Be Well Personal Training

Sunday, September 21, 2014

The case of the “sore” hip

My left hip has been sore. For months. More accurately, the front of my left hip felt like it needed to be stretched, and while it felt good when I stretched it during yoga, the sensation of tightness remained. I thought it was just something I would have to live with, and since there wasn’t any pain and I could do everything I enjoyed, I didn’t really devote much thought or attention to it. I should qualify this by saying I could do everything I enjoyed except backbends. (Not that I have ever truly loved backbends, but they are part of my yoga practice and many, many years ago backbends taught me how to use my lower traps and get rid of neck pain, so they hold a special place in my life as something that helped heal). My backbends were downright awful. They didn’t hurt, I was able to disperse the load in my spine, I just couldn’t lift up into any sort of arc shape. This was a new thing. I used to be somewhat good at backbends, though for a long time they didn’t feel good. Now they felt fine and looked awful.

3 weeks ago I went to DNS Movement Skills down in Carlsbad. I had a great time, and would definitely recommend it to people that study DNS and enjoy the exercise component. I had a really good partner for most of the course named Jonathon. At the end of the first day, we were working on the deadlift using DNS principles and despite a fairly good understanding of how to move my body, I couldn’t finish the lift. It was as though my brain didn’t understand how to move my femurs back and my hips forward. Jonathon told me I needed to learn how to use the posterior third fibers of my gluteus maximus or I was going to end up with a shortened gait cycle (chiropractors and physical therapists work with so many dysfunctional movement patterns, I think they tend to catastrophize a little bit, but that’s a personal opinion). Martina, the instructor, came over at one point when Jonathon was struggling with getting me to go into full hip extension. “You need to work on moving your femurs back."

Learning to use the posterior third of my gluteus maximus and moving my femurs back made sense. I began learning PRI about 18 months ago. I fit the worst pattern, and designed a restoration program for myself, both for personal gain and to understand how PRI worked. The PRI viewpoint is that the patterns are like an onion. At the deepest layer is PRI “neutral” which means a balanced pelvis in the sagittal, frontal, and transverse plane along with a balanced ribcage and shoulder girdle region. Layers add, starting with a transverse plane femur pattern, working all of the way up to complete lack of sagittal plane control, or “superior T4 syndrome,” which was me. PRI, like chiropractors and physical therapists, uses verbiage that can be a little disconcerting. Knowing I had a “syndrome” that could potentially lead to all of these awful things definitely prompted me to be a little obsessive about being “syndrome free.” Over the span of 4 months, I peeled away the layers from superior T4, to right BC, to patho PEC (yes, patho is short for pathological. Counseling may be required if your PRI professional tells you the names of some of these things), to L AIC until finally, I became “neutral.” Now, neutral didn’t solve all of my problems, but it did improve the efficiency of my movement. A lot. And it eliminated tightness in the mid back, improved mobility, and allowed access to muscles I hadn’t really been using. It also left me with a sore left hip.

If we look at the anatomy, it is pretty easy to see why. Let’s say the first layer of the onion developed when I was 13 (that is probably being generous. There is a good chance it was earlier than that because I was a high strung child, but I am giving young me the benefit of the doubt). The first layer of the onion involves my left pelvis living forward of my right pelvis in all situations. There are several muscles that cross the hip joint and attach and flex the hip, including the psoas major, the iliacus, the rectus femoris, and the sartorius. Now, imagine the left pelvis has been tipped forward for two decades, altering the length tension relationship of those muscles with the gluteus maximus. If you buy into the whole PRI thing (and I must say, for those of us that fit the patterns it can be hard to ignore), I had not had access to full hip extension with the pelvis in a neutral position on that side for 20 years. I was using the part of the muscle I knew how to use, and I definitely wasn’t using those lower fibers of gluteus maximus. That area had been in a lengthened position. I didn’t have the ability to use that part of the muscle for a very long time, and my brain didn’t know how to access that part of my body. (It is worthwhile to note I had the same problem on the right side as well, just not as severe, and I didn’t have any sense of chronic soreness on the right side. From a PRI perspective, this makes sense. The right side hadn’t been that way for as long).

The solution was surprisingly simply. I needed to learn to extend my hip. And so with the same tenacity I used when changing my “syndrome,” I taught my femurs how to extend. I used the supported lunge position, I used the finishing position of the deadlift, I discovered a very cool way to do this in a doorway. (Face doorway. Come into 1/2 kneeling position with back knee pressing into doorway to give you feedback. Exhale, allow ribs to come into expiratory position, inhale begin pressing thigh into doorway to create space between pelvis and femur and focus on moving femur back engaging the glute. The doorway keeps you honest and prevents your from cheating with your back). I began using the range of motion I had access to, which meant my hip soreness went away. Almost completely. It’s only been 3 weeks, but the fact that something that was there for at least 6 months has decreased 90 percent makes me pretty sure I can take care of the last lingering 10 percent of sensation in the next 2-3 weeks. More importantly, now that I understand how to extend my hips with my new range of motion, my backbends are dramatically improving, and since yoga is all about how pretty the asana looks, this makes me very happy. When people complain of things like tightness, it can be ease to assume it's a tissue quality problem (stretch more!) when sometimes, tightness is simply a motor control issue.

Yours in health and wellness,

Saturday, September 6, 2014


I was standing in line at Starbuck's the other day, looking around at nothing in particular. I noticed a woman waiting for her drink with an adolescent daughter or niece. "Wow," I caught myself thinking, "it's hard to believe adults can really be so little." As I paid and went over to the same counter to wait, I realized she and I were the same size. If anything, she may have been a touch taller.

Self-perception is a funny thing. I noticed early in my training career that when I asked some of my female clients to place their feet hip distance apart, they would set up with their feet wider than their hips. Their perception of their hips and the reality were different (I have also had the opposite happen, with people setting up more narrow than their actual hips). Becofsky, found in 401 individuals with osteoarthritis, perception of disability was more strongly correlated with depression than actual reduction of physical functioning; those with reduced functioning that didn't view their condition as a disability were actually in a better place psychologically than those with less reduced functioning, demonstrating that perception can affect both our physical and mental health. Our perception of our physical selves and abilities can be our biggest barrier (or our most powerful aid) in attaining our athletic potential. I often wonder how we get so out of touch with our physical bodies. Is it because we don't use them very much? Or that we are inundated with press about knee replacements, arthritis medication, and the obesity epidemic? Many of my clients that come to me as new exercisers don't trust their bodies to be strong. They wait for something to go wrong, assuming their bodies will fail them. It is my job to teach them their bodies are capable, and if they are patient, their body will perform feats far greater than they expected. The reverse is also true. Sometimes there is an expectation that "I should be able to do x because I could 30 years ago." While "x" might still be an attainable goal, if a person's body is different than it was 30 years ago, "x" might have to be achieved in a different way or on a different time schedule. A yoga teacher once said what we think we look like we while we are practicing yoga and what we actually look like are two different things. There are times where I think I must be in the deepest backbend ever, only to find my hands and my feet are miles apart. As a result, my perception of my ability to backbend is that I am not "good" at it and probably won't ever be able to do poses that require a lot of back mobility. This is in contrast with my perception of my ability to handstand. I know I can handstand in the middle of the room (I have accomplished this on several occasions, just not consistently); as a result, my perception is that eventually I will be able to always handstand in the middle of the room. My perception for handstands translates to confidence, while my perception of back bending borders on self deprecation ("I cannot currently backbend; therefore, I will never be able to backbend").

Perception also affects how people with chronic pain move and and their ability to perceive where their body actually is in space. Wand, found 50 out of 51 patients with chronic low back pain endorsed items on a questionnaire suggesting distorted body perception. (Body-perception distortion was found to be infrequent in the healthy control group). Recently, I trained a gentleman that had suffered from bilateral sciatica in the past year. While he was feeling better, he still suffered from a bit of pain, particularly walking up and down stairs. The first time I had him come into a supine position with his knees bent and feet flat on the massage table, I noticed his right pelvis was pressing heavily into the bed while his left pelvis was barely in contact with the surface. "Which side of your pelvis feels like it is most in contact with the bed?" I asked, assuming he would say his right. "My left," he responded with certainty. "My right feels like it's barely touching it." Though I learned a long time ago not to assume anything about how a person feels or experiences movement, I was a little bit shocked that his perception of his body and the reality were so different. His perception wasn't wrong; it simply didn't resemble what my eyes saw, further demonstrating the importance of asking rather than assuming what a person is feeling or experiencing.

Something that I find interesting about self-perception is the ease with which it can change. The new exerciser that perceives movement as a potential threat to injury with the right guidance can begin to view her body as strong and able. Using imagery and focused attention over time has allowed my client with low back pain to begin to perceive both sides of his back and where they are in space. I doubt I will look at a person while waiting in line again and think about how little she is, knowing now that that is a more accurate representation of me. While I think about movement and how my body moves a bit obsessively, I don't think much else of my physical self. If someone asked about my self-perception, I would describe myself as strong, not short or little, though I would probably qualify it with, "stronger than average, but there are many that are stronger than I am." If asked about my flexibility, I would quickly say my flexibility leaves something to be desired. Perception is relative and largely depends on one's frame of reference. Watching women regularly perform incredible feats of athleticism on the yoga mat and in the weight room (thank you, Youtube) gives me a different frame of reference of strength and flexibility, leading me to feel that compared to my peers, both could be improved upon. However, it could probably be argued that my strength and flexibility are above average when compared to the normal population. It is impossible to know a person's frame of reference and one's perception of his physical self. The client who has always been told her hips are bigger than her torso will probably regularly set up with her feet a little too wide, while the client that has been told she is frail might balk if given heavy weights too soon. The value of asking, "how does that feel," shouldn't be overlooked, either as a trainer, or as self-reflective question. Conversely, our experience of proprioception and how we move might be impacted by pain, our movement vocabulary (how much or how little time we spend thinking about movement), or our current psychological state. Connecting with our physical selves and beginning to paint an accurate picture of our body in space can improve athletic performance, self-confidence, and overall well-being.

Yours in health and wellness,

Becofsky, K., Baruth, M., & Wilcox, S., (2013). Physical functioning, perceived disability, and depressive symtoms in adults with arthritis. Arthritis, 2013.
Wand, B.M., James, M., Abbaszadeh, S., George, P.J., Formby, P.M., Smith, A.J., & O'Connell, N.E., (2014). Assessing self-perception in patients with chronic low back pain: development of a back-specific, body-perception questionnaire. Journal of Back and Musculoskeletal Rehabilitation.