I have been thinking about and working in orthopedic physical therapy since 1996, when I shopped around my very sad resume containing only the facts of my high school diploma and status as a peer counselor in high school.
During that time, I have witnessed many evolutions in practice- the most fascinating to me arising from the growth of the body of knowledge relating to movement science.
Open MRIs helped transform our rehabilitation processes around knee pain. Gait and EMG studies have changed what we think of as the “core” (and preferred methods of training it).
Indeed, our movement and practice requires a constant interplay between what is most current in the field of movement science- rather than relying only on what we “see and feel” (which can be subjective).
A marriage of both subjective and objective is, in my opinion, the beauty of a successful orthopedic rehabilitation.
There is something else that I have observed over time, and that I have been testing regularly for the past 18 months. I have already written on this topic (which I will refer back to later)- but I have been approaching it from a different angle.
First, think about all of the forces that you subject your body to in a given day- its a bit overwhelming. The number of steps you strike on a 30 minute walk reverberating a ground reaction force up through the bones of your tibia, tibial plateau, femoral neck etc. The amount of minutes you ask your intervertebral discs to sustain the gravity multiplied by your weight. The number of bends you ask the annulus of your discs and spinal ligaments to sustain during a barre class. The newtons of compression you expose your patellar fat pad to while squatting in releve in said barre class. (I’m not picking on barre classes- maybe just for their poor squat mechanics!). The number of rotations under pound of pressure you expose your meniscus to during a 5 minute jiu jitsu round.
On and on and on, the sum of forces we expose our tissues to can appear relentless when viewed in this context.
Now, take into account the total amount of force all of the tissues in your body are able to sustain or generate.
I am going to jam a footnote right in the middle of this paragraph- as this is a blog for Pete’s sake: note that some tissues, such as muscle and tendon, generate forces, while other tissue- such as ligament, cartilage or bone, dampen or contain forces.
Your bone has (a modifiable) and limited amount of compression it is able to withstand. Your cartilage too- it can come fatigued when you spend a long afternoon standing on concrete floor at the Getty.
Similarly, your active tissues have limited (though modifiable) capacities. Your quadriceps muscle is able to generate x amount of force (which is measured in different ways- Newton-meters being the most accurate, manual muscle tests being the most often used clinically).
Your biceps brachii tendon will have a certain tolerance of force it can transmit before it fails (in this case- tearing).
If you look at both of these summations in very loosey goosey scientific terms- the grand total sum of the forces you face externally (Fe)- ground reaction forces, gravitational pull, torque has to be equal to or less than what you are capable of generating/ sustaining internally (Fi)
I keep seeing this in my mind, over and over like this:
Does that make sense? I cannot help but see this moment to moment when I am speaking with clients and students. Some people tag me as an optimist- but in all things related to my field, I am an unwavering pragmatist.
Excess inflammation in the tendons overlying your hip bursae? Is it possible you were overdoing it by doing strengthening exercises everyday rather than 2-3 times per week? Check.
Disc irritation after a long drive? Is it possible you pushed your healing disc beyond its load tolerance since the kids were in the back seat and you couldn’t recline? Check.
Fascial discomfort after returning to hike after building strength? Is it possible you hiked 5 rather than 1 mile? Check.
Over and over and over again this equation is helpful in solving movement questions. The genius bit is that it doesn’t matter what tissue you are relating to- the thenar muscles of the hand, the menisci of the tibiofemoral joint. Know the tissue, know its general function (containing/ dampening or generating force) and you can go back in time and see where you might be overdoing it. I have never met an orthopedic problem that cannot be figured out by this accounting process. I have however, had many folks I have spoken with who are uninterested/ unwilling to take an honest accounting of forces and make changes to what they are exposing themselves to. As always, this is absolutely our human right.
When we look at our physical selves with this simplistic lens, we have two sides of the equation we can manipulate:
1) The forces we expose ourselves to
Can we ride for 5 miles less and not go past the limits of our spinal discs to sustain compression? Can we break up a 2 hour seated meeting with lying supine, or getting up to stand to unload our spinal cartilage and bone? If we can trail run 6 miles without pain, but our 7th mile irritates our quadriceps tendon, can we run on flats or drop down our mileage to reduce the load to what our muscle can tolerate?
2) And the forces we can generate/ sustain
This second piece is the goal of every quality strength training and rehabilitation protocol. Every single tissue in our body- with the exception of cartilage- is capable of growth and repair. How to navigate this growth process (of bone, tendon, the capacity of cartilage and bone to tolerate compression) is a BROAD topic- way too deep to explore in this simple post.
The "how to" of transforming our force production or ability of force containment is what I am most interested in playing with in exercise education. I am fascinated by growing capacity. My favorite practice for understanding if we are strong enough for how we are moving, is using the perspective of prerequisites- each skill has a prerequisite- and assessing if your mobility/ strength align with the prerequisites for the movement skills you find meaningful?
Balancing force exposure with force capacity, rest, how we eat, how we think about our bodies and our enoughness- all of these impact our internal capacities.
Of course this concept of balancing output and input is not new. I have actually written about it before, in my post about the checking account theory as described by my teacher Tim McGonigle at Folsom Physical Therapy.
However, there is something about the accounting of the tissues- identifying what they are named and what their function is- that makes this equation easier for my brain to interpret. I find myself going back to the simple equation over and over again.
Until we meet again, keep your checking accounts (your internal force capacity) full, and your withdrawals (the external forces you subject your tissues to) enjoyable!
Chana believes that when someone snaps a picture of her, a part of her soul is lost forever