Victory Friday | Issue 143
Orthopedic Insights: Breathing & Orthopedics, Part II • Elongation and Rotation Duo for Gait-Maxxing • Ribcage Renewal for Low Back Pain Relief
“As long as you’re breathing, it’s never too late to do some good.” ~ Maya Angelou
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Happy Friday! The weeks’s done, time to exhale: literally, for this issue, revolving around breath and the impact of efficient ribs in feeling good and moving well! Level up your life — and maybe relieve that chronic neck and back pain — with a little ribcage love!
What I’m Into: Breathing & Orthopedics, Part II. A few weeks back we introduced how breathing affects orthopedic function1.
It’s incredible to consider all the ways breathing can affect orthopedics: it directly or indirectly affects the entire body.
To appreciate its effect, here’s quick primer on what efficient breathing looks like:
Efficient Breathing Mechanics:
• use the whole ribcage: front, back, sides, upper and lower
• use the diaphragm as the prime mover: this key muscle, positioned at the bottom of the respiratory barrel, efficiently inflates and deflates the entire ribcage
• has balanced inhalation and exhalation. This is a key point, and leads to one of Joe’s Sayings:
In high-stress states, the brain only really cares about inhalation.
Exhalation isn’t as important.
In sympathetic (high-stress and anxiety) mode, the brain places priority on inhalation: getting as much oxygen as possible2. Emphasis will be on the expansion and elevation of the ribcage.
But prolonged rib elevation — ribs stuck in “inhalation” — can cause problems, including focal thoracic pain. But more significantly: this is a primary driver of shoulder pain and injury (see below).
Here’s what we know about breathing:
When breathing efficiency is lost, key movements are lost and/or compensatory breathing mechanisms create problems.
Here are some key examples of how inefficient breathing is a primary or secondary cause of common, chronic pain complaints:
Neck pain. One inefficient breath strategy is excessive apical breathing. This occurs when we predominantly breathe by elevating the upper ribcage — inflating mostly upward, and under-inflating the rest of the “barrel” of the ribcage.
Apical breathing is often a stress response — a way to maximize inhalation, when coupled with using the rest of the ribcage.
But many people breathe predominantly with this upper area. In doing so, they overuse the musculature responsible for elevating those upper ribs: the scalene muscles.
The scalenes are attached to the lateral neck. As such, chronic apical breathing overuses those muscles, which clamp down upon the cervical vertebrae. This overuse pattern often causes:
• chronic myofascial neck stiffness and pain (tight scalenes)
• neck joint stiffness and mobility loss (due to vertebral compression)
and sometimes
• radicular pain in the arms: the nerve roots of the upper limbs must pass between and beneath the scalene muscles. Additionally, chronic scalene tension can elevate the first and second ribs. This combined compression is the cause of thoracic outlet syndrome.
Shoulder pain. This is an interesting one. A healthy, high-functioning shoulder requires an efficient Shoulder Landscape3: namely, a scapula that can:
• rest in neutral, and
• fully move (forward and back, up and down)…
…on a neutral ribcage!
Inefficient breathing often causes ribcage mobility loss and movement and alignment problems for the shoulder complex.
Namely: elevated ribs block the efficient resting position and full movement of the shoulder blade.
In the “Landscape” model, stiff ribs create a “slanted platform” for the “shoulder crane”: the base (the scapula) is tilted at rest.
Then, when it is time for large, athletic movements — elevating, pulling and pushing — these elevated ribs block the full motion of the scapula.
In both rest and movement, the shoulder soft tissues can become impinged.
In my clinical experience, this is the root cause of most non-traumatic shoulder pain, stiffness, degenerative changes, and rotator cuff tears.
Low back pain. The mechanisms for poor breathing and low back pain are many. But here are some primary factors:
• Diaphragm as core. The diaphragm functions as a key core muscles: the “top” of the lower trunk pressure system:
top = diaphragm
front = transverse abdominis
sides = TA/obliques
back = multifidi
bottom = pelvic floor
A stiff, weak or otherwise inefficient diaphragm can compromise core function and lead to increased low back stress.
• Pelvis restriction. The diaphragm has profound fascial connections to the pelvis: diaphragm inefficiency can cause stubborn alignment and movement restrictions at the pelvis4. This impaired movement and alignment compresses the low back from below.
• Excessive lumbar motion. Efficient gait requires segmental motion of all 22 bones of the spine. One key motion: ribcage rotation to facilitate leg motion.
Inefficient breathing can result in thoracic vertebral and ribcage motion loss. If the ribcage cannot rotate, it transfers the burden of rotation movement to the lumbar spine.
Excessive lumbar rotation — a movement it isn’t designed to do — is a major strain on the lower back.
This is a key — and often overlooked — factor in chronic low back pain. And why I developed this exercise a decade-plus ago: to relieve back and hip pain my power-walking retirees!
Gut dysfunction. Here comes another Joe’s Sayings:
For optimal digestive function, the gut organs need to move!
Gut organs require both mobility and motility:
• mobility: the basic ability to “wiggle” in all directions, without being adhered to any other structures. (think: “coats on a hanger in a closet” — each organ has a position from which it “hangs”, but each has the ability to slide freely in every direction)
• motility: this is the slow, “rotational dance” each organ does as part of its functional movement. I liken it to a slow “washing machine twist”. This first requires basic mobility (a lack of adherence to other structures).
Visceral structures that lack either mobility/motility, at minimum, under-function. This under-functioning takes a variety of forms including:
• reflux (GERD)
• indigestion and bloating (stomach and small intestine restriction)
• bowel inefficiency: either high-frequency, low-density (diarrhea) or the opposite (constipation).
Diaphragmatic breathing creates a wave-like motion that (absent other stressors) naturally maintains both mobility and motility.
Without diaphragm activity the gut often becomes stiff and restricted.
Takeaway: breathing affects everything. As such, we should be evaluating and optimizing breath in almost every pain and dysfunction we treat!
Joe’s Articles & Cool Exercises I Like. Elongation and Rotation Duo for Gait-Maxxing. Restoring and teaching efficient, athletic ribcage motion isn’t easy.
I developed this exercise many years ago to help my power-walking retirees — many of whom, “despite” (but really, because of) walking every day, suffered from low back, hip and knee pain.
The reason: they were stressing these areas because they were lacking efficient ribcage motion.
The ribcage needs to move — to rotate and elongate — to both facilitate greater motion while adding cushioning to our walking and running gait.
Without it, attempts to walk or run fast and far come at the cost of excessive landing stress on the joints of the spine, hips and legs.
This article from iRunFar.com outlines the core movement, what I named, “The Short & Long”:
Trail Stability With The “Short And Long” Exercise
The exercise:
More recently, I accentuated the elongation stretch effect (and some stability and balance) by using an inflatable fitness ball:
Ribcage Opening Techniques for the Thoracic Spine, A Silent Culprit in Leg Stiffness
The exercise:
Give this one a try:
• as a morning mobility exercise
• as an active warm-up strategy before walking, running, or gym workouts
Victory Friday. Ribcage Renewal for Low Back Pain Relief. I want to share a couple key victories in a challenging chronic low back pain client.
• male, age 60s
• highly active, strong and otherwise very healthy
• history of chronic low back pain of nearly 20 years, including two lumbar surgical procedures
His primary issues include:
chronic lumbar stiffness, worst in the morning
episodic pain flares characterized as “biting pain”, accompanied by mobility loss and heightened sensitivity: when they happen, “it feels like I can’t hardly move without severe pain”.
I wrote a previous Victory involving this client, where he got substantial relief — both mobility gains and profound improvements in automatic core activation — from superficial fascial mobilization to his low back and pelvis, specifically around his old surgical scars5!
I wish I could say he’s stayed pain-free and highly active, but the truth is, he had another flare-up two months ago: acute “biting pain” accompanied by a prolonged mobility loss and pain.6
Given that his superficial fascia was mobile and his core was intact and functioning, we had to go back to the drawing board to find a source of strain.
And we found one.
At every visit I ask clients about activity level. For highly active people, this can be more difficult than you think. These athletic clients tend to only list “the workouts”: running, cycling, yoga, weightlifting, etc.
When I pressed him about activity, he noted that he’s walking every day: “3 miles every morning, mostly flat”
And whenever I hear that walking is a daily activity — and especially if it’s a primary fitness activity — I always ask about speed and terrain.
His reply: “Pretty fast”
For nearly every person, fast-and-flat walking is inefficient walking. It’s very difficult to walk fast and flat: fast speeds demand long, fast strides.
But efficient walking gait demands the person walk using their whole body, including a spine that elongates and rotates.
I asked him to walk for me:
As you can see:
• there is zero trunk motion: no ribcage rotation, no scapular motion
• while there isn’t a lot of lumbar rotation, there is significant impact stress: the hard landing from the legs is transmitted and absorbed by the low back.
I showed him a more efficient style7:
Note how, on the return, you can see the buttons of my shirt oscillate side to side. This is a good metric of functional rotation of the ribcage.
To promote efficient trunk motion I taught him The Short & Long — which served as both a mobility generator (stretch) and proprioceptive tool.
He also doubled down on thoracic spine mobilization using the foam roller8 (namely: attention to the mid ribcage and diaphragm with rotation emphasis).
Then we hopped on the treadmill and, using mirror cueing at the front and side, he practiced light-but-significant trunk elongation and rotation.
Since then, some key improvements were made:
• significantly less back pain upon waking: he’s not “beating up” his low back the day before!
• improved mobility: less compressive impact stress, more free motion!
• decreased sensitivity: less sensitivity and more confidence in daily movement
Take-Aways. Always Assess Walking Efficiency! Watch every client walk and assess for:
• ribcage rotation
• scapular (forward and back)
The more they walk, the more that gait efficiency is a crucial aspect of their pain relief and recovery!
This counts for lumbar and leg pain, but also upper back and neck pain! Fast, stiff walking creates compressive impact that can reverberate throughout the body.
Walk a lot, but walk well!
Issue 143 is complete!
Help people move, function and feel better: please share this publication!
Thanks for reading, and have a great weekend,
Issue 137: Breathing & Orthopedics, Part I. Efficient diaphragmatic breathing with full three-dimensional ribcage expansion creates a powerful fascial wave that, through fascial connections with the lungs, ribcage and diaphragm, mobilizes the whole body. Inefficient breathing is linked to common, persistent dysfunctions such as spinal (neck and low back) pain, pelvic/hip alignment and mobility deficits, and downstream upper and lower limb dysfunctions, to name a few.
And, likely, retaining carbon dioxide. There are several physiological advantages to “holding onto” a moderate amount of CO2. We may expand on this concept in a subsequent Issue.
Issue 23: The Shoulder Landscape. The “Shoulder Landscape” analogy advocates treating persistent shoulder pain from the core outward: first restore smooth mobility and positioning in the thoracic spine and ribcage (“the foundation”), then improve shoulder blade stability (“the crane base”), cervical integrity (“power supply”), and finally work directly on the shoulder joint itself (“the crane arm”). Sustained pain relief and optimized efficiency of the shoulder requires this systems-based approach.
Issue 74: Gregg’s Gems. Low Back Pain & Impaired Diaphragm Function. A study finding that impaired diaphragm function is correlated with increased low back pain, and diaphragm training improved back pain measures in a group of athletes.
Issue 40. “Hips In Captivity”: Diaphragm Dysfunctions Hindering Hips. Treating diaphragm restrictions in two young runners (male distance, female sprinter) with hip pain and pelvic/hip dysfunction resolved ~75% of mobility and alignment issues before any direct hip/pelvic work. This underscores the diaphragm’s key role—via fascial connections—in pelvic/hip alignment. Recommend assessing thoracic mobility and diaphragm function in all lower-quarter clients.
Issue 108. Fascial Freedom: Scar Mobilization Restores Lumbar Motion & Core Strength. In a highly active 60+ male with chronic low back pain and two prior lumbar surgeries, superficial scar tissue from the incisions had glued down the lumbar fascia, inhibiting deep abdominal core activation and causing compensatory overuse of the lumbar extensors. Initial systems-based work on the hips, pelvis, and thoracic spine yielded only mild gains. Targeted three-dimensional scar and superficial fascial mobilization instantly improved deep core firing (from “F” to “B+”), enhanced lumbar motion, reduced morning stiffness, and delivered noticeable 24/7 ache relief within one week — with no additional core exercises.
This pain behavior is typical of a facet joint sprain: the articulation of one vertebrae with another. Too much or abnormal movement of one bone on another will result in sharp pain followed by movement restriction: much like a “rolled” ankle, which is another “abnormal motion” that creates a tissue strain, pain and prolonged recovery time as this tissue strain heals.
Don’t judge the boot! I stubbed my toe badly in my office a week prior!
Advanced Ribcage Strategies: sustained breathing mobilization of the lateral and posterior diaphragm and ribs, emphasizing rotation.
Advanced Ribcage Strategies, Part 2: working the anterior ribcage (sternum and diaphragm) using lower trunk rotation.