Reduction in Severe, Chronic Mid-Back Pain Following Correction of Sagittal Thoracic Spinal Alignment Using Chiropractic BioPhysics® Spinal Rehabilitation Program Following Prior Failed Treatment: A Case Report with 9-Month Follow-Up
Chronic mid-back pain (MBP) is a challenging condition, particularly when it persists despite conventional treatments. A newly published peer-reviewed case report in Healthcare (MDPI) documents a successful outcome using Chiropractic BioPhysics® (CBP®) spinal rehabilitation, supported by objective radiographic analysis using PostureRay® software.
Study Overview
Patient: 40-year-old female with over 10 years of severe, chronic mid-back pain
Prior failed care: Physical therapy, traditional chiropractic manipulation, and trigger-point injections
Pain severity: 8/10 at baseline
Objective Assessment Using PostureRay®
A key strength of this case report is the reliance on quantitative spinal alignment data obtained via PostureRay® Version 26 (PostureCo®, Trinity, Florida).
PostureRay® was used to:
Perform AI-assisted radiographic mensuration
Quantify thoracic kyphosis and sagittal balance
Establish baseline deformity and objectively track correction over time
This case reinforces several clinically important points:
Structural spinal correction may be necessary when symptom-based care fails
Objective radiographic analysis is critical for documenting meaningful change
PostureRay® provides reproducible, reliable measurements that support evidence-based clinical decision-making
The authors specifically note the importance of PostureRay®’s AI-assisted spine mensuration in accurately tracking sagittal alignment changes over time.
Conclusion
This peer-reviewed case report demonstrates that CBP®-based spinal rehabilitation, guided by objective PostureRay® radiographic analysis, can lead to sustained pain relief and measurable structural improvement in patients with chronic mid-back pain.
For clinicians focused on outcomes, documentation, and evidence-based posture correction, this study highlights the clinical value of integrating PostureRay® software into practice.
As children start going back to school this month, many parents don’t realize that their kids’ backpacks may actually be doing a lot of harm to their young and impressionable postures.
According to recent studies, it turns out that 6th graders carry anywhere between 14 and 20 pounds (some as much as 30 pounds) of books, notebooks, snacks, and supplies in their backpacks. When that amount of weight is incorrectly placed on the shoulders, its force will pull the child backwards. To compensate for this, most tend to bend forward at the hips or arch the back – which leads to spinal misalignments, pain, discomfort, and even sciatica.
Children who choose to wear their backpacks over just one shoulder, will end up forcing themselves to lean to the opposite side, in order to offset the extra weight. This will not only cause shoulder strain / pain, as well as back and neck pain, but for those with scoliosis, it will be downright uncomfortable and lead to worsening of the condition.
There are three things you can do for your child, to help him or her avoid long-term spinal problems:
1. Wheeled backpacks
2. Online text books (where available)
3. Corrective chiropractic care
Without help, children will develop spinal misalignments – leading to a wide range of health problems in the future. Besides the obvious back pain, neck pain, and shoulder pain, most children with spinal misalignments suffer from weak immune systems, headaches, migraines, allergies, asthma, fatigue, and acid reflux disease. While wheeled backpacks and online books are a great way to keep children from carrying heavy loads, one must remember that school-age children can also develop poor posture and spinal injuries during sports, slouching in their chairs in class, or horsing around with their friends.
Chiropractic BioPhysics or CBP is the most researched, scientific, and results-oriented corrective chiropractic technique in the world. CBP chiropractors aim to realign the spine back to health, improve posture, and eliminate the source of pain and nerve interference.
The Ideal Spine Health Center – the largest corrective chiropractic care facility in the United States – located right here in Boise / Eagle / Meridian, has helped THOUSANDS of patients – young and old eliminate pain, fatigue, and disease. Please call us for a complimentary exam and consultation to see if you qualify for corrective chiropractic care.
The ability to perform a squat or partial squat is an essential primal movement in life we must all be able to do, whether you are 8 or 80 years old. When we think of a squat, most of us associate the move with weight training or a specific sport activity. However, we all perform variations of a squat everyday with activities of daily living ranging from lifting a box to picking up a child or sitting down in a chair. Our ability to do this in a safe and correct manner can be the difference between injury and living a healthy, pain free life.
When done properly, the squat is a safe and effective exercise that can be used for strengthening the entire body. It is estimated that correctly performing a squat requires over 200 upper and lower body muscles to work synergistically. (17) Together, both the upper and lower body must properly work in unison to move through triple flexion and extension of the hip, knee and ankle. This exercise can also be used from rehabilitation to the sport-specific setting by simply changing the range of motion. For instance, in the rehabilitation setting, if quadriceps enhancement is the goal, then keeping the squat to less than 90 degrees is desirable since moving past this range of motion has limited benefit. (1) However, if the intent is to increase hip extensor strength, then increasing the squat depth would be beneficial. (2)
Performing a squat assessment can provide valuable information about a client and potentially reduce their risk of injury. In addition to musculature stability and postural control, dysfunctional movement patterns can also be identified. The inability to perform a squat can be a predictor of a low back or ACL injury. (2, 3, 4) In this article each body region will be discussed along with common movement faults to be aware of. Part 2 will discuss intervention strategies to correct these dysfunctions.
PERFORMING A SQUAT ASSESSMENT
Ask your client to wear shorts and a short sleeve shirt for the assessment. This will make it easier to identify faulty movement patterns. Position the client so that you can observe them from the front and side, as well as being able to observe any rotational movements in the transverse plane.
To perform a squat assessment, begin by instructing the client to stand with their feet shoulder width apart (inside of their feet aligned with the outside of their shoulders). Feet should be straight forward and arms straight above head or with hands gently behind their ears (Figure 1). This position retracts their shoulder blades and activates the upper back musculature providing stability. Their head should be in alignment with their shoulders and eyes gazing straight forward.
Figure 1
Figure 2
Instruct them to descend as far as comfortably allowed while keeping their heels on the ground and pushing the hips back as if sitting in a chair (Figure 2). The tempo should be 2-3 seconds on the way down. Do not attempt to cue them on improper movements you initially see. Have them repeat the squat 3 to 5 times. (2, 5, 6)
HEAD POSITION
Forward head posture has been associated with neck pain, shoulder pain, and temporomandibular joint dysfunction, therefore it is important to assess (Figure 3). (7, 8) Assess from the lateral (side) view watching for anterior head carriage or excessive extension of the neck. From the anterior and posterior view the head should remain in midline and not move side to side. (5, 6)
Figure 3
Eye gaze is also important to monitor as it indicates ones ability to disassociate eye from head movement. As they perform the squat, eye gaze should remain straightforward and not move upward with any head tilt. (5)
UPPER BACK AND SCAPULAR POSITION
Hyperkyphosis or excessive rounding of the upper back has been associated with forward head posture as well as limiting cervical range of motion. (9) Therefore it is important to maintain proper upper back and scapular position. When performing the squat assessment a slightly extended thoracic spine position is recommended to maintain a chest up position (Figure 4). This will also allow the scapula to be retracted. Any rounding of the shoulders and scapula protraction similar to upper cross syndrome should be quickly identifiable. (5, 6)
Figure 4
LOW BACK POSITION
Maintaining a neutral low back position with a slight lordosis is essential to proper and safe motion (Figure 5). Intravertebral disc pressure increases as lumbar lordosis is lost, putting one at risk for injury. (10, 11, 12) Therefore maintaining a lordosis throughout the squat movement is essential. It also allows for proper abdominal bracing necessary to maintain the intra abdominal pressure for proper support. (13)
Figure 5
PELVIC POSITION
Pelvic rotation and tilting should be assessed as this could be due to compensation for the low back or hip musculature. Monitor the level of the hips in relationship to the floor. If the hips lack mobility then this may be seen with excessive thoracic forward lean as the body attempts to compensate. Proper pelvic alignment also allows the muscles of the lumbar spine, erector spinae, quadratus lumborum and oblique muscles to function optimally providing support to the lumbar spine reducing the risk of injury. (5)
Figure 6
KNEE TOE ALIGNMENT
ACL injuries occur at a four to six fold greater incidence in females than males and have been associated with increased knee valgus angles. (14, 15) Therefore assessing the knee and toe alignment from the anterior and posterior view is essential (Figure 7). As the client squats down pay close attention and note if the outside of their knee crosses their medial malleolus. (5) This movement dysfunction may be the result of hip muscular weakness, an ankle dorsiflexion problem or over pronation.
Figure 7
TIBIAL TRANSLATION
There is a general consensus among fitness professionals that increased tibial translation allowing the knees to glide past the toes is harmful and should be avoided. Although knee torque increases as tibial translation occurs, there is no evidence to support ones risk of injury is increased (Figure 8). (5) Conversely, if tibial translation is limited, an increase in trunk anterior lean may occur in order to compensate. This is supported by Fry and colleagues who demonstrated limited tibial translation inappropriately transfers forces to the hips and low back. (16) Therefore as a general rule, assess whether the tibia and the spine are in parallel alignment (Figure 9).
Figure 8
Figure 9
FOOT POSITION
A stance with feet forward, or with a slight degree of external rotation, and approximately shoulder width apart is desired as a wider stance will change the torque about the knee and hips as well as the muscle activity of the lower extremities. (2) As one descends the foot pressure should shift from the mid foot toward the heel and lateral foot during this loading phase. (5) Toes should remain on the ground to maintain balance (Figure 10). From the lateral view assess if the heel is rising, which may be due to an ankle dorsiflexion limitation of the joint or from overactive gastrocnemius muscles. (18) When assessing from the anterior and posterior view, knee valgus as noted above may be the result of an over pronation problem.
Figure 10
START POSITION KEY POINTS:
Arms extended above head
Feet shoulder width apart
Feet pointing straight
Eye gaze is fixed straight ahead
BOTTOM POSITION KEY POINTS:
Arms stay straight
No excessive forward lean
Feet stay pointing straight
Heels stay on the ground
Knees stay in line with feet
It is of utmost importance that clients are pain free when performing any movement assessment. Refer to the NASM Essentials of Corrective Exercise Training book for recommendations. Part 2 of this article will discuss appropriate corrective exercise intervention strategies based on the movement dysfunctions identified here.
REFERENCES
1) Escamilla, RF, Fleisig, GS, Zheng, N, Lander, JE, Barrentine, SW, Andrews, JR, Bergemann, BW, and Moorman, CT. Effects of technique variations on knee biomechanics during the squat and leg press. Med Sci Sports Exerc 33: 1552–1566, 2001a.
2) Schoenfeld, B. 2010. Squatting Kinematics and Kinetics and Their Application to Exercise Performance. Journal of Strength and Conditioning Research 24(12):3497-3506.
3) Chaudhari, A., et al. 2006. The mechanical consequences of dynamic frontal plane limb alignment for non-contact ACL injury. Journal of Biomechanics. Volume 39, Issue 2, 2006, Pages 330–338.
4) Myer, G., et al. 2008. Trunk and Hip Control Neuromuscular Training for the Prevention of Knee Joint Injury. Clin Sports Med 27:425-488.
5) Myer, G., et al. 2014. The back squat: A proposed assessment of functional deficits and technical factors that limit performance. Strength Cond J. 2014 December 1; 36(6): 4–27.
6) Clark, M., Lucett, S., Sutton, B. (2014) NASM Essentials of Corrective Exercise Training. Burlington, MA, USA: Jones & Bartlett Learning.
7) Ruivo, R., et al. 2014. Cervical and shoulder postural assessment of adolescents between 15 and 17 years old and association with upper quadrant pain. Braz J Phys Ther. 2014 July-Aug; 18(4):364-371.
8) Harman, K., et al. 2005. Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults: A Randomized, Controlled 10-Week Trial. The Journal of Manual & Manipulative Therapy Vol. 13 No. 3, 163- 176.
9) Quek, J., et al. 2012. Effects of thoracic kyphosis and forward head posture on cervical range of motion in older adults. Manual Therapy 1-7.
10) Harrison, D., et al. 1998. Elliptical Modeling of the Sagittal Lumbar Lordosis and Segmental Rotation Angles as a Method to Discriminate Between Normal and Low Back Pain Subjects. Journal of Spinal Disorders. Vol. 11(5).
11) Panjabi, M., White, A. (1990) Clinical Biomechanics of the Spine, Second Edition, USA: LWW.
12) Callaghan, J., McGill, S. 2000. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clinical Biomechanics 16:28-37.
13) Kavcic, N., et al. 2004. Determining the Stabilizing Role of Individual Torso Muscles During Rehabilitation Exercises. Spine Volume 29, Number 11:1254–1265.
14) Myer, G., et al. 2004. Rationale and Clinical Techniques for Anterior Cruciate Ligament Injury Prevention Among Female Athletes. Journal of Athletic Training. 39(4):352–364.
15) Hewett, T., et al. 2010. Understanding and Preventing ACL Injuries: Current Biomechanical and Epidemiologic Considerations – Update 2010. North American Journal of Sports Physical Therapy. Vol. 5(4):234-251.
16) Fry, A., et al. 2003. Effect of Knee Position on Hip and Knee Torques During the Barbell Squat. Journal of Strength and Conditioning Research, 2003, 17(4), 629–633.
17) Solomonow, B., et al. 1987. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med 15: 207–213.
18) Riddle, D., et al. 2003. Risk Factors for Plantar Fasciitis: A Matched Case-Control Study. The Journal of Bone and Joint Surgery. 85-A(5):872-877.
DAVID CRUZ, DC, CSCS, FMS, SFMA
Dr. David Cruz practiced as a sports chiropractor for 18 years treating athletic injuries, from weekend warriors to professional athletes. He received his bachelor’s of science degree in athletic training and has completed graduate course work in kinesiology. He is a Certified Strength and Conditioning Specialist (CSCS) as well as having both FMS and SFMA certifications. The combination of his background in sports medicine and interest in technology made him passionate about bringing these two worlds closer together, resulting in the foundation of his company WebExercises in 2005.
WebExercises is an end-to-end solution for exercise rehabilitation professionals and is currently integrated with several EHR companies. In addition to WebExercises.com, Dr. Cruz is co-founder and partner of two other software businesses within the health care and technology industry.
Anterior cruciate ligament (ACL) injuries are one of the most common among young female athletes occurring at a conservative estimate of 38,000 incidences per year. (1) With the cost of a surgical repair ranging between $17,000-$25,000 (2), the economic impact is significant, not to mention the long term sequela to the athlete which includes a significantly greater risk of osteoarthritis in the future. (3) Approximately 80% of these injuries are non-contact, suggesting many of them can be prevented. (4)
The ACL is a ligament running from the posterior femur anteriorly to the tibia. It originates from deep within the notch of the distal femur and its proximal fibers fan out along the medial wall of the lateral femoral condyle. The ACL attaches in front of the intercondyloid eminence of the tibia and is blended with the anterior horn of the medial meniscus. It provides approximately 85% of the restraining forces preventing anterior tibial translation. It also limits excessive internal or external rotation of the tibia. (5)
Pubertal females are four to six time more likely to sustain an ACL injury compared to males, thereby representing the largest demographic of athletes at potential risk. (6) This is due to a variety of reasons including the rapid growth of the femur and tibia that generate larger joint forces making neuromuscular control of the lower extremities and trunk much harder. A lack of core stability has also been shown to influence knee injuries in female athletes as reported by Zazulak and colleagues. They demonstrated this decrease in core neuromuscular control increases uncontrolled trunk displacement leading to higher knee ligament strain and ACL injury. (7)
In order to identify at risk athletes, implementing a screening method such as the Landing Error Scoring System (LESS) test or Tuck Jump test is essential when working with all athletes in this age range. The LESS involves having the athlete stand on a 12-inch box and then jumping forward with both feet to a predetermined line followed by an immediate jump for maximal height.
The Tuck Jump test requires the athlete to perform repeated jumps flexing the knees toward the trunk for a duration of 10 seconds. Both tests have been validated in the literature to identify neuromuscular imbalances. (9) (10) (For more information on each test please refer to NASM Essentials of Corrective Exercise Training for a detailed review. (8))
One of the most common muscular imbalances identified in females over males is increased knee valgus and coronal plane rotation that has been shown to be a predictor of injury. This common finding has been associated with increased quadriceps firing and decreased gluteal activation in females, causing anterior shear stress on the tibia, which is then transferred to the ACL. (11)
In order to establish proper gluteus maximus activation, a hip bridge with a resistance band above the knees is recommended. Choi and colleagues found that gluteus maximus EMG activity was significantly greater while anterior pelvic tilt angle was significantly lower in the hip bridge with isometric hip abduction compared to the hip bridge without the band. Therefore, they concluded that performing hip bridges with isometric hip abduction against isometric elastic resistance can be used to increase gluteus maximus EMG activity and reduce anterior pelvic tilt during the exercise. (16)
Hip Bridge with Resistance Band – Begin by lying on the floor with knees bent and feet flat on the floor. Place a resistance band around the thighs just above the knees. Slightly abduct the legs while simultaneously performing a hip bridge. Slowly lower to start position without bringing knees together. Perform 3 sets of 10 repetitions.
Valgus collapse of the knee can also be associated with weakness of the hip external rotators and gluteus maximus. Paterno and colleagues identified this finding as an eight times greater risk of sustaining a second ACL injury. (12) Performing the clam shell exercise will mitigate hip rotator weakness, helping to minimize this potential risk.
Clam Shell with Resistance Band – Begin by lying on the side with knees together and bent to 90 degrees with resistance band around knees. Lift top knee upward while keeping feet touching. Continue lifting knee to the point just before pelvis begins to move. Perform 3 sets of 10 repetitions.
The hamstrings are also synergistic to the knee helping to stabilize the tibia against the anterior forces created by the quadriceps. A stability ball leg curl is a great open kinetic chain exercise and has been showed to elicit high EMG activity of the hamstring muscles while co-contracting the core musculature. (13)
Stability Ball Leg Curl – Begin lying face up with arms extended at sides and ankles on top of the stability ball. Activate core and form a bridge position. Then flex knees, bending legs as you draw the ball inward. Reverse the movement, extending knees, and return to start position. Perform 3 sets of 10 repetitions.
In order to establish lateral stability, the side step “monster walk” with knees bent is a functional and effective exercise. Increased hip abduction strength has been shown to improve the ability of female athletes to control lower extremity alignment. (14) When performing this exercise, the stepping motion should be performed in a squat position rather than an upright straight leg position in order to generate greater gluteus maximus and medius muscle activity. (15)
1/4 Squat with Lateral Steps Using Resistance Band – Begin standing with a resistance band around the thighs just above the knees. Keep your feet and knees apart enough to put resistance on the band. Perform a ¼ squat with both feet supporting body weight. Hold squat position, shift weight fully onto one leg. Take a lateral step with the other un-weighted leg. Repeat, taking several lateral steps in one direction and then doing the same in the other direction.
Another potential risk of injury occurs when landing with a knee flexion angle of less than 45 degrees. Therefore, performing long jumps can be used to train proper landing patterns. This exercise is similar to the Tuck Jump test with the addition of forward motion and is also a great way to introduce plyometric exercises. If the athlete is unable to “stick” the landing with toes straight ahead and no inward knee motion, then regress them to submaximal jumps of a shorter distance until perfect technique can be attainted. (6)
Long Jump to Backward Hop – Begin in quarter squat position. Jump forward in an explosive long jump trying to “stick” the landing for 3-5 seconds. Make sure the knees are flexed to approximately 90 degrees on landing. Hop backwards two or three times returning to the start position. Perform 3 sets of 10 repetitions.
One of the most significant findings, which has been shown to reduce the incidence of ACL injuries in a number of studies, is the incorporation of high-intensity plyometric exercises as part of the training program. The split jump offers these plyometric benefits.
Split Jumps – Begin in a split stance lunge position with arms raised at shoulder level. Jump upward and quickly reposition legs and land with feet in opposite positions. Raise arms while you are jumping. Continue jumps by alternating leg positions. Perform 3 sets of 10 repetitions.
If an athlete fatigues to the point that she can no longer perform the exercise perfectly, then she should be instructed to stop. The duration of each completed exercise should be noted with the goal of the next training session to continue to improve technique and to increase volume or intensity.
In addition to the NASM corrective exercise continuum of inhibit, lengthen, activate and integrate, three additional components should also be considered as part of a comprehensive training protocol. These are biomechanically correct movement patterns as noted above; neuromuscular patterning based on the identification of underlying neuromuscular imbalances as found in the assessment test; and constant biomechanical assessment through the LESS, Tuck Jump or similar test with feedback and verbal cueing to athlete both during and after training. (10)
An incorporation of a core stabilization program is not only integral but also essential in order to provide dynamic stability for the lower extremities. A weak core results in energy leakage as described by McGill requiring the weaker joints to make up for this difference. An example of this is when jumping or changing running direction, the lower extremity musculature must compensate for the lack of core stability, negatively effecting performance. (17)
All of the above displayed exercises are easy to execute and include minimal risks if performed as described. To achieve satisfying results, it is important do them on a regular basis and for a minimum of 4 weeks. The general guideline for progressing student athletes is the “10% rule”, where total training (intensity, frequency, duration, or any combination) is not increased more than 10% per week. Although there are many approaches to knee strengthening, hopefully this has provided insight into some basic strengthening strategies. Should your client’s condition worsen at any time, an evaluation with a medical professional would be warranted.
To download a copy of the above exercises, click here.
References
1) Toth AP, Cordasco FA. Anterior cruciate ligament injuries in the female athlete. J Gend Specif Med. 2001; 4:25–34.
2) de Loes, M, et al. A 7-year study on risks and costs of knee injuries in male and female youth participants in 12 sports. Scand J Med Sci Sports. 2000;10(2):90-97.
3) Ruiz AL, Kelly M, Nutton RW. Arthroscopic ACL reconstruction: a 5-9 year follow up. Knee. 2002;9(3):197-200.
4) Sadoghi, P, et al. 2012. Effectiveness of Anterior Cruciate Ligament Injury Prevention Training Programs. J Bone Joint Surg Am. 2012; 94:1-8.
6) Myer, G. 2004. Rationale and Clinical Techniques for Anterior Cruciate Ligament Injury Prevention Among Female Athletes. Journal of Athletic Training 2004;39(4):352–364.
7) Zazulak BT, Hewett TE, Reeves NP, et al. The effects of core proprioception on knee injury: a prospective biomechanical–epidemiological study. Am J Sports Med 2007;35(3):368–73.
8) Clark, MA, Lucett, SC. (2014). NASM Essentials of Corrective Exercise Training. Burlington, MA. Jones & Bartlett Learning.
9) Padua, D. et al. 2011. Journal of Sport Rehabilitation. 20, 145-156.
10) Myer, et al. 2008. Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk. Athl Ther Today. 2008 September 1; 13(5): 39–44.
11) Zazulak, B, et al. Gender Comparison of Hip Muscle Activity During Single-Leg Landing. Journal of Orthopaedic & Sports Physical Therapy.
12) Paterno, M, et al. Biomechanical Measures During Landing and Postural Stability Predict Second Anterior Cruciate Ligament Injury After Anterior Cruciate Ligament Reconstruction and Return to Sport. Am J Sports Med October 2010 vol. 38 no. 10 1968-1978.
13) Panagiotis, T., et al. 2015. Muscle and intensity based hamstring exercise classification in elite female track and field athletes: implications for exercise selection during rehabilitation. Open Access Journal of Sports Medicine. 6:209-217.
14) Myer , G, et al. 2008. Trunk and Hip Control Neuromuscular Training for the Prevention of Knee Joint Injury. Clin Sports Med 27:425–448.
15) Berry, et al. 2015. Resisted side-stepping: the effect of posture on hip abductor muscle activation. Journal of Orthopaedic & Sports Physical Therapy.
(16) Choi, C, et al. 2014. Isometric hip abduction using a Thera-band alters gluteus maximus muscle activity and the anterior pelvic tilt angle during bridging exercise. Journal of Electromyography and Kinesiology.
(17) McGill, S. Core Training: Evidence Translating to Better Performance and Injury Prevention. Strength and Conditioning Journal. Vol 32(3):33-46.
(18) Myer, G. 2006. The effects of plyometric vs dynamic stabilization and balance training on power, balance, and landing force in female athletes. Journal of Strength and Conditioning Research. 20(2), 345-353.
THE AUTHOR
DAVID CRUZ, DC, CSCS, FMS, SFMA
Dr. David Cruz practiced as a sports chiropractor for 18 years treating athletic injuries, from weekend warriors to professional athletes. He received his bachelor’s of science degree in athletic training and has completed graduate course work in kinesiology. He is a Certified Strength and Conditioning Specialist (CSCS) as well as having both FMS and SFMA certifications. The combination of his background in sports medicine and interest in technology made him passionate about bringing these two worlds closer together, resulting in the foundation of his company WebExercises in 2005.
WebExercises is an end-to-end solution for exercise rehabilitation professionals and is currently integrated with several EHR companies. In addition to WebExercises.com, Dr. Cruz is co-founder and partner of two other software businesses within the health care and technology industry.
Shoulder pain and shoulder injuries are among the most common conditions within the general population and among athletes. Approximately 75 to 80% of these are caused by conditions related to the rotator cuff (1). The rotator cuff consists of four muscles, including the supraspinatus, infraspinatus, subscapularis and teres minor. These act to provide dynamic stability and control the position of the humeral head relative to the glenoid fossa during motions ranging from throwing to performing a push-up (2). There are many factors that can lead to shoulder pain and dysfunction, one being a muscular imbalance between the rotator cuff muscles and its relationship to the scapula and clavicle.
This two part series will describe the function of the rotator cuff and its synergistic relationship to the scapula and clavicle, while also providing exercises to strengthen the muscles of the shoulder complex. Correcting dysfunctional movement patterns of the shoulder complex typically requires a multifaceted approach including inhibiting, lengthening, and activating muscles whether the goal is preventative or rehabilitative. This part of the series will focus on corrective exercise strategies that inhibit and lengthen muscles by self-myofascial release in combination with static stretching. Part 2 of the series will provide you with corrective exercise protocols to stabilize and strengthen the rotator cuff muscles.
To understand how to implement corrective strategies we must first look at the anatomy and kinematics of the shoulder. The shoulder complex can be broken down into three distinct regions, the upper arm or humerus, scapula, and clavicle, which are working together providing movement in all three planes. These three regions create a mechanical linkage that is dependent upon one another for proper shoulder motion that is controlled by the upper trapezius, lower trapezius and serratus anterior.
Dysfunctional movement patterns are in part based on the concept of relative flexibility that suggests movement occurs through the pathway of least effort. For example, if hip movement is relatively stiff compared to that of the low back, then the movement is more likely to happen in the back (3). In the case of the shoulder, if the trapezius muscles are limiting proper scapula thoracic motion, the rotator cuff muscles will then compensate for this and become the “pathway of least effort” leading to compensation patterns. Therefore, inhibited or tight trapezius and serratus muscles will alter proper scapula motion. This results in improper clavicle movement due to these muscular imbalances ultimately affecting the rotator cuff.
In order to have properly working rotator cuff muscles, proper scapula thoracic motion must be established in order to maintain the correct length-tension ratio of the rotator cuff muscles. The motion of the scapula and upper arm is defined as a 2:1 movement ratio, meaning for every 2 degrees of upward humeral motion there is 1 degree of upward scapular motion. Muscles involved in creating this movement are the upper and lower trapezius and the serratus anterior. A change in scapula position or motion may cause an internal rotation of the humerus resulting in a shortened internal rotator muscle (subscapularis) and a stretched or weakened external rotator muscle (teres minor). Any dysfunction of these muscles will require opposing muscles acting on the shoulder complex to be affected due to their relationship with one another.
Proper shoulder motion and rotator cuff function are also dependent on clavicle movements that include protraction, retraction, elevation, depression and posterior rotation. As the scapula rotates upward the clavicle elevates up to 30 degrees at the acromioclavicular (AC) joint (4). Then as the arm elevates further the clavicle begins to rotate posteriorly along its axis allowing the scapula to further elevate upward.
This posterior clavicle rotation has been described in numerous studies including one by Ludewig and colleagues who performed a three dimensional analysis (5). Their findings indicate that as the arm elevates, 8 degrees of posterior rotation occurs when the arm is elevated to 110 degrees. Any loss of normal scapula motion will alter the clavicle motion and ultimately restrict the range of motion of the upper extremity. Therefore, prior to initiating any specific rotator cuff exercises it is imperative to restore the muscular function of the scapulothoracic, AC, and sternoclavicular (SC) joint regions.
In order to inhibit and lengthen these muscles a self-myofascial release (SMR) approach with either a foam roll or a tennis ball can be utilized. SMR using a foam roll has been shown to be effective for increasing flexibility when combined with static stretching. Mohr and colleagues demonstrated this when they compared foam rolling and static stretching of the hamstring muscles (6). Their study findings indicate using the foam roll for SMR in addition to static stretching is superior to either SMR or static stretching alone. Therefore, in order to maximize range of motion it is recommended to foam roll prior to static stretching.
The following protocol is based on the above-described findings and can be performed daily or at least 3 times per week. The SMR exercises are performed on the floor applying as much body weight pressure as can be comfortably tolerated for up to 1 minute at time.
Trapezius and Rhomboid SMR
Begin seated on floor. Lie back placing foam roll across upper back. Cross arms in front, placing hands on shoulders. Lift hips off floor. Slowly massage upper back, rolling up and down as tolerated, for duration of 1 to 2 minutes. Maintain consistent pressure with foam roll. If a painful area is found, stop rolling and REST on the area for 30 seconds as tolerated, then continue.
Posterior Shoulder Tennis Ball SMR
Begin lying on floor facing up. Place a tennis ball behind shoulder. Raise arm so elbow is at shoulder level and bent to 90°. Lift opposite shoulder slightly so that pressure is felt against tennis ball. Grasp wrist with opposite hand and move arm upward and downward massaging shoulder muscles. Perform massage for 1 to 2 minutes. Maintain consistent pressure with tennis ball. If a painful area is found, stop rolling and REST on the area for 30 seconds as tolerated, then continue.
Pectoralis Major and Minor SMR with Tennis Ball
Begin lying face down with a yoga or tennis ball situated between the floor and below the clavicle with forearm flat on the ground. Applying constant pressure on the ball, slowly move forearm upwards, pause momentarily, and then slowly return to starting position.
Static stretching to compliment the SMR exercises can be performed daily or at least 3 times per week. It is recommended that each stretch is held for 30-60 seconds and repeated three times resting 30 seconds in between stretches. When stretching the posterior shoulder a cross body stretch is recommended as this was found to be more effective than the side lying sleeper stretch by McClure and colleagues (7).
Cross Body Stretch
Begin seated or standing (ideally this is best done with the back against a wall to help stabilize the scapula and emphasize the stretch on the posterior shoulder). Extend one arm in front, and across body, at shoulder level. With opposite arm grasp arm above elbow and gently pull towards chest until a stretch is felt in the back of the shoulder. Hold for 20-30 seconds and repeat on opposite side.
Static Foam Roll Chest Stretch
Begin by positioning yourself lying on foam roll with feet flat on floor. Foam roll should support the head and run along the spine down to pelvis. Place arms to sides. Bend both elbows to 90º at shoulder level with palm facing up. Relax as chest and shoulders stretch for 30-60 seconds. Do not try to force arms to floor.
All of the above displayed exercises are easy to execute and include minimal risks if performed as described. To achieve satisfying results it is important do them on a regular basis and for a minimum of 4 weeks.
References
(1) Clark, M.A., Lucett, S.C. (2014). NASM Essentials of Corrective Exercise Training. Burlington, MA. Jones & Bartlett Learning.
(3) Lehtola et al. BMC Musculoskeletal Disorders 2012.
(4) Kisner, C., Colby, L.A. (2002). Therapeutic Exercise Foundations and Techniques. Philadelphia, PA. F.A. David Company.
(5) Ludewig, P., et al. (2004). Three-Dimensional Clavicular Motion Durning Arm Elevation: Reliability and Descriptive Data. Journal of Orthopaedic & Sports Physical Therapy, 34(3), 141-150.
(6) Mohr, A., et al. (2014) Effect of foam rolling and static stretching on passive hip-flexion range of motion. Journal of Sport Rehabilitation.
(7) McClure P, et al. (2007). A randomized controlled comparison of stretching procedures for posterior shoulder tightness. Journal of Orthopaedic & Sports Physical Therapy 37:108-14.
DAVID CRUZ, DC, CSCS, FMS, SFMA
Dr. David Cruz practiced as a sports chiropractor for 18 years treating athletic injuries, from weekend warriors to professional athletes. He received his bachelor’s of science degree in athletic training and has completed graduate course work in kinesiology. He is a Certified Strength and Conditioning Specialist (CSCS) as well as having both FMS and SFMA certifications. The combination of his background in sports medicine and interest in technology made him passionate about bringing these two worlds closer together, resulting in the foundation of his company WebExercises in 2005. WebExercises is an end-to-end solution for exercise rehabilitation professionals and is currently integrated with several EHR companies. In addition to WebExercises, Dr. Cruz is co-founder and partner of two other software businesses within the health care and technology industry.
We all know that our clients are doing good things for their bodies while we are with them, but probably not during the other hours of the week. Especially the prolonged time they potentially spend sitting, now considered detrimental to overall health. We see the effects of this everyday in the form of poor posture, and we continue to overlook it as something benign that naturally occurs over time without consequences. According to the American Journal of Pain Management “Posture effects and moderates every physiological function from breathing to hormonal production. Spinal pain, headache, mood, blood pressure, pulse, and lung capacity are among the functions most easily influenced by posture.” 1 There is also evidence that poor thoracic posture shows “a trend towards greater mortality” as discussed in a study by the Journal of the American Geriatrics Society. 2
Another fairly new risk factor that is starting to become more common is excessive usage of mobile phones, tablets and PCs. Over the past seven years mobile device usage has grown from .3 hours a day to 2.8 hours a day for the average adult. Comparatively, our computer use has remained about the same over the same time period at 2.4 hours per day. 3 A recent article by Kenneth Hansraj, MD, the chief of Spine Surgery at New York Spine Surgery and Rehabilitation, describes that as the head tilts forward its weight effectively goes from 10 to 12 pounds in the neutral position to as much as 60 pounds at 60 degrees of flexion, which is the typical position that we have while using a mobile device. 4
Over time this forward head position leads to ligamentous creep deformation having lasting neurophysiological effects. This was demonstrated with a feline study that found the creep deformation that occurred over the first 30 minutes did not recover with 10 minutes of rest and was present up to seven hours later. 5 The other finding of this research was even more alarming: the primary risk factor was not the load but rather the duration of the load. The implication of this is concerning given we spend an average of 2.8 hours a day using our mobile device.
In addition to the ligamentous deformation, muscle adaptations occur resulting in the Upper Cross Syndrome (UCS) as described by Janda. The UCS is characterized by tightness of the upper trapezius, levator scapula and pectoral muscles along with weakness of the deep cervical flexors and middle to lower trapezius muscles.
As these postural changes occur with the neck and upper body, our lower body becomes susceptible to adaptions as well. These include weakened back muscles as evident in a study by Sanches-Zuriaga that found a decrease in low back muscle activation after soft tissue creep, suggesting that prolonged or repeated flexion could increase the risk of injury. 6 These findings support the fact that prolonged sitting should be interrupted with breaks in order to decrease this risk along with exercise intervention.
For the purpose of this article the focus will be on the Active Subsystem (spinal muscles) as described by Panjabi in his spinal stability system model. The following five exercises can be used for most clients, requiring minimal time and no equipment. These exercises will not only help with preventing the above-described deformation and adaptation risks, but also encourage clients to stand up regularly and perform mini-exercise breaks throughout the day.
We will start with the forward head posture as described by Harman and colleagues who found that this position is associated with weakness of the deep cervical flexor and mid thoracic scapular retraction muscles. 7 Additionally, shortening of the opposing cervical extensors and pectoral muscles was also noted. A combination of strengthening exercises for the deep cervical flexors and scapular retraction muscles coupled with stretching of the cervical extensor and pectoral muscles was performed for 10 weeks. The findings of the study demonstrated that a short, home-based targeted exercise program can improve the postural alignment related to forward head posture.
Based on the above findings, the following three upper body exercises are suggested as they are ‘low-barrier’ homework for clients that they can perform daily without any equipment.
Head Retraction
Begin seated, or standing, looking forward with shoulders back, neutral posture. Activate core muscles. Attempt to draw head directly backwards. Maintain level head position. Do not tilt head up or down. Hold for two seconds. Return to start position. Beginners should start with 3 sets of 10 repetitions.
Shoulder Retraction
Begin standing with good posture. Shoulders should be back and head up. Bend elbows to 90 degrees and keep elbows near sides. While maintaining good posture, draw shoulders back squeezing shoulder blades together. A stretch may be felt in the chest and front of shoulder. Do not allow shoulders to raise upward. Hold for 5-10 seconds. Beginners should start with 3 sets of 5 repetitions.
Doorway Chest Stretch
Place forearm on wall, or doorway, with elbow bent at 90º. Elbows should be slightly below shoulder level. While maintaining forearm contact, lean body into doorway until gentle stretch is felt in the chest and shoulder. Hold for 20-30 seconds. Beginners should start with 3 repetitions on each side.
As described earlier, prolonged sitting and its effect on posture is not limited to the upper body alone but also affects the lower body. Tightness of the hip flexors along with an inhibition of the extensor muscles can lead to an aberrant motor pattern know as “gluteal amnesia” according to McGill. 8 He recommends exercises to enhance gluteal muscle function to unload the back in addition to hip flexor mobility with specific psoas muscle targeting.
Here are two very effective and easy to perform exercises that clients can do during short exercise breaks throughout the day.
Standing Hip Flexor Stretch
Begin standing in front of a chair about 18 inches away. Place one foot flat on the chair seat. Slowly allow hips to glide slightly forward until a gentle stretch is felt on the front of straight leg. Hold for 20-30 seconds. Beginners should aim for 3 sets each per side.
Glute Hip Bridge
Begin lying on floor, facing up. Bend knees so feet are firmly on floor and arms extended. Activate core muscles. Lift hips off floor to attain a bridge position with knees, hips, and shoulders in alignment. Slowly return to start position. Initially, some cramping in the back of the thigh may develop. A simple hamstring stretch, before and after, may prevent this from occurring. Beginners should aim for 3 sets of 10 repetitions.
All of the above exercises are easy to execute and include minimal risks. Most important here is the regular execution and mid- to long-term adherence to the program. A calendar that reminds clients of the exercises and allows them to check off performed sets and reps could be a motivational tool for them and helps you track their compliance.
References
(1) Lennon et al. (1994). Posture and Respiratory Modulation of Autonomic Function, Pain, and Health. American Journal of Pain Management. 4 (36-39).
(2) Kado et al. (2004). Hyperkyphotic Posture Predicts Mortality in Older Community Dwelling Men and Women: A Prospective Study. Journal of the American Geriatrics Society. Volume 52 (10) 1662.
(3) Bosomworth, D. Mobile Marketing Statistics 2015. Retrieved from: http://www.smartinsights.com/mobile-marketing/mobile-marketing-analytics/mobile-marketing-statistics/
(4) Hansraj, K. (2014). Assessment of Stresses in the Cervical Spine Caused by Posture and Position of the Head. Surg Technol Int. Nov;25:277-9.
(5) Jam, B. (2005). The Neurophysiological Effects of the Creep Phenomenon and its Relation to Mechanical Low Back Pain.
(6) Sanchez-Zuriaga, D. (2010). Is Activation of the Back Muscles Impaired by Creep or Muscle Fatigue? Spine. Vol 35, (5) 517–525.
(7) Harman, K. (2005). Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults: A Randomized, Controlled 10-Week Trial. The Journal of Manual & Manipulative Therapy. Vol. 13 (3) 263-176.
(8) McGill, S. (2010). Core Training: Evidence Translating to Better Performance and Injury Prevention. Strength and Conditioning Journal. Vol. 32 (3) 33-46.
On May 13, 2014, Dr. Joe Ferrantelli was notified by the United States Patent and Trademark Office (USPTO) that after a very vigorous review, he was awarded the full utility patent for the technology that powers the PostureScreen Mobile application.
Patent for PostureScreen Mobile awarded by the USPTO
Dr. Ferrantelli noted, “We at PostureCo, Inc. are very excited to see our technology is now protected not only by copyrights and trademarks, but now a full utility patent.” The patent US Patent Number US Patent No. 8,721,567 B2,is the first of many submitted patent pending both in the United States as well as abroad internationally.
PostureCo, Inc. (http://www.PostureAnalysis.com) just announced that it has submitted a new one-of-a-kind patent pending application to the iTunes App Store which can predict a person’s body composition simply from photographs.
According to CEO Dr. Joe Ferrantelli, “Our new update is extremely exciting for anyone in the health and fitness industry as this is the first app ever to simply allow a user to click points on a photograph and predict body composition. We call it LeanScreen – The Fat Analysis Photo Finish.”
Using this method of analysis, Dr. Ferrantelli goes on to state, “Using our new system, no longer will a professional have to measure manually with calipers or use a tape measure. Many software packages allow end user to manually enter the measurements that they obtained. However, what makes our patent pending technology novel is that we bypass manual methods and allow simple clicking of anatomical locations.” This leads to a body composition analysis, including Basal Metabolic Rate (BMI), Waist-to-Hip ratio, Percent Body Fat mass, Percent Lean Body Mass, as well as of course the client’s Body Mass Index (BMI). Dr. Ferrantelli notes, “In all of our testing we have found that our new method falls consistently within 3% of validated body composition tests such as water displacement and even DEXA scan estimates – truly exciting and cutting edge.”
Using LeanScreen, photographs will also document changes in body composition and results can be easily emailed securely to patient or clients. Using the exercise module, a health care professional can then prescribe exercises through the WebExercises cloud platform (http://www.WebExercises.com).
According to company spokesman, Tim Brown, LeanScreen is set to debut on the iTunes App Store within the first two weeks of October.
PostureCo, Inc. is a technology company focusing on posture and movement analysis, evaluations and screenings as well as spinal x-ray biomechanical mensuration EMR products for healthcare professionals. These software products are utilized by countless thousands of clinicians around the world, generating documentation from everything from postural and movement spinal health screenings to computerized radiographic X-Ray analysis documentation. PostureCo, Inc can be reached at 866.577.7297 http://www.PostureAnalysis.com , or on http://www.Facebook.com/PostureAnalysis for more information.
PostureScreen Mobile®, PostureScreen®, SquatScreen®, LeanScreen®, PostureTrend Analysis® and PostureRay® are REGISTERED TRADEMARKS of PostureCo, Inc.
