The Most Common Postural Problem ( that you've probably never heard of )

Many of my patients have alternating symptoms of neck pain, shoulder pain and low back pain. They come to my office for the symptom that is currently the worst, and tend to downplay the symptoms that are currently minimal. They don't realize that all of the symptoms are related to the same dysfunction. Their spine is too straight.

When you look at a spine from the front, you want it to be straight (see pic below). But if you do see curvatures here, it is called scoliosis.

When you look at a spine from the side, there are normal curvatures. In the picture below the person is facing right. The forward curve to the neck and low back are called lordosis. The backward curve of the upper back is called a kyphosis. The pelvis tilts forward slightly as well. These are all natural and necessary for normal pain free function. These curvatures, along with the intervertebral discs, help to provide normal movement as well as shock absorption.

Many of us have lost touch with our bodies to the point where WHAT WE THINK is straight and upright really IS NOT. This is most common in those that have a job which requires them to sit. Sitting usually tilts the pelvis back, slouches the low back, and gives our upper body a slight forward lean. With good intentions, many of us try to correct this posture. But instead of tilting the pelvis to initiate the change, we straighten our upper backs. This eliminates the natural and necessary kyphotic curvature.

This dysfunction results in elongated low back and neck muscles that can't do their job. Muscles get weaker as they get longer. They tend to fatigue more quickly. This position also puts more pressure on the intervertebral discs of the neck and low back. So not only can your muscles hurt, but your joints as well. The muscles around the shoulder blades (scapulae) also become painful because the joint surfaces don't match up. The scapulae have a concave underside to them, which glides along the ribcage. The backside of the ribcage should be convex to match the surface, as in the picture below. But with a flat back, it is not. As the scapulae are pulled away from the ribcage, the muscles are elongated. Again, an elongated muscle is weaker, and fatigues more quickly.

Flat back posture also makes it difficult to take in a full breath, as the ribcage cannot fully spread out like it should. Altered breathing patterns result in fatigue of the muscles of the neck and low back, as these are relied upon more often. This spinal flattening plus a slight pitch forward is the most common postural problem I see in the office today. I know what you are thinking - "What can I do about it?" Stay tuned. You get your answer in my next blog.

Washboard Abs vs.Strong Core

I must admit I don't have "washboard abs". I have what you would call a "two-pack" instead of a "six-pack". But is having washboard abs really the same thing as having a strong core?

To answer that question, one must first define what "core" means. I don't always agree with Wikipedia, but here is what they have to say on the matter: "Major muscles included are the pelvic floor muscles, transversus abdominis, multifidus, internal and external obliques, rectus abdominis, erector spinae (sacrospinalis) especially the longissimus thoracis, and the diaphragm. The lumbar muscles, quadratus Lumborum (deep portion), deep rotators, as well as cervical muscles, rectus capitus anterior and lateralis, longus coli may also be considered members of the core group. Minor core muscles include the latissimus dorsi, gluteus maximus, and trapezius."

So there is well over a dozen muscles listed there, even if you don't include the latissimus dorsi, gluteus maximus, and trapezius, which I do. There also a few more I would add to the list such as serratus anterior. I understand the temptation to look at what you can most readily see and identify it as the "core". But we all need to get over this idea that sit-ups, crunches, or planks are the go-to core exercises for someone trying to decrease their pain levels through core muscle development. It is my humble opinion that the world of fitness, exercise science, and physical therapy have been overly influenced by the bodybuilding. The idea that we need to "isolate" one muscle at a time is quite ridiculous. In real-life scenarios, muscles don't work in isolation. Therefore training and developing them in this way is likely to end up in pain and dysfunction. Certainly the muscles look good on bodybuilders, but these folks are not as athletic as they look. Just ask one of them to run and you will see what I mean.

Here is a link to my Youtube channel. In it you will find the three core exercises I give the most : Up Dog, Side Bridge, and Bird Dog. I explain them in the videos, and in previous blogs as well, and there is no need for redundancy. Notice that none of these three main core exercises directly targets the abdominus rectus muscle. This is because the abdominus rectus muscle is one of a dozen core muscles, and is not THE important muscle. But, of course, it is still wise to train this muscle. The best way to train them is to do "Frog Abs". This exercise, like most of my core exercises, puts you into a position and hold it for three audible breaths. The breaths are very important, and it is necessary to keep them audible for two reasons. Not doing so will lead to holding your breath, guaranteed. The second reason is because it helps to stimulate the core muscles, many of which are involved with forcible inhaling and exhaling. Passive breathing (what you are likely doing right now), does not stimulate these muscles.

Click here to see Frog Abs video.


The video posted above also shows a hip position that minimizes low back pain. The turn out of the hips fires up the gluteal muscles, so that they work in conjunction with the abdominus rectus. Otherwise it is possible that the low back muscles fire up instead of the glutes, creating low back tension. Also, the lack of movement minimizes any risk of jerking your head forward, and injuring your neck.

Doing planks can be a good core exercise as well. Yet there is one inherent problem with it. The person doing it can't see their own back. I think if they did see it they would be surprised. Most people have such a gap between the shoulder blades (scapula) and their ribcage, that you could stick your fingers in there and pick them up like a suitcase. This is a sign of weak serratus anterior. Scapular winging has other possible causes, but weak core is the most common.

I guess I can't expect too much from people. They have been taught the same core exercises for decades, and now Dr. Schafer wants to start from scratch. I get it. I don't have the washboard abs, so what do I know about core muscles, right? Well, for starters, I don't have back pain.

Top 5 Running Mistakes

In the fall of 2010, I started training for the Grand Rapids Marathon in 2011. I had never run for exercise before. Gradually and slowly increasing my distance allowed me to complete the goal. However, it took me 12 months to get there, and more importantly, to do it without injury. Here I am in the final stretch, when my daughter decided to join me. When we crossed the finish line, she was quite upset that she did not get a medal. I tried giving her mine, but to her credit, she would not take it.

I try to inspire people to exercise in whatever capacity they can. I want to help my patients help themselves. When they do, I know that their long term success in fitness and health will translate into less pain overall. Yet there are always road blocks on the journey. Knowledge is key. If you want to run for exercise but are afraid, don't be. But be smart about how you train. And don't expect to go from running 0 miles to 26.2 overnight. So here are the most common mistakes made by beginners, and by those who just haven't done it for awhile.


1. Too much too soon.
This is easily the most common problem. Everybody has physical limitations. Testing your limits occasionally is good, but don't do it every time you run. Follow the 10% rule- don't increase your total weekly mileage or pace by more than 10% per week. That means you can't jump from running 1 mile to running 2 miles. Nor should you run 2 miles twice in one week, and then three times the next. It is the same principles for increasing your pace. Expect injury if you go from 14 minute mile (4.3 mph) to a 10 minute mile (6 mph).

2. Stretching but not strengthening calves.
It is just as often that I find weak calve muscles as I do short and tight calve muscles. It is also possible to have both. To test yourself, see if you are able to stand on one foot, then lift the heel. A surprising number of people can't do this. Compare right foot to left foot for how high the heel goes up. Usually you will feel one foot is not as strong, and your balance is worse. For this problem, do one leg calf raises at the bottom on the stairs, and hang on to one railing for balance if you need to. You can do the same on a curb with a signpost nearby. Go through a full range of motion up and down and pause briefly at each end. Think of it as an exercise that something between stretching and strengthening. Not only can weak calves lead to plantar fasciitis and achilles tendonitis, but it can also create overuse injuries at the hip or knee.

3. Stretching hamstrings with knees bent
Going down to touch your toes is probably the most common stretch done by runners. But in trying to push the limits of how far down they go, they will often unknowingly bend the knees. If you cannot fully straighten your knee, then you cannot correctly push off every time you stride. Your push-off will become a twist-off as the hip muscles try to make up for lack of knee motion. This can lead to hip or knee pain. Instead, try putting one leg on a chair or bench. Make absolutely sure your knee is straight. Then bring your toes toward you. If you still don't feel much stretch then stick your butt and chest out. When done correctly, even a contortionist will feel the stretch.

4. Foot Midline Crossover.
If you frequent a shoe store where they have a video treadmill setup, try using it the next time you are there. You don't need to be a specialist to see how one foot will be in the middle of the treadmill and the other will be out near the edge. If you can, ask the salesperson to drop a line down the center of the treadmill running surface, and count how many times each foot touches the "midline". I have seen many injuries on both the midline foot and the lateral foot. The midline foot supports more weight, but the lateral foot has to push harder to complete the same movement. Once again, the overuse scenario can produce pain at the foot, knee, or hip. One way to help overcome this is by "straddling the line". Find a high school track to run on. When you do, see if you can keep your right foot on the right side of the line, and the left foot on the left side of the line. This is surprisingly difficult for most people.

5. Doing the same run every time you run.
You will help stave off injuries if you can vary the terrain, distance, and pace of your run. If you do not, you are setting yourself up for a repetitive stress injury . Try running on a trail. You will notice your foot lands in a slightly different position every time. Many roads have a slant or a pitch to them to help water run off. Running on the same side of the road every time can create problems as your body tries to adjust for that slant. Try alternating types of running shoes, with different heel heights and arch supports. This will again vary the positions of your foot for every stride. Varying the pace and distance also can help. There are plenty of free couch to 5k running logs you can find online. Use those as a general guide, but listen to your body.

You are different. Your body is unique. Not everyone can or should do marathons, but most people can and should run. Especially if they like to.

Runner's knee may not be a knee problem

The recent warm weather has certainly inspired people to start running more. The increase of knee pain complaints at the office is a sure sign that summer is almost here. Knee pain is by far the most common running injury, yet it has many possible sources. Conventional wisdom suggests that since the knee is a joint, then any knee pain must be a joint problem. Patients often claim that their pain is due to a partially torn ACL or meniscus from an accident which occurred years ago. Recent research, however, indicates that muscular strain or weakness is a common cause of knee pain. Even muscles that don't directly attach to the knee can be a problem. In fact, numerous studies have shown that hip strengthening exercises greatly reduces pain on the outside of the knee (iliotibial band syndrome).

Healthimage [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

A quick look at the anatomy shows how some of the hip muscles are connected to the knee. The iliotibial band does exactly this. It is a thick band of fascia. Fascia is very strong connective tissue which does not contract. In fact, fascia also runs through your entire body. It is better thought of as a super strong spiderweb (or matrix) that permeates the entire musculoskeletal system. That's a fancy way of saying it goes through and connects muscles, tendons, ligaments, and even bone.

So, if fascia permeates and interconnects all muscles, tendons, bones, and joints, AND the source of anyone's knee pain can be far from the actual knee, one could theorize multiple other muscular scenarios where the problem is muscles other than the hip ones described above. A thorough check of strength and flexibility of all possible offending muscles is best done by a skilled specialist. However, one could make attempts to stretch or strengthen these areas with no real repercussions if they were wrong. The worst that would happen is that their muscles would get more flexible, or maybe stronger.

If your pain is on the outside of the knee, it is likely due to weak hip muscles. A side laying leg raise is a good exercise to start with, just like the ones Jane Fonda would do. (Wow, I am dating myself with that reference.)

If your knee pain is on the inside part of the leg (medial), there is a good chance one of your groin muscles (hip adductors) is tight and short. Stretch'em.

If your knee pain is just underneath the kneecap (patella) in the front, there is a good chance that your front shin muscle (anterior tibialis) is either overused (usually from steel toe shoes), or it might be short and tight. Keep in mind that pain in this area could also be due to TMTS (Too Much Too Soon). Back off on the distance of your training by 2/3 and progress your mileage no more than 10% per week.

If your knee pain is under the kneecap (patella), but more to the inside of the leg (medial) it could be the posterior tibialis. This muscle is largely responsible for maintaining the arch of the foot. Have you been told you "pronate" too much? Strengthen this muscle by doing heel lifts while standing on one leg. Hold on to a chair or wall until you develop enough balance.

If your knee pain is in the back of the knee, it could be one of the hamstring muscles (biceps femoris) or tight calf muscle (gastrocnemius). Check to see if you are able to fully straighten your knee. Many people CAN'T do this, and usually blame previous knee injury. Yet they have never tried stretching the muscles BEHIND the knee. Try this stretch: stand with both feet pointing straight at a chair. Put one heel on the seat of the chair. That's all. Just keep in mind that your body will try to cheat the movement by twisting out out the supporting foot, or twisting the pelvis to the side of the supporting foot. Look at your foot on the floor to make sure that it is still pointing forward. Also look at your belt buckle to make sure that it is still pointed forward. If you can do this with a straight knee and no difficulty, then bring your toes toward you, and push your chest up. DO NOT TOUCH YOUR TOES!

Seeing a specialist for your knee pain is also a good idea. Finding one with experience in running is extremely helpful. Finding one who also runs themselves is better yet. Unfortunately, there are many "orthopedic specialists" who will focus solely on the knee. This is unfortunate because, as stated previously, often times the problem is starting somewhere OTHER THAN THE KNEE. It is true that many people with kne pain do have meniscus tears or other damage. Keep in mind that an MRI, X-ray, or CT scan can show where damage is. But it is no guarantee that the pain is coming from that damage. If the focus is only the knee, and no other changes are made to surrounding structures, it is just a matter of time before the pain returns.

If you have any questions about this blog, or any questions regarding running injuries, you may come to our class "Running Injuries and How to Avoid them". It will be held on Tuesday, May 21 at 6pm. There is no fee, but if you think you may be coming, let us know. Give us a call at (616) 301-3000. Or personal message us on our Facebook page here.

DON'T Make This Mistake During Core Exercises (Know Your ABC's)

As a personal trainer in the early 1990's, it was pretty standard operating procedure to give people sit-ups or ab crunches as part of their routine. I don't use these exercises much anymore, but honestly if done right they do have some benefit. I would always emphasize the breathing as I showed them the exercise. Nonetheless, EVERY SINGLE PERSON would hold their breath at some point. Then I would remind them. "OK Mr. Smith. Your form looks good, but just don't forget to breathe." Of course they would start breathing again. And of course, about 3 or 4 repetitions later, they would start to hold their breath again. EVERY SINGLE PERSON!

Fast forward to today. I am still giving people "core" exercises. By my standards "the core" means any part of the torso that connects one limb to another, or a limb to the head. That covers a lot of ground. Needless to say it's not just the "abs" anymore. Nowadays I give patients exercises which they are going to do at home without me. I can't be there to say "Breathe!". So how can I ensure that they are breathing? They need to know their ABC's

Active Breathing Core (ABC) is system of exercises that I developed in which the person holds a position, and counts breaths. They do not count repetitions. But they have to be big audible breaths. Not so big that they are hyperventilating, but big enough to challenge the respirator muscles beyond the "rest phase". It's really not as complicated as it sounds. It is similar to yoga, but you just have to count your breaths.

At rest, our breath is controlled at a subsconcious level. It involves the diaphragm, the elastic recoil of the lungs, and some parts of the intercostal muscles (the muscles between the ribs). This process happens even though we are not consciously aware of it. Therefore I call it a passive breath pattern.

Active breathing occurs when our heart rate goes up and our demand for oxygen increases. Most anything beyond sitting and resting can do this. Light activities like walking, washing dishes, or cutting the grass are good examples. Our bodies need to increase the volume of air that is taken in, and begin to use different muscles to do just that. This includes muscles of the neck and shoulders (SCM, scalenes, pec minor) for the inhale, and abdominal and low back muscles for the exhale. These "active" exhaling muscles are rectus abdominis, external oblique, internal oblique and transversus abdominis, iliocostalis and longissimus, the serratus posterior inferior and quadratus lumborum. All of those muscles are "core". Those muscles, which are activated in elevated breath patterns, are also necessary to help stabilize and support the torso during the activity. Therefore, these muscles need to be taught to be able to COORDINATE their function of breathing with their function of stabilizing!

Try this test. Stand up. Then squat down as if you are about to pick up a pencil. Then stand back up. Go ahead and do it now.
Done? Chances are you just held your breath to complete this movement. Your body should not need to shut down the breathing process in order to do such simple tasks. Now think about running. Do you think you need some core muscles during this movement? Do you think you also need to breath? Bingo!

So for simplification, I now give these positional exercises and have the person count three big audible breaths. Then come out of the position and relax for a breath or two. This is repeated at least 5 times. Coming out of position is often necessary. The longer someone holds a position, the less likely they are to hold GOOD position. So the small break helps them "reset".

Don't worry, though. You won't have to go back to school to learn your ABC's. You can see them here on Youtube.

How to tell if your headache is really from sinus pressure

Many of my patients already know that they have allergies. For some it is new territory. The idea that allergies can increase or decrease through the course of one's life is still surprising to many. ("I've never had allergies before!") In addition, many people with allergies don't really know what they are allergic to. This makes them all more difficult to diagnose. Yet allergies can definitely combine with other factors and contribute to existing headaches. It may be often enough that people may become confused about where there usual headache ends and the sinus headache begins. Then add to the mix possible sinus infections? Even more confusing.! So here are a few distinguishing characteristics.

Most people will describe their headache as "pressure" when it is sinus related. Otherwise headaches are usually felt as dull aches or bands of tension. If the pain is around the eyes and cheeks and central forehead, it is likely sinus related. Pain or pressure in the teeth is also sinus related. When it is more around the temples, or a band around the head, it's a tension headache. Near or above one eye is usually a migraine. If this does not help, try this quick test. Bend forward or tilt your head forward. A sinus related pain will usually create more pressure and more pain. Most other headache variations do not worsen when you move this way. Lastly, migraines are the only headache to also cause nausea and/or vomiting. If you experience this, then it is usually a migraine.

Attributing the allergy to the allergen is helpful in figuring out the patterns. Seasonal allergies often play a large role. Depending on what season it is can help you determine what you are reacting to. Late winter/early spring is usually from snow mould. (This is actually a fungus). Mid to late spring is more often tree pollen. Late spring to mid summer is usually grass pollen. Mid to late summer is usually weed pollen. Late summer to fall is most often leaf mold. Some sources say winter is high in mold as well. This may be true, but keep in mind indoor allergies such as dust mites. Most people don't spend much time outdoors through the coldest months. In fact, using an air purifier in your bedroom can help cut down on all allergens, especially the indoor ones. You can also use weather apps or allergy specific apps to help track the allergens according to your specific climate.

To make things even more confusing, chronic allergies can weaken your immune system to make you more susceptible to getting a sinus infection. There are some general guidelines that can help regardless. Current research suggests that people suffering from chronic sinusitis often have poor gut flora. This is where the immune system starts. Probiotic supplementation therefore can go a long way to help one's immune system under these circumstances. Herbal remedies can also be helpful. I have seen the best success in allergies with feverfew, stinging nettles, and Vitamin C. Chronic infection seems to be better treated with oregano oil. Of course, if you have a fever or other symptoms in addition to sinus pressure headache, please consult your primary care physician.

Chronic knee pain: is it really arthritis?

There are few injuries that will slow you down as much as knee pain. In circumstances where there is trauma and /or accident, the diagnosis and treatment are fairly obvious. Think of someone being tackled from the side and their knee buckles in. This is likely a tear of one or more ligaments of the knee. Treatment depends upon the degree of damage, and surgical reconstruction may not be a bad idea. But more often the pain is more mysterious. It arises with no obvious cause. It comes and goes at seemingly random times. Many people conclude it must be arthritis.

If you follow this blog or my Facebook page you likely have likely read about how there is POOR CORRELATION of pain to joint damage and arthritis. Scientists have always assumed that x-rays, CT scans and MRI imaging were the "gold standard" for diagnosing musculoskeletal pain. What they are looking for is evidence of joint damage and/or arthritis. But recent studies have shown that MRIs of "normal" or "healthy" populations WITHOUT pain also show significant levels of damage and arthritis. So the question is- how can you be certain that it is the cause of YOUR pain, when there are so many other people with the same damage and NO PAIN?
So here is some perspective. The old way of thinking goes something like this:

In the old way of thinking, ALL damage was due to overuse and overactivity. The problem with this is that everything is considered "too much". Is it really "too much" when someone squats down to pick up a small child? What about going up or down stairs? Should an otherwise healthy 25 year old woman need to stop running 5k races because it is "too much" for her knee arthritis? I think not.

The new way of thinking looks something like this. It is a double feedback loop.

You can see how even if you surgically "fix" damage and arthritis, the pain is likely to continue. It's not that damage and arthritis are always completely unrelated to pain, it's just that it's not a direct one to one relationship as previously thought.

Too often in the past, we have been told to be "careful", and "don't overdo it". Unfortunately this has led to many of us being overly cautious and fearful of daily activities. We start to see our bodies and weak, and need to avoid pain at all costs. Opioid prescriptions are a good example. They don't heal you. Your body does the healing. We just need to optimize the heeling environment. How do we do this? MOTION! Gradually increasing the activity level is crucial. Muscular resistance exercise is necessary. Studies have shown that even in the presence of arthritis, training the surrounding muscle structures helps to improve function and decrease pain. So the first question is- does such training decrease the level of arthritis? No. Arthritis can't be undone. Then there is the second question. Is the pain really from arthritis?