Back pain steals your freedom. Core connection and healthy movement. Bring it back. So before we get started, I want you to strap your walking shoes on. Or better yet, no shoes at all. Grab your headphones and get your body moving while you listen to the insights that helped me climb out of a decade long struggle of debilitating lower back pain and led to the creation of Core Balance Training, which has helped thousands of people climb out of the back pain spiral for good. Welcome to the Back Pain podcast by Core Balance, where we share practical insights to address back pain at its root. I'm your host, Doctor Ryan Peebles, doctor of physical Therapy, specializing in spine and core rehabilitation. Each episode brings you a recording of one of my live sessions with my students. We start with a focused topic on back pain, then move into a live Q&A where I answered real questions in real time. My hope is that these episodes get you on the path to climbing out of the back pain. Spiral for yourself so you can live life the way that you want to. Let's dive in. This week's topic is going to be about tendinitis. It's not something that people often think of when you think of chronic lower back pain, or just back pain in general, but it is most often involved. It's most often a factor that is contributing to the pain, and it's just not highly recognized. So there are things and we can do and kind of strategies that we can use to try and reduce tendinitis, which by definition is inflammation of the tendons. And so we can talk about what tendons are and a little bit about the anatomy in a minute. And actually one of the reasons why I thought tendonitis was an appropriate topic is because it builds off of what we talked about last week. The best strategy to get out of tendonitis to reduce it is, is to listen to your body. And we'll talk more about that in a little bit. So that's one of the reasons why we're going to talk about tendonitis is that it's a perfect thing to transition to from last week's topic. And also we had a couple students actually who emailed or commented in the lessons this week, one who might be experiencing tendinopathy of the gluteal muscles. So glute tendons, irritation. So tendinopathy is just a bigger umbrella term for tendonitis. And so we'll get into a little more of those definitions as well. I believe all muscles have tendons that could be wrong. But let's say all skeletal muscles, what you think of as a typical muscle. They have tendons on all their attachments. It's where the muscle attaches into the bone. And so basically anywhere where you have a tendon, if it has repetitive stress, the tendon can break down and gets inflamed. And we call that tendonitis. And so that happens a lot in the lower back. It's not often called tendonitis. We just call it back pain. And it's not really popular. It's not a really popular thing to be talked about. But when our muscles if you are in the program or you have just seen the master class, you know that I talk about muscle imbalances and an imbalance between certain muscles being overactive to hyperactive and other muscles being underactive or kind of inhibited. And, you know, that's often some of the deep spinal support muscles. So these overactive muscles that are working too hard and compensating for the underactive muscles will get irritated. When the muscles constantly in attention mode, it's constantly pulling and overworking. What gets yanked on is the tendon where the muscle attaches to the bone. And so that can get irritated. And it's most common seen like the most popular types of tendonitis would be the patellar tendon of the knee. Another one would be the elbow on the top of the elbow that would be called tennis elbow. If it's on the inside of the elbow, they would call it golfer's elbow I believe. And then the patellar tendon of the knee is extremely common. So just under the kneecap that one tends to get really irritated. That's a form of tendonitis as well. Achilles tendonitis. And so if you've experienced pain along, I would call it your belt line along your lower back belt line and right at the top of your pelvis. If you have chronic lower back pain, I'm guessing you've experienced something like that. That would be the equivalent of tendonitis. And that's just where the lower back muscles attach into the pelvis. The bone, that's all it is. It's pretty simple. And so I'm going to talk about some strategies. Mainly one strategy for reducing tendonitis. And it's the best strategy I know. If you were here last week we talked about listening to your body and letting your body be your guide for what to do and what not to do. And sometimes what that requires is reflecting back onto activities you did the day before, because there is a delayed onset of back pain after you do activities. It's quite a strange phenomenon, but sometimes you can do an activity and it feels okay while you're doing it. And then maybe that night or even the next day, the back really starts screaming at you. And so that would be a delayed onset of soreness. There's a name for that is called Doms, delayed onset muscle soreness, or even just the delayed nature of the back. We can get into some philosophies why that happens, but that's not the purpose for today. So what I'm trying to say is that sometimes listening to your body requires you to reflect back in time and not just go, what am I doing right now? And does it feel good or feel bad? But my back is feeling this way right now. Maybe it's based on something I did yesterday or this morning. And so that kind of idea of listening to your body can help guide you to decide. Okay, I don't feel good now and I know I did that earlier, so maybe I shouldn't do so much of that. Or maybe I should do it differently. Maybe it's just the way that you're doing yard work, right? Or the reverse? Oh, well, I'm feeling really good today, and I went for a walk last night or this morning. Okay. My body likes walking. I should do more of that. So letting the body's communication to you through its good feelings and bad guide you. What to do is the best strategy. And they teach this in school. Uh, physical therapy school. It is the best strategy for getting out of tendonitis. Because. And the reason is because tendonitis is an irritation of the tendon that results not only from overactivity and repetitive trauma doing too much, too much of the wrong thing, or just overusing a muscle because it's overactive. So there's one side of the scale of too much, and then it's also exacerbated and made worse by doing not enough. And so a lot of people fall into this cycle where your body starts to hurt, and maybe it's tendonitis and maybe it's from doing too much. And so you go into rest mode. And what happens when you go into rest mode, if you go into it for too long, is that the tendons become weaker. And when they become weaker and the tissues don't have the tensile strength that they normally have, and you go back to an activity at some point because you have to at some point, the weak tendons get even more irritated and it exacerbates the problem. It worsens the tendonitis. And so what you have to do is stay somewhere in the middle. Okay. The strategy is to operate somewhere in this middle space where you're not doing too much and you're not doing too little. Letting the tendon get weaker. And the only way you can know that is by listening to your body and reflecting back. Okay. Last time I went to the gym and I played two hours of handball and my knee, my tendonitis and my knee started killing me the next day or my back. So this time I'll only play for one hour. And so to be able to reflect back and learn and not do nothing, because the solution is not to not play handball at all. And it could be anything. It could be lifting weights, it could be doing work, could be playing or exercising. It's just the amount of repetitive stress needs to be. You need to be thoughtful about it. And so I encourage you to when you feel pain in your tendons or just general pain, if it's not a traumatic injury, but if it's a chronic injury, which tendonitis falls under, the umbrella of the solution is not to do nothing. That can exacerbate the problem and often does. And the solution is not to go extra hard and work harder and do better and do more, because that's the cause could be the cause of the problem in the first place. There is an element of the muscle imbalances that we want to try and bring into balance, so that they're not overworking, and the muscles that are not doing their job start working and helping out. But you're always making decisions about your activity. And so that's really the message I wanted to send is to listen to your body and find that middle ground, unless you have a fracture or a torn fill in the blank ligament, tendon or muscle, whatever. The answer is almost never to just rest and do nothing. You have to be active, and sometimes there's a little bit of pain involved in that. But it's better to keep your tissues strong than to do nothing. And you also want to be careful not to do too much. And the only way for you to know what too much is, is to reflect back on what you've done in the past and how your body responded to that. Let's get into some questions. So this is a student question from Sherry, uh, about in the back anchor awareness lesson. So she is having difficulty with being in the position of the back anchor awareness because of tailbone pain, something she's been dealing with for a while. So she says, I'm trying this with my arms underneath my glutes. Palms down. And so it takes the pressure off her tailbone, but not sure if it's useful at all or even advised. I don't want to do any harm. What are my thoughts? So I think this is great. Sherry. I believe that it's an excellent modification for you to be able to do this exercise, if you call it that. This awareness and connection. It's not going to do any harm to anything. I don't see it doing any harm. But if if you feel it doing any harm by listening to your body, then do listen and adjust. Or maybe do less or even stop if you feel that way. But I don't see this doing any harm. I believe it's an excellent modification and very creative. It's more important that you start building this connection and activating these deep core muscles by connecting to your back anchor zone, then avoiding Doing this at all because of tailbone pain. So if you can make a modification even in future exercises, I recommend you do so that it allows you to build this connection, which may help solve the problem with the tailbone pain because it is chronic. And so we're not dealing with any kind of traumatic fracture or injury like that. So thank you for sharing. And this does remind me I have another student who was doing a creative modification. He was having trouble with the. This is later down in the program where you're doing the back anchor challenge with both legs up in the air, and he was having trouble bringing both legs up and maintaining connection. He couldn't keep that back anchor connected to the floor while bringing that second leg up. So he did a modification where he had his heels on the couch. So laying on the floor on his back heels up on the couch. And so instead of lifting from the floor all the way up, the couch was supporting them. And you could only just have to lift a little bit. And it was a regression. It was a training ground for him to be able to build that strength and very creative modification. So I support that. Let's go to the next question. So this is from Amy and I believe Amy is a brand new student. This is also in the back. Anchor awareness lesson. She says I'm a little confused doing this exercise. I've been working a long time in pelvic floor specific PT to try and activate my lower deep abdominal muscles, and I feel as if I'm only engaging the upper abdominals to lower my rib cage. So that's specific to the back end awareness. So you think that you're using your upper abdominals to do the work of lowering the rib cage? Okay, so my body wants to pelvic tilt to get the desired position. I'm aware that most of my muscle imbalances, and therefore pain issues stem from weak core and glutes. So was thrilled to come across your program. Okay, Amy. So if you look at the anatomy of the abdominal muscles, you'll see that the six pack abs, the rectus abdominis, attach all the way from the rib cage. There is a lot of talk and kind of like accusation of lower abdominals versus upper abdominals. But the truth is, they're the same muscle. And so I don't want you to be concerned by that. One of the goals of this program is to learn healthy movement organically, which doesn't require you to learn the anatomy or to learn which muscles do what, because we're modeling it after human development how a baby learns movement. And they did that without knowing anything about the anatomy or biomechanics. And they learned perfect, healthy movement by the age of four. And so if we can go into this process, this core balance training process with a blank slate, a babies mindset, it's one of the best ways to do this. And so the goal is just to have that pure, very simple intention of connecting and pushing away and don't worry about which muscles are doing it. Because if you break it down to the most simple intention, the right muscles are eventually going to learn how to do this. It becomes automatic. And so my encouragement to you is just to stick with this. Stay consistent. Get down on the floor and just have that intention of bringing your ribcage cage down. Don't try to control how that happens and get it to the point where you can feel it connect to the floor, and we're going to build off of that over the next few days. I think you're probably only in day one, so it wouldn't make sense for me to talk about what's coming next. But I'm glad you asked this. So that's my answer is don't be too focused on upper versus lower abdominals. We're going to get into those deeper abdominals, because there's no other way for the body to accomplish what we're going to do. Coming up. All right. And this is just the beginning. And let's see you also mentioned pelvic tilt. We're going to be talking about pelvic tilt later in this first week. We'll also get to that. And it's okay for now. If your body wants to do that let it do that. Just don't don't try to control it. If you need to pelvic tilt to get that back anchor connected to the floor, let it happen. And as you're these deep core muscles get stronger, everything becomes easier, and progress tends to happen pretty quickly with these deep muscles, because a lot of it is just electrical connection that we're building. The muscles are there, they're not strong, and we just need to increase the connection from our brain to those muscles and activate them. And you start to see progress pretty quickly. So this is the front anchors awareness from Bridget says, hi Doctor Ryan, this was interesting. I just wanted to comment that Bridget had posted after my response in last week's live Q&A, that she had found that just simply putting this, she rolled up the sleeve of her sweatshirt and put it under her forehead. Was extremely helpful for this. And if anybody else experiences discomfort on their head in the front anchor's position. That is a solution that we've used in the past. Just a rolled up washcloth, like something really small, just a little padding for your forehead that can help. So yeah, great job Bridget. That was very creative. Loving these modifications that people are making. And I don't have any problem with them as long as it allows you to get down on the floor and make those connections, they're extremely beneficial. This is another question from last week, and this is what I discovered was probably tendonitis. So I wanted to expand on this a little bit. So Ed was having pain in his outer hips when doing the bridge and amplified when he puts the band around his knees. So later in the program, we have the Butt Buster bridge, where you put a band around your thighs, and it's one of those strengthening exercises, one of the few that really build strength with a lot of intensity in your glutes. And so I responded to him last week, he responded again with a little more specifics, and I found that based on what he said, I believe this is gluteal tendinopathy. And so I hope that you can catch this. What I was talking about earlier about the strategy of getting out of tendinitis is you got to continue being active and you don't want to do nothing because of the pain, because that can help it get worse. And you don't want to do too much. So you got to stay right in the middle. I did forget to mention that if you go to physical therapy for tendinitis, they'll often have you do eccentric exercises. So any eccentric is pretty much doing any what you think of a normal exercise in reverse. So the most simple example would be like if you're doing a barbell curl that's concentric and eccentric would be doing it in reverse. So lowering the weight. And so in physical therapy we use Eccentric exercise to treat tendonitis because it builds strength faster with less repetitions. So repetitive trauma contributes to tendonitis, and you'll want to try and get those tendons nice and strong without a whole lot of repetitions. And so eccentric exercise is a great tool for that. Like if you were going to do just a squat down. So squatting down into a deep squat and then help yourself up by like using your arms to push yourself up so you get that eccentric load on the lowering of the squat. But then the pushing up, which is the concentric exercise. You help yourself. Assisted assisting yourself up. You can pull yourself up on a band or push yourself up with your arms. And so you're not getting the concentric load, but you're getting the benefits of the eccentric load. That would be a great way to do that. Do physical therapy type training on your glutes with a deep squat. And so similar thing with the bridge. If you were bridging, you could help yourself up into a bridge and then lower with the glutes and just do less repetitions and get more of the strength benefit. Next question. This is from Marcy. She says breathing is more difficult when in full bridge. Very true. I'm assuming it just takes more practice. Very true. It makes me want to breathe shallow, to hold the anchor correctly. Very common. Also, my hamstrings have been so tight since I started the bridge. I wanted to comment on that for sure. So hamstring tightness is common with the bridge. Hamstring tightness is not something that I have a big problem with. Actually there is a lot of attention around stretch your hamstrings for back pain. It's been that way since I was a small child. I just know that people, when people have back pain, their first tendency is stretch your hamstrings. And I believe that one of the reasons that is the case is because it feels good on the lower back, because when you're stretching your hamstrings, oftentimes what's happening is you're not actually stretching your hamstrings very much. You're stretching your lower back muscles. It's the same type of motion to stretch both muscles. And so if you have super tight hamstrings and you do a hamstring stretch, most of that stretch is going to go into your back. And that feels good. But it's not the solution. Just stretching out those muscles offers relief, but it actually could potentially contribute to the problem. If you think about tendinitis, if your back muscles have a tendinopathy or tendonitis from repetitive trauma from overactivity, and you continue to stretch them over and over. You're just continuing to pull on them and yank on them when what you actually want to do is provide support around them from the muscles around them. By doing something like in this program, where we build up the deep core muscles and allow those muscles to kind of relax and let go. And so that was a little bit of a tangent off of the hamstrings, but into tendonitis. But I have no problem with tight hamstrings. Marcy. The reason it doesn't bother me is because they help keep that pelvis in a posterior tilt when they're tight. And it's very common for people with chronic back issues to have an anteriorly tilted pelvis. And so if you fall into that eighty percent, I would say category of people with back pain that have an anteriorly tilted pelvis. That's the predictable pattern. Then tight hamstrings will help keep that pelvis in a neutral to posterior tilt, which should be good. It may feel unusual. It may feel uncomfortable. It's not a long term strategy. I think the long term strategy is to have a stable core, but it could help in the beginning and it doesn't really cause lower back pain. I don't see a strong correlation with tight hamstrings and back pain. I think that was somewhat of a myth. There's probably some correlation because the whole body is connected, but I think the major cause of back pain is other muscles like the hip flexors. And so not a big problem for me. And so going into the breathing yeah, it's just going to take more practice learning how to breathe when in full bridge. Marci is a process and it's extremely rewarding. So as you get better at it. Your bridge will get stronger, your breathing will get stronger. The ability to breathe into a tight container, a cylindrical space, and build up that intraabdominal pressure that I talk about in the day zero lesson is a great skill to have. And yeah, it takes a lot of concentration. It makes the bridge feel really complicated. But I just wanted to let you know that yes, I agree, and it's a very common comment to receive from students is that the breathing is challenging, but you'll get better at it and you'll feel the benefits. Moving on. Oh, this is also from Marcy. It's actually it was in the same kind of comment area. It says I am an Or nurse and stand a lot on concrete floor. I have chronic intermittent lumbar pain, but for the past year pain has been referred into lateral legs into bottom of my feet. My physiatrist wants to do an EMG. I've been debating on delaying that test until I finish your program. Any thoughts? She says yes, I've had the MRI, but I agree with you that I shouldn't. It shouldn't determine my treatment. So Marcy, I'm not sure from your comment, but I have to say this anyway. I would recommend that you watch my presentation I did on imaging just so that you can have exposure to a certain belief, a certain belief supported by data and research about the impact of imaging. So go ahead and check that out. Uh, but I can't tell from your comment whether you've already. Maybe you've already done that because you say, yes, I've had the MRI, but I agree with you that it shouldn't determine my treatment. You know, the MRI can help with determining treatment. Of course, it's a useful tool to be able to see what's going on. The purpose of my presentation on MRI and other imaging is to not let it determine your fear, and determine your psychology about whether you're broken or not. Being able to see in that much detail the injuries and the degeneration of our spine has a large psychological impact. And the truth is that the majority of people with no back pain at all have, on average, at least one diagnosable condition in their spine, like a herniated disc or a degenerative disc disease, but they have no pain at all. And then we have people with severe back pain that have much less degeneration or damage in their spine on imaging and they have severe pain. And so there's a very poor correlation between damage and pain. Pain is much more than just this structural effects that you see in imaging. So the purpose of that research and that presentation was to just let you know that it doesn't determine your future. Whatever shows up in the MRI. There are amazing stories of people who get back to full life and full function without pain. They have way worse imaging than any of us have. And so that's what I meant. And to determine the treatment. Yeah, MRIs can help. But I do believe that the solution is pretty much going to be the same. Whether somebody has this kind of condition in their lumbar spine or that kind of condition. Fill in the blank. And often the solution is simply building up the support around your spine with your natural musculature. And the deeper you can get into those muscles, the ones that are closer to the spine can provide more support. Much better support than the ones that are superficial far away from the spine. And so yeah, the solution is often the same. Whether you have a herniated disc or stenosis. It's going to be to build up the support for your spine. So to get real specific to your kind of your question, you're asking for my thoughts on whether you should get an EMG. I think based on what you said, chronic intermittent lumbar pain. So it comes and goes, but it's been chronic for a long time. Probably. Let's see. Did you say how long? For the past year? For the past, past year, pain has been referred into the lateral legs and bottom of your feet. And so I'm going to associate standing on the concrete floor with when those symptoms become triggered. And that would make sense. It would probably make the most sense to me if there's kind of a stenosis type situation in there, when people have pain in standing and it's by both legs, so stenosis is often equal bilaterally, it's going to affect not always but often affects both sides. Similarly, and the referral pattern into the lateral legs would be kind of lower down like L5 and bottom of the feet l5 S1 nerves. I would say that the EMG isn't really going to do anything for you, because the problem most likely is coming from your spine. The finding and the EMG is not going to give you any solution. It's not going to give you anything. We don't know. But at the same time it probably won't hurt anything. So I don't have a problem with you doing it. I'm curious to know what your motivation to delay the test is, because it's different than imaging in that you're not going to see the damage, but you will get a report. And my expectation is that the report is going to have really no conclusion. I don't think they're going to find a nerve problem. It's what you're experiencing is consistent with a nerve compression, and it could potentially be in the lumbar spine. So we would treat that just the same. As I was talking about before. I have high hopes for you in this program because I can see that you've been consistent, you've been very active in the lessons. And so, you know, stick with the program, stay the course. And I think you're going to notice the benefits. And if you want to get an EMG, go ahead, because I don't think it's going to do a whole lot. It's not going to change what we're going to do. I don't believe, and at the same time it's not going to hurt anything. So those are my thoughts. Hopefully that helps. That was my last student question for the day. And so we'll start wrapping things up. So we were talking about how the best solution to tendonitis is to stay active and not to do nothing. You have to be active, but to also not do too much. If you're experiencing muscle imbalances and you're in the program, then you're already doing a really beneficial thing to help take the load off of those overactive muscles. But to help guide your levels of activity and what to do, you got to listen to your body. And so if you didn't catch last week's presentation, please do that and you'll see what I mean. But getting out of a tendonitis situation will require a lot of you knowing where your thresholds are, how much activity your body can tolerate, and doing activity up to before that point, but not past it and not doing nothing. And so I encourage all of you to stay active and go get out there and move with confidence. I believe that's going to be a topic we will be talking about very soon. For one of these weekly live coaching is the concept of moving with confidence. It completely changed my life. It changes the way that your body operates and the way it works, and the way that the muscles fire and connect. All right, guys, I think that's it for today. Thank you. I'm super grateful for all of you showing up. And yeah, everybody go do something for your body. That's what I'm going to do. Get down on the floor and give some love to your core because it does so much for you. So until next time, take care of yourselves.
