated and compassionate people in the healthcare and medical field that can help you. Here’s to pain free training and good health in the New Year!

 

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