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Wisdom from the Orthopedic Office: focus on movement

Hi Friends,

How are you this fine first Sunday in February? A lot of folks up here will be watching the super bowl today, which means the trails will be prime for MTB!

As I sit this morning, I am thinking not of football or biking, but of the ways in which our ideas around movement and injury may inhibit our movement capacity and health.

I was in a dance class yesterday and the teacher was speaking about her injuries. She said she had seen a doctor who had told her she should not do squats because they were damaging her knees.

In situations like these, I take a deep breath and relax my mind. I have been working in orthopedic physical therapy specializing in movement instruction and observation since 1995. I immediately want to switch into my professional role. The clinician within me wants to collect more information like “did your doc watch you squat?” "what is his/ her training in movement analysis?"“are you loading (using weight) while you squat?” “what depth are you squatting to?” “what is your ankle and hip mobility like?”

The truth about squatting, is that it is the same movement pattern as getting in and out of a chair- something that we all need to maintain the ability to do well into later life. Squatting, like all movement, is not good or bad. It is a potentially extremely helpful movement depending on the nuances of how it is performed.

If we do not prepare our bodies to squat with good mechanics in our 40s, and keep squatting throughout our lives, how can we hope to maintain the ability to get into and out of a chair when we are in our late 70s and 80s?

Another point to make, and this is with no disrespect to medical doctors who I value deeply, is that your medical doctor has very little training in movement and exercise. With very few exceptions, it is simply not part of medical school education. Some medical doctors (such as movement disorder docs and physiatrists) may have specialized training in gait patterns and functional movements. But by and large the domain of movement education (in the field of western medicine) occurs in the realm of physical therapy. Physical therapists are western medical professionals with doctorate degrees in general application of rehabilitation medicine.

I can write that without bias, your physical therapist should be your go to for questions relating to movement and injury within the domain of western medicine.

It is also important to acknowledge that the field of movement science is evolving and we are discovering science which helps us advise on movement on an ongoing basis. As I have written before, there is just not that much research in movement science to definitively prescribe exercises. Things such as, the general strength required in the lower body to run one mile vs. twenty- those kinds of questions have not been sorted out and answered--- yet.

But after working in the field of physical therapy and movement science for 24 years- instructing in movement, observing patterns of movement and dysfunction- there are some things that I know to be true though science has not yet established proof.

Here is an example of how my orthopedic mind would work in advising someone on activity:

Movement tends to be painful when we don’t have critical features required to make that movement successful

Critical features can be flexibility (joint and soft tissue), strength, neuromotor awareness of correct biomechanics. It can be a combination of the above factors.

So, let’s take the example of the dance teacher above. Her medical doctor has told her to stop performing one of the critical movements to maintain function as we age. That may or may not have been appropriate advice for this person. But more importantly, the dancer has now internalized that concept that squatting is “bad for the knees” and that she should not be doing it. Period. This is really harmful advice.

When you look at movement on a spectrum, and the goal of aging healthfully is to keep that spectrum of movement as large as possible for as long as possible. Every time someone advises that you stop doing an activity (especially one of the Functional 5 that I will write about next post), your spectrum of movement is irrevocably diminished. There must be an understanding and a plan in place to help you get back into activity.

Identify an Impairment:

If I were working with this woman as a patient, I would have her demonstrate her squatting. I would likely notice one or more common anomalies commonly seen in a squat when folks have knee pain (sometimes predictable by the location of pain) such as:

-Knees translating over the toes in the sagittal (forward) plane of motion

- Long leg bones of the femur diving in toward each other during the descent (eccentric) phase of the squat

If I was unable to observe a poor movement pattern here (which is really very rare) I

would have the dancer try a squat just on her symptomatic side (single leg)

Based on what I observed above, I would test flexibility and muscle strength to confirm or reject my hypothesis of what is causing her pain during this activity. Some common findings with squats are:

-Not enough ankle flexibility to allow for normal movement at the tibiofemoral joint

-Not enough strength at the hip (abductors and external rotators) to stabilize the femur during the lowering phase

-Poor squat mechanics- patient does not have proper alignment during movement

As I stated it can also be a combo of all three of these conditions! By and large the two things I notice the most often is that:

-People are performing activities they have not yet built the strength or flexibility for

-The activities themselves are not the issue and there are movements that are occurring in the person’s life that are irritating the tissues

Establish a Plan to Address the Impairment:

In rehabilitation medicine, once you have a working idea that has been proved through testing of the tissue that is creating pain and inhibiting normal mechanics, you work on that selectively to restore normal motion. Some of the impairments can be restored on your own, while others may require hands on care. I may do hands on therapy to restore knee mobility orgive someone a stretching or strengthening program. We may work on core and ankle strength, though it is the knee that is painful. Once someone has made changes in the underlying impairments, I will retest the movement and reintroduce if the conditions are sound.

Reintroduce Movement:

And so, in the course of a week I might have a conversation with someone that, indeed a squat is not the right exercise for them at this time (and I would explain, that it is because of limitations in strength, flexibility, etc.) and we would work together on a plan to restore this impairment, and re-establish functional movement (the squat).

When you look at movement through this lens, there are very few movements that are “wrong”- instead, we are challenged to develop responsibility in how we are moving our bodies and what we bring to our movement.

What are your thoughts on looking at movement this way? Does it help you feel empowered and capable of making change? Does it challenge you by asking you to become more responsible in maintaining your movement?

Please send comments you might have, I would love to hear your thoughts.

Happy Moving!


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