The Pain Game

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We’re led to believe that experiencing pain is a dangerous phenomenon and should be suppressed by any number of medication currently on the market. If you’ve got a headache take a headache pill, joint ache take a pill or rub pain relieving cream into the area etc.


But what is the pain trying to tell us?
Pain is the way the body can communicate injury, infection and dysfunction to the conscious part of the brain. Is this something you really want to ignore? Unfortunately turning down the pain doesn’t address its cause but purely the symptoms. Its like disabling the fuel warning light in your car. It doesn’t address the fact you’re nearly out of petrol.

It’s therefore fair to say that PAIN IS NOT THE PROBLEM. It’s just an alert telling us there’s more going on.

But how accurate is pain as an indicator?
Although essential for our survival pain isn’t particularly good at telling us what the problem is, in fact at times it can be quite misleading. For example we have a huge amount of pain receptors in our mouth and lips. Biting your tongue can be extremely painful for a reasonably small amount of damage done while other people experience minimal pain after rolling their ankle which can cause significant damage to the ligaments.
With spinal dysfunction pain can also be quite misleading. Our spines are an incredibly strong, flexible structure which is comprised of a number of extremely versatile tissues. It is very difficult to damage a healthy functioning spine. Pain arising from the spine is often the last part of a bigger picture of dysfunction to arrive. Postural issues, prolonged sitting, incorrect lifting, previous injury etc can grumble in the background slowly disrupting these strong tissues causing us minimal to no pain. In fact slight stiffness might be our only conscious indicator. And then one morning we bend to put our shoes on, pick something up, twist awkwardly and ouch PAIN! When asked what caused the pain we attribute the putting on of our shoes when in fact it’s been building momentum over a long period, like a car rolling down a hill with no brakes. The putting on of the shoes was the final straw.

What separates chiropractic from other health modalities is we address the underlying cause of your problem and although we are compassionate about the pain you’re experiencing we know there’s more going on. In fact getting rid of your pain can often be the easy part, correcting its cause is where we stand head and shoulders above other practitioners.


As mentioned earlier pain is the last thing to show itself with musculoskeletal conditions and is the first to go. Unfortunately that doesn’t mean the problem has gone and unless the underlying dysfunction is addressed a relapsing cycle of painful spells is likely to occur with no real progress being reached. You’ll be treading water. That’s not how we, as Chiropractors, work.

The Pain Game is a multi billion dollar industry.  Why? Because pain will always comes back if you don’t address its cause and masking pain may lead to further injury and the cycle starts all over again.

What’s your strategy to tackle pain? But more importantly what’s your strategy to address the cause?

Early morning exercises: The hidden danger to your back.

early morning run

Its important to say at the beginning of this article that the people who get up early before work or on their day off to exercise should be commended and this article is not meant to discourage. My aim is that it highlights a couple of easy to do actions which could prevent low back and disc injuries creeping in.

To fully understand the concerns with early morning exercise we need to review the anatomy and physiology of the spinal discs in the low back. The discs primary role is to aid the spine in distributing weight and force evenly through the body. It was often thought that their main role was shock absorption but this has since been dis-proven and they are now more accurately described as force distributors.

The discs are made of two types of tissue. A toughened rope like outer structure called the Annulus fibrosis and a softer toothpaste like inner structure called the Nucleus pulposus (see picture below). Over time poor posture, prolonged sitting and repetitive movements can cause small tears in the outer tougher Annulus. With repeated tears over time the inner Nucleus will migrate to the outside of the disc. It is at this point symptoms are felt as the disc presses on surrounding sensitive tissue and nerves.


The discs absorb its nutrients and water when we are sleeping and non weight bearing. These nutrients are vital for the health and strength of the disc. Like a sponge filling with water the discs become saturated. On waking first thing in the morning the discs are at their fattest. We are actually slightly taller first thing in the morning compared to last thing at night. This though can be an issue when wanting to do strenuous exercise. When the discs are fully saturated more pressure and stress is exerted on the Annulus during compressive loading. This means that excessive stresses and strains through the disc could cause tearing of the outer fibres and/or bulging. Exercises like running, squats, dead lifts, lunges and jumping place large compressive loads on the spine and discs and therefore could cause problems. Morning sit ups are definitely not sensible, no matter what the Rocky training montages may suggest.

So should I completely avoid doing these exercises during my morning routine?

Definitely not. It is important though you take the time to prepare your body for the demands of these exercise. Spending the first 30-40 minutes of the morning weight bearing (standing and walking) allows the discs to adapt to the pressures and loads not experienced during sleep. This will actually remove some of the water from the disc but in doing so allowing it to be more strong and stable. Discs can also be put under huge stress from sitting so people who have a long commute to work or those to tend to sit down early on should take note. I advise my clients to have their breakfast standing if possible. This will help the disc adapt to the stress of weight bearing without stressing it enough to cause an annular tear. After weight bearing for the first 30-40 minutes a thorough warm up is needed. Don’t start with a weighted bar when doing squats or dead lifts. Use body weight and dynamic movements which increase in range as the warm up set progresses ie. Cat Camel.  If running, spend the first part fast walking slowly building to your running pace over 5 minutes.


Although swimming doesn’t put as much compression through the spine as the other exercises described I would still follow the advice just to be safe.

In conclusion early morning training is a great way to start the day and can give you an energy boost which is felt for the rest of the day but rolling out of bed chucking on the trainers and hitting the gym hard is not the way to do it. Give yourself time to adapt. Walk and move then spend time warming up with dynamic body weight exercises. It might meaning having to get up a little bit earlier but it could mean the difference between staying fit and healthy and having a disc injury resulting in time off work and exercise.

Standing desks : Fashionable or Functional?

Open plan office

I get asked the question weekly by my clients if they should ask work for a standing desk. So here are my thoughts on the new kid on the block that HR departments worldwide are investing plenty of money in.

Firstly the effects of prolonged sitting are well reported. As discussed my previous article Tight Hip Flexors: A catalyst for dysfunction, sitting has been dubbed the new smoking by Dr. Camelia Davtyan, clinical professor of medicine and director of women’s health at the UCLA Comprehensive Health Program. Its effects include heart and lung disease, Increase risk of a whole host of cancers and metabolic conditions like diabetes to name just a few.

So it seems that getting a standing desk is the obvious solution, right?

Well I would disagree with this quick fix approach. Sitting becomes dangerous when done for a prolonged period and the same is true for standing. Regular movement is the key preventative factor for the detrimental effects of sitting. From a musculoskeletal view point the spinal curves are designed to distribute weight and force evenly through the frame into the ground. Its is not effective at doing this when we sit. Tissue creep, the process where ligaments and disc tissue starts to change shape, is one of the detrimental repercussions of prolonged sitting. This can lead to disc derangement (bulging discs) and increase in degenerative changes to the lumbar spine (Osteo arthritis). Getting up and moving for 2 minutes after 20 minutes of sitting is enough to stave off the effects of tissue creep.

The same is true for those with standing desks. Standing for more than 20 minutes without movement can cause postural muscles to fatigue often leading to the adoption of compensatory postures ie: Placing more weight on one leg as seen below

standing posture

Here this person is placing the majority of their weight on their left leg. This will soon lead to fatigue of the Gluteus Medius and an increase ‘slant’ of the pelvis. This over time increases the force placed on the lumbar spine and left hip. Repeated daily over a long period will cause similar spinal dysfunction as seen with prolonged sitting. Add into the mix high heels which places increase stress on the low back curve, tightens the calf’s and over engages the lumbar muscles and this could cause spinal troubles quicker than sitting ever could.

So what’s the solution?

Being able to change from sitting to standing every 20 minutes in conjunction with 2 minutes of walking is, in my opinion, the ideal way to keep healthy whilst at work. You can improve this further by having a glass of water whilst you’re up. Some standing desks are able to raise and lower which is ideal but without the movement factor the so called health benefits are redundant.

But I can’t leave my desk every 20 minutes that’s ridiculous”…

Fair point but be prepared to have aches, pains and a decrease in overall health. When it comes to our health there aren’t many excuses that stand up to scrutiny. Make health the number one priority and the excuses quickly disappear. Here are some more tips to improving your health whilst at work:

  • Put the printer in the furthest corner of the office so you have to get up and move.
  • Set reminders every 20 minutes to remind you to move. Stand Up! The Work Break Timer app By Raised Square is free to download and a great tool.
  • Invest in a digital wrist bands which counts your daily steps. Take a note and have a target you aim to reach. Being accountable for our health has never been more easy, the only issue is we have to do it.

So in summary movement is the key to being healthy at work. There are no quick fixes to keeping a healthy spine and nervous system despite claims made by many ergonomic companies. Invest in making changes through routine rather than expensive solutions.

Stressful Breathing


Humans incredible ability both chemically and physically to react to external stressors has enabled us to develop into the most dominant species on the planet. The intricate cascade of chemical reactions that occurs every second of every day allows us to move, communicate, learn, heal and live all the while keeping our bodies within its normal range via the mechanism of homoeostasis.

The bodies sensitivity and reaction to a perceived external stressor, whilst the driving force to our evolution, can have detrimental effects on our health.

Throughout humans evolution stress has always been something that would lead to a physical action. For example seeing a predator would cause us to run away (or run towards it). This system is called the Sympathetic Nervous System or the more commonly known as the ‘Fight or flight’ response. On seeing something dangerous our brain stimulates different parts of the body to release hormones to ready us for action. These hormones increase our heart rate, divert blood away from digestive organs to the muscles where it will be needed and readies us for action. The main player in this system is the chemical cortisol. The big daddy of stress hormones. And the system has worked beautifully for hundreds of thousands of years.

There is a problem however. The brain is unable to differentiate between a real perceived physical stress or danger ie: Big lion just walked into the room, and non physical stress ie: Printer has jammed for the third time today and you need to print a very important document for your boss, oh and its 5pm on a Friday! Either way the same chemical cascade occurs.

The cascade of chemical reactions, if repeated numerous times a day, can lead to health problems. It is known to increase heart rate, blood pressure, decrease the immune response, cause nausea and  headaches. It can reduce our bodies ability to digest food and absorb its nutrients. This can lead to diarrhoea, bloating, flatulence and indigestion. It also has huge effects on our mood leading to irritability, short temper, agitation, inability to relax, feeling overwhelmed and depression. From a musculoskeletal view point it tightens muscles, particularly our fight muscles (Upper Traps, Scalenes and Rhomboids) and flight muscles (Gluteals, low back extensors and hip flexors) which has an affect on the function of our frame.

Stress also has an effect on our breathing cycle. Normally the main respiratory muscle, the diaphragm, contracts and relaxes drawing air into our lungs allowing them to fully expand. The abdomen should expand as air is taken in. Shallow breathing or ‘stress breathing’ is driven by the Intercostals and Scalene muscles not the diaphragm. It draws less air into the lungs with more upper chest and shoulder movement than abdominal expansion. The reduced oxygen intake can have an effect on our concentration, sleep quality leading to lethargy, headaches and a further increase in heart rate.

So how do we overcome the shallow breathing?

Firstly its important to address the stress in our lives. Unfortunately most of us are unable to quit work and live on a desert island free from stress and the worries of everyday living.

Wishful thinking

Wishful thinking

What we can do though is simple daily actions that reduce the Sympathetic response to everyday perceived stress. Coping mechanisms, mediation, breathing techniques and daily exercise are a few of the most popular. Acupuncture, mindfulness and visualisation techniques are also becoming more popular with large corporate industries offering many of these to their employees. A health happy employee after all is going to be more efficient in the long term.

A simple and effective technique which I use with many of my patients is diaphragmatic breathing. This not only reduces stress by taking our focus away from the daily grind but also re-trains the body how to breath effectively, efficiently and correctly.

Here’s how you do it:

  • Lying on your back in a quiet peaceful place. This can be in your bed or on the living room floor as long as it’s quiet.
  • Have a pillow behind your head and get comfortable.
  • Place your hands on your lower abdomen.
  • The diaphragm should contract downwards towards the belly button when breathing in, causing the abdomen to come out, NOT the chest up and out.
  • Focus on this movement of the diaphragm and abdomen by taking slow deep breaths in. Taking 5 seconds for the in- breath, 5 seconds out. Do this for 5 minutes

This can take time to get right but the action of focusing on the breathing cycle is enough to reduce the sympathetic response even if not done 100% correctly. Doing this every evening is a great way of de-stressing after a long day at work. It can also be done sitting. If work’s getting too much, turn off the monitor, close your eyes and focus on your breathing for a couple of minutes. It can be done on the bus or train so you feel relaxed before walking in the front door. I have had patients tell me how this has improved their relationship with their partner as they feel less stressed before getting home and less likely to argue over the small things.


Stress breathing is linked with poor posture. A predominance to slouch when sitting makes it difficult for the diaphragm to fully expand and contract further encouraging the secondary respiratory muscles to be used. Learning how to set up the work station, car seat, and sitting posture at the dinner table is important. The core muscles, which support our spine and frame, tend to switch off after 20 minutes of sitting. This increases the likelihood of adopting poor sitting posture. Getting up and moving for 2 minutes can help re-activate the core and prevent poor posture creeping in.

But what is a chiropractor doing giving stress advice?

To provide the best possible care to a patient I feel I need to look beyond the presenting symptoms and to the underlying cause of the problem. Often that involves looking at posture, lifting technique and exercise routine but it should also include their nutrition and possible emotional drivers. Although my focus is predominately on the musculoskeletal issues at work it would be unethical of me to ignore these other factors as they play such a big part in the recovery process.

In summary stress is often an inevitable part of life whether you like it or not but our perception of stress and how it effects our health is completely up to us. It shouldn’t be viewed as a sign of weakness but embraced as the incredible evolutionary response that has kept the human race the most dominant species on the planet.

Thoracic Dysfunction – My clinical observations


Whether the presenting complaint or a cog in the chain of dysfunction I have found a restricted hyperkyphotic thoracic spine a recurrent finding in patients of all ages. Seemingly caused by the repetitive demands of daily life i.e. sitting, driving, and poor posture, this is one of the most important areas to address with patients. This article will go into detail why I think this is the case and how I go about treating it.

The knock on effects of a restricted hyperkyphotic thoracic spine are numerous. Lets go through a few of them:

  • Increased degenerative changes to the thoracic, lumbar and cervical spine. The curves of the spine work as the body’s suspension system. Beautifully distributing load,weight and forces through the frame into the ground without over-loading one area. The thoracic spine is the middle link in this suspension chain. An increase kyphosis and reduced flexibility of the thoracic means that this load cannot be distributed evenly instead being focused on key linkages of the spine, namely: C/T junction, mid-lower thoracic spine and lower lumbar spine.

  • Altered respiratory function: Reduced thoracic mobility will in turn reduce rib motion and lung capacity. The accessory respiratory muscles become over activated (Sternocleidomastoid, Scalenes group and Pectoralis minor) and the primary respiratory muscle (diaphragm, intercostalis, upper abdominals) become tight. This is a hot topic for research with some links between chronic disease and increased kyphosis being found.

  • Reduced scapular and shoulder function. An increased kyphosis is often accompanied by tight anterior neck and chest muscles. The shoulders becomes drawn forward placing the scapulars in a chronically protracted position. The scapular stabilisers become weak and under-activated whilst the upper traps become over-activated. This position of the scapular shortens the rotator cuffs leading to trigger points, shoulder pain and possible knock on effects of sub acromial bursitis and rotator cuff tendinopathy.

  • Forward head position: The anterior position which the head tends to adopt with this presentation can often lead to headaches, reduced concentration, migraines and neck pain. This in itself can lead to reduced sleep quality and fatigue.

So the chronic effects of a forward drawn / slumped posture are much more than just low back or shoulder pain. Worryingly this is becoming more common in children who are picking up bad postural habits from sitting at school and having to carry a heavy backpack. Highlighting the importance of correct posture to kids and showing them how to effectively pack their back packs to reduce strain on the spine is tremendously important in the prevention of long term dysfunction.


I like to use the following analogy to describe the issue with my patients.

The spine is influenced by muscles at the front and back to keep us upright. Like the guide wires of a tent these need to be pulling evenly for a balanced, stable platform. Prolonged sitting, slouching, working with laptops, carrying bags etc cause the front muscles to become tight, pulling the mid back and shoulders forward. This is the same as tightening the guide wires on one side of the tent only. As you can imagine this causes the spine to be unbalanced. The body tries its best to correct this by recruiting other muscles but adopting the troublesome postures everyday means it is in vein. Chiropractic can help re-establish the normal balance and movement to the spine and muscles. When you’re moving better and more balanced we will then look to strengthen the muscles which have become weak to get you more stable.

This can be elaborated or stripped back to suit the needs of your patient.

How do I tackle this postural epidemic.

Firstly its important to mention that this pattern of symptoms is not caused by the dysfunction of the thoracic spine alone. As I mentioned in my earlier article :Tight Hip Flexors: A Catalyst For Dysfunction, prolonged sitting causes shortening of the hip flexors which has numerous knock on effects. I have found that addressing this dysfunction in conjunction with the thoracic spine has great outcomes.

When treating patients with this presentation I focus on a few key areas.

  • Correct spinal restrictions / dysfunction with adjustments.

  • Release anterior tight muscles (Psoas, Pecs, abdominals, Scalenes, SCM) with soft tissue techniques (Active release, PIR, massage, Dry needling, Graston technique – all work well)

  • Home exercise prescription: Hip flexor stretching, pectoral stretching- 3 x 30 second holds twice every day. Foam roller thoracic extension stretches. Ergonomic advice

Once the patient is moving better I start to incorporate strength and stability work.

  • Dead bug exercises,

  • ‘Y’ exercises for scapular stability,

  • gluteal activation exercises (see What is Hamstring Dominance?)

  • Bruggers relief position whilst at work – every hour for the first week. Progression to Bruggers relief with theraband.

  • All the while continuing with the home stretching

Of course every patient is different with their presentation. The stresses and strains they put on their bodies will be unique to them and their bio-mechanics. The above treatment techniques are a rough guide to what I have found useful. However assessing the bio-mechanics of a patients feet, pelvis, looking at their pillow, exercise routine and stress levels are also useful to rule out other possible contributing factors.

Education is also a key step in the long term health of any patient. A real understanding of the importance of good posture, keeping mobile and functional is just as important as any home advice. Arming the patient with knowledge and tools so they can go onto educate their family, friends and colleagues is a duty of care we should all be implementing.

Encouraging Yoga, Pilates and exercises classes are a great way for patients to stay mobile in a fun structured way. Encouraging mobility exercises as part of their already existing exercise routine is a great way for patients to stay compliant. Patients who have to make changes in their routine to accommodate their exercises tend to give them up.

In summary the numerous knock on effects of a dysfunctional thoracic spine means that its correct identification, treatment and rehabilitation is crucial for the health of our patients. This includes looking beyond the thoracic spine as the sole area of dysfunction. Giving our patients the tools and education on how to prevent recurrences empowers them to take control of their own health and function.

The perfect core exercise

I often get asked “what’s the best exercise for the core?”. Many people have their own opinion on this. Simply typing “Best Core exercise” into Google results in hundreds of variations of exercises which all claim to be the best.

To understand which exercises are better for building core strength and endurance we must first understand what the core is comprised of and it’s role.

What is the core and what’s it’s role?

The core is a name for the group of muscles encasing the torso which assist in the maintenance of good posture, balance and stability of the spine and frame, especially during movement. It is also key in the safe distribution of forces through the spine, preventing one area becoming overloaded and injured.

Often thought of as just the abdominal muscles its clear from this definition that the core is made up of many muscles which work together to bring about stability. These include gluteals, hip flexors, abdominals, obliques, erector spinae’s to name just a few.

Core muscles

Core muscles

The demands placed on these muscles will vary depending on the movement and activity undertaken. The core must therefore be able to cope with a large range of movement patterns. Finding a single exercise which is able to do this is almost impossible. So the real answer to the question ‘What’s the Best Core Exercise?’ – There isn’t one. Some exercises are better than others at challenging the core muscles in different planes and movements but a strong functional core will need to be trained using many different exercises.

Many gym goers are guilty of spending 5 minutes on their “core” at the end of a session only to do sit ups and the plank. Never straying from these two household favourites. This begs the questions:  are these functional? Do they provide the balance and stability the spine and frame requires? Almost definitely no. A core routine should involve movement based exercises demanding strict form and should never be rushed.

Below are three of my personal favourites which I find are under utilised.

Dead Bug:

This exercise is great. It challenges the low back stabilisers, abdominals and scapular stabilisers . It can be progressed or regressed to suit the needs of anyone and everyone.

Dead Bug

Dead Bug

Dead bug progression

Dead bug progression

Single Legged kettle bell Dead lift:

Balancing on one leg stresses the stabilisers and can highlight any discrepancies when comparing left and right sides. It challenges the core in a different way to floor based exercises. Again this exercise can be progressed to suit all levels.

Single legged Kettle bell deadlift

Single legged Kettle bell deadlift

Cable machine wood chops:

The variability of the weight and angle of the chop means this exercise is great for challenging many of the core muscles in differing planes.

Cable machine wood-chop

Cable machine wood-chop

Its also important to point out that the core is never trained in isolation. Going to the gym and strengthening legs, chest and arms, if done correctly, will use the core. Running on the treadmill requires the core to maintain upright posture and form. Swimming lengths of the pool requires the core muscles to keep your torso rigid whilst the legs and arms remain mobile. Everything we do involves the core. Being strict on form and posture during all exercises is a great way to work out your core. Once a core exercise has been mastered add weights to increase the work load.

In Summary a good core should be able to cope with the demands of many movements. Training should therefore reflect this with exercises that challenge the core muscles thought differing movement patterns, which can be progressed.

There is no such thing as the ‘single best core exercise’. Its a myth invented by the quick fixers of physical training. Incorporating core exercises throughout a workout as well as being strict on form and posture during training will give a good base to work from.

What is Hamstring Dominance?

In my previous article I discussed the role of the hip flexors in musculoskeletal dysfunction. The knock on effect of chronically tight hip flexors are numerous but two very important ones, which I only touched on last time, are weak under activated gluteal muscles and hamstrings that become dominant in hip extension.


The Gluteus Maximus is the main hip extensor in the body. Attaching from the  ilium, sacrum and coccyx  it inserts into the outer aspect of the hip. It’s needed in nearly all movements. The gluteals also bring about stability of the Sacro-iliac joint via its influence on the thoracolumbar fascia and the posterior fascial slings.

Although the hamstrings also influence the hip into extension the Gluteus Maximus is the main player in this movement.

Hamstring dominance is when the Gluteus Maximus doesn’t initiate hip extension, instead leaving the work to the hamstring muscle.

But why does this happen?

The mechanism behind this is called reciprocal inhibition, where a tight / over activated muscle inhibits its antagonist. In this case the over activated and tight Hip flexor inhibits the activation of its counter part, the Gluteus Maximus. In doing so the hip extension movement pattern, over time, has become initiated by the hamstring instead of the Gluteus Maximus.

Not only can this lead to an overuse strain of the hamstrings but due to the Gluteus Maximus’ key role in spinal stability it increases the chance of injury to the lumbar spine and sacrum.

Hamstring dominance can be tested for with the patient prone and asking them to actively extend the leg. Not always easy to see with the naked eye, feeling the hamstrings and Gluteus Maximus muscles during the active hip extension can be quite revealing. The Gluteus Maximus should be the first to contract followed by the hamstrings but with hamstring dominance its the other way around.

How do we get the Glutes firing again:

Gluteal activation exercises are well documented but often under utilised. To become hamstring dominant the neuromuscular pathway needed for hip extension has been re-learnt using the wrong muscle group. So to re-establish the correct movement pattern this neuromuscular link is best established through repetition. Addressing the tight hip flexors with stretching is important but strengthening of the Glutes will also be needed. As mentioned in the last article the main four I encourage patients to focus on are

1.Gluteal Bridge.

glute bridge

2.Quadruped Hip extensions

quadruped leg ext

3. Single Legged Bridges

Single legged glute bridge

4.Standing functional reaches

Standing Functional Reach

Performing these regularly in isolation will encourage the Gluteus Maximus to take back its role as the primary hip extensor. Performing these as part of a warm up before weight lifting, running or sporting activities is a great way to re-establish the neural pathways that have been lost over the months or years of deactivation.

This doesn’t sound like chiropractic?

Some may think that the topics I write about aren’t chiropractic but I certainly don’t agree with that. As a chiropractor I am concerned with the function of the neuro-musculoskeletal system which includes the relationships between the nervous system, muscles and joints. Having an understanding of the chronic repetitive nature of many of the  presenting complaints allows the cause of the problem to be addressed rather than purely the symptoms. And if this understanding means using research and techniques devised by physiotherapists, osteopaths and chiropractors then that’s what I’ll do.

You can find a handout on these glute activation exercises in the ‘Material for patients’ tab at the top of the page.

Tight Hip Flexors: A catalyst for dysfunction

As a Chiropractor I see clients present every week with a similar pattern of musculoskeletal dysfunction. Often masked by differing presenting symptoms the same underlying bio-mechanical cause can be identified more often than not.

The spine, hips, knees, pelvis and sacrum are all strongly influenced by one of the biggest groups of muscles in the body. This group consists of the Psoas, Iliacus, Rectus Femoris and Sartorius muscles and is commonly termed the Hip Flexor complex. Responsible for bringing the knee towards the torso, these groups of muscles are very important in walking, running, squatting, lunging, balance and spinal stability. Often thought of as a secondary cause of dysfunction the hip flexor complex plays a more prominent role than it’s often given credit.


The problem starts when the hip flexor becomes chronically tight. This doesn’t happen overnight thankfully but after prolonged hip flexion repeated daily. Most commonly this is from sitting. A large percentage of the population spend a significant part of their day sitting, whether it be in the car, at work or relaxing at home. Sleeping in the foetal position also promotes prolonged hip flexion

Over the past decade the detrimental effects of sitting have been a hot topic of research. In 2013 Dr. Camelia Davtyan, clinical professor of medicine and director of women’s health at the UCLA Comprehensive Health Program dubbed ‘sitting as the new smoking’ because of its effects on our overall health.

Focusing on its effects on the spine sitting causes the hip to be flexed, normally at 90 degrees, causing the hip flexors to become slack and bunched. Like brining two ends of a tightened rope closer together. Spending large amounts of time with the muscle in this position will cause it to adopt a chronically short and bunched (tight) position. The rope becomes shorter. This becomes a problem when we need to use the hip flexor through the hips full range of motion.

The Iliopsaos muscle, one of the big players in the hip flexor complex, attaches from the lesser trochanter of the hip to every segment of the lumbar spine. A hip flexor which is shortened will become taught during standing placing stress on the spine. Walking and running will increases this stress further. The long-term effects of tight hip flexors are an anterior pelvic tilt, which is when the pelvis tilts forward due to the pulling from the tight muscles. Alteration of the pelvic biomechanics due to this tilting has a number of knock on effects:

  • The hamstrings become chronically pulled placing them at tension even at rest (increased risk of hamstring strains).
  • The Lumbar Lordosis (low back curve) is increased placing stress on the lumbar facet joints altering the load distribution of the lumbar spine.
  • Reciprocal inhibition of the Glutes. The tightening of the hip flexors reduces the activation of the muscles primarily responsible for hip extension (glutes). This causes them to become weak. It also alters the firing patterns of the posterior muscles of the hip. The hamstrings often become the dominant hip extensor instead of the glutes. I will discuss this hamstring dominance in more detail in my next article.

This is often when people present to their chiropractor with back pain, flank pain and/ or hip pain. Sometimes it can present as recurring hamstring strains, more commonly seen in soccer players.

 ant pelvic tilt                                   

So its clear to see how the chronic shortening of the hip flexor can lead to a cascade of musculoskeletal issues which if treated in isolation may bring about temporary relief but do not address the underlying cause of the problem.

So how to we over come this?

Whether symptomatic or not people who spend a lot of time sitting should be doing the following regularly to prevent long term issues creeping in.

Stand and move often: Break the monotony of sitting and its damaging effects. If possible use a standing desk. If not then set a reminder on your phone or computer to get up and move every 20 minutes. This has been shown to help reduce the effects of prolonged sitting on the muscles, ligaments and spinal discs and well as giving the hip flexors a chance to lengthen.


Stretching or yoga regularly. Unfortunately stretching for 10 minutes once a week is not best. Spending small amounts of time every day stretching the hip flexors will have a greater influence in restoring a good functional length. After all we do the things that cause them to tighten every day without fail.


 Gluteal activation and strengthening. Keeping the Glutes activated and strong is very important for the stability of the pelvis and low back. Glute bridges, Quadruped Hip Extension, Single legged Glute Bridges and Clam shells are all great at activating and strengthening the Glutes

glute bridge

                                                                      Glute Bridge

quadruped leg ext  Quadruped Single Leg Extension

single legged glute bridge Single Legged Glute Bridge

Core stability. The core is a general term given to a large group of muscles that work together to bring stability to the spine and pelvis. Core stability exercises re-establish the correct firing pattern of these muscles that is often altered with the biomechanical effects of tight hip flexors. The dead bug is a great exercise which can be stripped down or built up to meet the conditioning level of your patients.


 Dead Bug

See your Chiropractor: As I mentioned at the beginning of this article the hip flexors are involved a lot of the time but not all the time. All of the above tips are great but if you have to sit everyday for long periods of time there is no substitute to seeing your chiropractor regularly for an adjustment.

Exercise Compliance

For the health professionals reading this who regularly give their patients homework (exercises, stretches or nutritional advice) I’m sure you can agree there is nothing more frustrating than the patient reporting they feel no better at their next visit then only to confess that they haven’t done what you’ve asked them to do.

There are always a number of different reasons for this but have you ever thought about how you present the information and tasks to your patients in the first place?

If you present the information to patients in one format only then there is no wonder why their compliance is poor.

As humans we learn using three main techniques. Auditory, Visual and Kinesthetic. Everyone will favor one of these three techniques when learning whether they know about it or not. A quick summary of the three learning techniques:

Auditory Leaners:

  • Learn by reading out loud and repetition
  • Listen to material. Prefer audio books

 Visual Learners:

  • Likes to be shown tasks.
  • Prefer diagrams, pictures, charts, videos and demonstrations.
  • Like to write out notes and instructions

 Kinesthetic / Tactile:

  • Learn by doing
  • Hands on approach.
  • Likes to show actions for understanding

Prescribing a simple stretch exercise can therefore be done in three very different ways.

  1. Auditory leaners: Tell them the steps/ instructions and ask them to repeat them to you to check for understand.
  2. Visual learners: Need a diagram of the stretch, possibly a video and a demonstration from you.
  3. Kinesthetic learners: Need to do the stretch in your office in front of you to check for understanding.

Presenting all your information in these three ways should be a priority. After all the more the patient follows your home advice, the quicker they will feel better, the higher in their estimation you are and the more likely they are to refer friends and family in to see you.

But how do you know what type of learner your patient is?

The best way to do this is to ask the patient. Many people know which way they prefer their information to be presented. If they are unsure give them the options of how you have the information to hand. And if they’re still unsure make sure you give the homework to the patient using all three techniques. Demonstrate, ask them to repeat the instructions, get them to do the exercise in the office and give them a diagram of the exercise to take home.