The cause of chronic pain is often twofold - an incorrect diagnosis of the pain in the first place, and/or only treating the pain without looking for and correcting the real culprit. For example, not every foot pain is plantar fasciitis. It can be an array of other things such as an issue with abductor hallucis. Further, a rehabilitation plan focused on treating plantar fasciitis solely by addressing the pain in the foot without assessing functional movement would miss a motor control dysfunction of, let's say gluteus maximus, and thus failing to address the real cause for the chronic foot pain.
In treatment of lower extremity pain, the spine is often overlooked as a source of problems in triathletes because the pain typically manifests at the shoulder, knees or feet. Basic spine anatomy is as follows: cervical, thoracic and lumbar spine with seven, twelve and five vertebrae respectively, plus the sacrum and coccyx or tailbone. Each vertebra has a body, spinous and transverse processes to which muscles attach. Ribs articulate with thoracic spine. Shoulder blades or scapulae articulate with the ribs and thoracic spine via the scapulothoracic “joint", with the humerus (arm) bone through glenohumeral fossa and with the clavicle at the acromioclavicular joint or AC. All this anatomy is important to know because one can see how stiff the thoracic spine (most often lacking mobility in extension), could affect the motion of the shoulder and cause pain in an overhead athlete (swimming in triathlon). Thoracic spine assessment/treatment needs to be included in any shoulder rehabilitation program.
The big culprit for shoulder pain is often pectoralis minor. With its attachment to the coracoid process, also an anatomical part of the scapulae, a shortened pectoralis minor cause by poor postural habits (computer work) will tilt the scapulae anteriorly. From the side this would look like the bottom tip of the scapulae is lifted off the rib cage. Furthermore, perpetually poor sitting posture can trigger an excessive (functional) kyphosis (forward curvature) of thoracic spine. Looking at this situation functionally, a shortened pectoralis minor will inhibit lower trapezius and such dynamic will affect the activation sequence of scapular musculature during arm elevation, as it needs to occur during freestyle swim. Therefore strengthening the lower trapezius without increasing thoracic spine mobility and releasing the pectoralis minor won't result in a successful rehabilitation of shoulder pain. Stabilization exercises will not “stick" without proper mobility around the joint lacking stability [Functional Strength Training].
Similar to the example at the shoulder a scenario can be drawn at the hip joint. The sacrum, which is a part of the spine, articulates with the ilium. Ilium is a part of the pelvis. The long bone in the leg, the femur, articulates with the pelvis and thus with the spine through the acetabulum. During gait pelvis rotates forward and back and should stay level between weight bearing and non-weight bearing sides. Typical movement pattern is to activate the core for stability followed by activation of prime movers to execute desired action. We have evidence that with low back pain, for example due to increased compressive forces on the lumbar spine, core activation is delayed and there is more excursion with perturbation. In other words, core stability is anticipatory, meaning that the brain knows that it has to trigger stability mechanisms before mobility can occur. When in pain the muscles in low back, in particular, turn on later and not as strongly. Lower extremity power and strength will be affected by poor stability of core musculature of the spine (other core muscles are shoulder and hip stabilizers). Think of the old saying, “you cannot fire a cannon from a kayak". Based on personal experience as a physical therapist, I find that most athletes with lower extremity pain lack lumbar spine extension either due to weakness of prime movers as a result of a dysfunction in a stabilizing muscle, due to a lot of tone at the erector spinae because of poor muscle coordination or due to lumbar spine stiffness as a consequence of poor sitting posture. In general sitting posture regressed to sitting on the tailbone or coccyx and rest on ligaments for support. Instead, the weight should be brought forward between the sit bone and the pubic bone: this requires more core activation and is frequently undesired because it is harder, i.e. more work for the core musculature.
In some ways the spine should also be viewed as shock absorption mechanism much like in a full suspension mountain bike [Body Mechanics]. The deepest back muscles only attach from one vertebra to the one above allowing for segmental mobility and stability. A stiff spine is like broken suspension. Ground reaction forces do not get absorbed up the chain and one can see how that can cause problems at the feet and knees if a runner cannot control his body segmentally. Remember, mobility before stability.
Our body is an interconnected field that can rarely be treated or addressed in isolation. As a species our bodies have not changed much since we got out of the caves. The purpose of our biomechanics is to climb trees, run, throw and carry. We made functional adaptations to the way our body is used and that's resulting in poor alignment and consequently, faulty movement patterns. Thorough postural and movement analysis should be at the core of any rehabilitative and preventative approach for return to sport or staying healthy. Deciding whether the cause of the chronic pain is mobility related, motor control related or both is a crucial piece to success. The “how" will not be relevant until the “why" and “what" are identified.
Hopefully this article has shed a light on complex simplicity of our bodies and will trigger curiosity for further reading on more specific injuries.
About the Author: Martina Young is a Doctor of Physical Therapy, a Triathlon Coach and PES through NASM and an avid triathlete.
