Date: December 14th, 2017
About Esther Smith
Esther Smith is a Doctor of Physical Therapy, a Nutritional Therapy Practitioner, a Pilates instructor, and the owner of Grassroots Physical Therapy in Salt Lake City. She is a 5.13- climber who’s reaped the benefits of her own physical therapy practices, having healed a shoulder injury, a finger injury, a recent foot injury, among others with exercises, stretches, pilates, and alternative therapies.
She works almost exclusively with rock climbers, which is rare for a physical therapist. For a complete bio and list of certifications and qualifications, please visit www.grassrootsphysicaltherapy.com. This is my fifth interview with Esther, and here’s a list of the other interviews I’ve done with her:
This interview is all about hip and knee injuries. We talk about the most common hip and knee injuries among climbers, why we get them, what they feel like, how to get a proper diagnosis, and mostly… how to make the injuries go away.
During the interview, you’ll hear Esther talking about the videos she created to help you understand what she’s trying to explain. You’ll find all those links below. If you have shoulder, neck, elbow, or other injuries, she also has video tutorials for sale on her website, www.selftreatment.com, which very well may make your pain go away without the help of any practitioner.
In fact, I’ve had at least 10 people approach me at crags or at the gym and tell me that these interviews with Esther “fixed” their (insert body part here), so we’re extremely happy that these interviews and Esther’s videos are helping people around the world.
Esther Smith Hip and Knee Interview Details
- Most common hip and knee injuries in climbers
- Why we get them
- Exercises to strengthen them
- What kind of practitioner to see first
- How to stretch hips and knees
- The different kinds of knee injuries
- How to avoid injuries with warm-ups and general maintenance
Self Treatment Videos
These are trailers of video tutorials that Esther Smith and Eva Kauffman created to help you heal your hip and knee pain. They each cost $14.99, but that is a very small price to pay to potentially be rid of your pain.
Esther Smith Links
- My first interview with Esther about shoulders
- My second interview with Esther about elbows
- My third interview with Esther about fingers
- My fourth interview with Esther about Neck and Back
- Esther’s website: www.grassrootsphysicaltherapy.com
- Esther’s resources and protocols for injuries: www.selftreatment.com
- Esther’s article on how to Hang Just Right on the hangboard
- Esther’s article about elbows: Hang Right: Part 2
- Esther’s Youtube channel
- McKenzie Lumbar roll that I use when sitting: amazon.com
Training Programs for You
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- Finger Strength : www.trainingbeta.com/fingers
- All of our training programs: Training Programs Page
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Neely Quinn: Welcome to the Training Beta Podcast, where I talk with climbers and trainers about how we can get a little better at our favorite sport. I’m your host, Neely Quinn, and today we are on Episode 94 of the podcast.
Before I tell you about that episode, I want to ask you for your input. The podcast- I’m almost at one hundred episodes. That’s just of the main podcast episodes- there have also been fifteen or so mini-episodes, so I’ve done a lot of these podcasts. I’m wondering if I need to serve you guys something different. If you’re looking for some other kind of interview, or some other kind of talk, or something else- topics that I haven’t covered as much. Maybe you want to hear an actual session between a client and a trainer, so that you can hear what a trainer actually would say to a specific person. I’m not sure what you want, but I want to make sure that I’m doing the right thing, and giving you guys information that’s very useable, very pertinent to your lives. If you want to give me your input, please e-mail me at firstname.lastname@example.org. That’s N-E-E-L-Y. I’m open to new things for 2018.
Speaking of the New Year, Christmas is almost coming up, and other holidays. That means gift giving for a lot of people. I want to remind you that we have training programs of all kinds on TrainingBeta. We have programs created by Kris Peters, we have programs created by Steve Bechtel, Kris Hampton, Acacia Young about nutrition, Jared Vagy about injury prevention. If you want to give those as gifts, you can do that. At the checkout you’ll find a check box that asks if it’s a gift, and you can give those programs to your people for the holidays. If you don’t see that box, it means that I need to do something specific for you to make it a gift, so you can just e-mail us at email@example.com, and I’ll make you a gift certificate or whatever it is that you want. Don’t forget about us in the holiday season, and you can go to trainingbeta.com, and you’ll find all of our training programs there.
So now, this is like I said, Episode 94, and I’m going to be talking with Esther Smith. I actually just got off my Skype call with her this morning. We talked about hip and knee issues among climbers. Esther Smith is a physical therapist. She’s also a nutrition therapist, she’s also a pilates instructor. She’s been on the show a lot of times before. We’ve talked about neck and back issues, we’ve talked about finger injuries, we’ve talked about elbow and wrist issues, and shoulders. So we’re just going to make our way through the body. We’re doing hips and knees today, like I said, and then in a few months we will do feet and ankles. In all of these episodes we talk about the most common injuries that climbers face with these parts of their bodies, and how to rehab them, when to know if you should go to a doctor, what kind of practitioner you should see, and all that good stuff. So I’ll just be quiet now, and let you listen to Esther Smith. Here she is, and I’ll talk to you on the other side.
Neely Quinn: Welcome back to the show Esther thanks very much for talking with me today.
Esther Smith: Thank you Neely, happy to be back.
Neely Quinn: So today we are talking about knees and hips. We’re just, like, traveling through the human body and talking about all of the common injuries that you see as a physical therapist among climbers, and what people can do about them. Before we get into that, in case people haven’t heard your other interviews, can you give use little intro to who you are?
Esther Smith: Sure. I’m a physical therapist, I practice in Salt Lake City, UT. The name of my practice is Grassroots Physical Therapy. I’ve got another PT working with me, Katy Scott Martin, and we specialize in treating climbers, and we see climbers every single day. Definitely more than half of our practice is associated working with climbers, and we love it. Over all these years that we’ve been doing it, we’ve really been able to understand some of the patterns, and injuries that affect climbers in particular- the specialization that we have in our sport, and how that relates to physical therapy and rehab. It’s been awesome to work with you, and kind of take this tour of the body and share this insight that we have, garnered over our years of experience, working with this population.
Neely Quinn: Yeah, and you have a couple of other side specialities it seems like. You’ve studied nutrition?
Esther Smith: That’s right- I’m a nutritional therapist. More recently, this last month, I finished a Pilates teacher program with Streamline in Salt Lake, so now I am also a Pilates instructor. All of that kind of gets blended into a really holistic approach to physical therapy.
Neely Quinn: Yeah. And how long have you been doing this?
Esther Smith: Six years, just over six years. It’ll be seven years in May. Grassroots I have had open or three years, and that’s really where I focus my practice on athletes, and particularly climbers.
Neely Quinn: And then you also are a climber, obviously.
Esther Smith: Yeah, I’ve been climbing for over fifteen years. It’s the sport that I love and am most dedicated to. I think Salt Lake has a special community of climbers- we have a lot of climbers in this valley, and they are definitely my people. I absolutely love investing my time and energy into the sport personally, but also professionally.
Neely Quinn: You’re kind of the full package for climbers, and I wish there was one of you in every city. There are a ton of physical therapists out there, but not a lot of them understand truly what goes on with a climbers.
Esther Smith: I think it’s becoming a little more popular. I went to one of Eva Lopez’s workshops- she had a little string of workshops and seminars in the Denver/Boulder area. She was saying how internationally, when climbing gyms open up, that there is more physical therapists associated with each climbing gym, and even maybe in-house in climbing gyms now. I think it’s cool to see that as a sport, where we are developing more professionalism around training, coaching, rehab, and physical therapy. I think more and more, PT’s are going to orient themselves towards this popular. I’m happy to be contributing to that pool of knowledge. It’s such a great population to work with. And climbers aren’t just climbers- most climbers are athletes beyond just that sport. It’s fun and dynamic in that way to see how things relate. I think that ties into our talk today on hips and knees. We’re not just climbing usually- we’re also out hiking, running, biking, you know? Doing a bunch of different sports, and that does affect us, plus or minus as climbers- especially in our lower extremities.
Neely Quinn: Yeah, yeah. So speaking of our lower extremities, do you want to jump in with hips and knees?
Esther Smith: Yeah, let’s start talking.
Neely Quinn: Okay. So usually we start talking about- well actually, I don’t know if we have a usual scheme to this [laughs]. Why don’t you tell us how exactly we use our knees and hips in climbing? That might seem obvious, but I think you have a deeper insight to it.
Esther Smith: Yeah, I think as I’ve been trying to brainstorm about this particular talk, I like to think of the hips and the knees a lot like our shoulder and elbow, you know? The shoulder being that joint that connects our upper extremity to our trunk, and close to our spine, right? If we think about shoulder problems, we have to think about the spine, neck, ribcage, and our trunk in that way. Then we think about how the shoulder affects our elbow, hand and our wrists. We’ve taken that tour already, and we’ve seen the upstream and downstream affects of imbalances and strength and weaknesses in that area.
The same is true for the hip. It’s the part of our body that connects our whole, heavy lower extremity to our trunk and to our spine. The health and the balance of the hip really, really affects the knee. It’s sort of like that mirrored upstream in the upper extremity, how our shoulder health really affects our elbow. When we are talking about the hip as it relates to climbing, I think we will see how if we take care of that region of our body, we are much less prone to injury in our knee.
The amazing thing about the hip, the knee, the lower extremity as climbers, that is where we should be generating most of our power and upward force on the wall. I think we lose that, and I go and do these injury assessments at the local climbing gym at Momentum here in Salt Lake City. Most of the time, people are wanting me to observe them for injuries for their shoulder, elbow, hand and wrist. So often, what I’m focused on in terms of helping them heal from their upper extremity injury, or prevent upper extremity injuries, is their footwork, lower half, and core support. That goes right into the hip-knee interaction. We should be focused on that as climbers, on being really strong, developed, and balanced in our lower extremity, and then our core, which includes our hip-pelvis region.
I want to talk about some things that way, but then particularly this idea of posterior chain strengthening. We hear that- maybe it’s more talked about in running and sports that way. That means our backline musculature, particularly our glute-hamstring connection in our hip zone. That is so important. If we can really harness a lot of strength there, we can improve our power, our performance on the wall, and we can really take a lot of work out of our upper extremity and preserve our more delicate musculature of our shoulders and elbows.
Neely Quinn: Great. You always have the most thorough answers. Through and succinct.
Esther Smith: Well good!
Neely Quinn: Thank you for that.
Esther Smith: You’re welcome. You have great questions Neely, you are a great interviewer.
Neely Quinn: Well thanks. Okay, so let’s talk about- we’ll come back to those things, as this interview progresses, but let’s talk about the common injuries that you see among climbers in their hips and knees.
Esther Smith: Okay- and maybe let’s partition it out a little bit, and focus on the hip first. I don’t know how you want to do it, but talk about that, and then skip down to the knee if you want. Common injuries at the hip, for climbers, can I think be broken up into more of a joint-type injury or more of a musculature-type injury. All of the interviews we’ve done when we talk about joint injuries among climbers, we talk about that derangement syndrome, which is the idea that in our ball and socket joint of our hip, we can get tissue inside that joint that displaces and causes pain and range of motion loss, and mobility and functional issues.
For derangement, like in the spine, or any joint- shoulder, finger, whatever- we need to understand how to move that joint in a way to make it feel better, and to restore range of motion, decrease pain, and improve mobility. If you have what you feel like is more of a deep hip pain, something that hasn’t responded to stretching and strengthening, and you think that maybe there is something going on in the joint, that’s where you should probably be diagnosed and find a good PT in the area- maybe a McKenzie PT like I always advocate for- to understand if there is a derangement. You can have labral tears, you can have osteoarthritis of the hip- all these things affecting the joint structure. Those are a little harder to self-diagnose, self-treat. In general, you want to try to find movements and positions that are relieving for that joint, and avoid the movements and positions that make you worse.
Also in the hip zone, make sure that you are ruling out a lumbar spine issue, because the low back or lumbar spine can refer as buttock pain, glute pain, and even pain down into the thigh and hip and groin, all the way down to the knee potentially, or beyond. I think noticing that this hip region is complex, that there is the spine interacting with is, there is the SI joints, and then there is the ball and socket joint. There can be various injuries that occur in all those reasons, but I think probably more common for climbers are things like hamstring strains, groin strains, and hip flexor strains- these muscular-type injuries that we get. Those can be treated with more common general strategies, if you can identify that that’s what you have.
I see that people with those muscular injuries, we can kind of pick out what happens frequently, like the mechanism of injury for climbers with those, so we can talk about that. Also how to prevent them, and rehab from them if you do encounter a more muscular type injury.
Neely Quinn: So for the hip we have derangement syndrome, labral tears, osteoarthritis, and then the muscular hamstring, hip flexor, and groin strains.
Esther Smith: Yeah, I think those are the most common.
Neely Quinn: Do you want to talk about knees before we go further?
Esther Smith: Also quite common in the knee joint is this derangement problem, where there is displaced tissue in the knee joint. Again, it’s stiffness, difficulty hinging the knee, either bending or straightening. There can be range of motion loss, and pain with motion, pain under certain loads and torques. In the knee, you have a ton- I mean any joint in our body is not just the connection of two bones. There’s a capsule around that that allows us to hold fluid to lubricate the joints, and then there is a bunch of tissue packed in there. Pretty much every joint in our body is packed with tissue, and if there is space there is fat packed in there, and that’s cushioning. All of the things that go into this joint complex can get in the way of our joint hinge motion, and that’s called a derangement. You get loose bodies or debris of tissue that screws up our range of motion. Usually, whether in the hip or knee, if you are having a derangement problem, you’re going to experience range of motion loss. With a musculature problem, you’re not going to really see a distinct range of motion loss issue.
In the knee, you have these two meniscal discs on either side of the knee, and those are often stressed, or strained, or torn under certain demands in climbing. For instance, the drop knee. That’s probably the most common way to get a knee joint issue for climbers, is to strain or sprain or tear more often than not the medial meniscus, or the ligaments that support either side of the knee, which are collateral ligaments. Those can be sprained or torn. Those are kind of the common knee joint issues- derangement, meniscal tears, or collateral ligament issues. Then around the muscular system of the knee, you have all of this muscles that attach, being your calf musculature, your hamstring musculature, your quad musculature and your inner thigh as well. Those are really prone to strains and chronic tendinitis issues, even tears under more extreme forces.
Neely Quinn: Okay.
Esther Smith: So the knee is really similar to the hip, in that it’s either this joint issue that happens and you get this displaced issue range of motion losses, or you get muscular strains or tears. The interesting thing about these two joints is that a bunch of muscles that cross the knee also cross the hip. So you have these really long, expansive, strong, powerful muscles- our hamstrings, our quads, our inner thigh. They go all the way down- they interact with the knee, but they also interact with the hip. That’s why the two are so interconnected that a healthy hip means a more healthy knee, and vice versa. Particularly the hip dictating more about the health of the knee than vice versa.
Neely Quinn: So having healthy hips and healthy knees means that we can more successfully do drop knees, heel hooks- what else?
Esther Smith: Yeah, totally. Froggy position, like the ability to actually squat and lower down on the wall, and open your knees into that low froggy squat. To me, that’s the foundation of your ability to be able to rest on the wall. Particularly we are talking more about sport climbing here, I think. In that way, you can get low and squatty and propel yourself from this low squat into really powerful, upward movement. We see that to be so important on steep climbing, and so many of us are on steeper terrain these days.
Your hip mobility, the ability to have range of motion- a healthy hip is a hip that has full range and a capacity to twist, turn, open, and bend. The more you are opening your hips, the more you are able to get into the wall in more efficient positions. The more your hips are open, the less kind of twisty-torque will occur at the knee. If you are in a drop knee situation and you have a lot of range of mobility in your hip and spine, then the knee has to do very little to finish out that motion. But, if you are really stiff in your spine, your hips, in that zone, then the knee is going to be under a ton more torque.
For people that I see that get hip and knee injuries, mostly they happen to be a little more traumatic. They occur actually while you’re climbing and there’s a pop- you’re heel hooking and there’s a pop, and you strain your hamstring or your gastroc, and usually that’s because we haven’t really focused on adequate mobility strength balance there. We aren’t adequately warmed up. These kinds of things lend us to being more vulnerable to injury. The more we can every day do a little maintenance to maintain healthy hips and knees, the less likely we are to get one of those sudden traumatic injuries while we are on the wall climbing.
Neely Quinn: Okay. Very important, and it’s not something that we think about very often I think. You go up into the weight room in the gym, and you see people doing upper body stuff, but rarely lower body stuff.
Esther Smith: Yeah and it would help so much. I think it’s a complete injury prevention strategy. I think we are stronger, better climbers when we have a stronger posterior chain musculature. That goes all the way- the back body of our upper back, shoulders, lower back, all of the extensor muscle strength from our erector spine down to our glute max and hamstring musculature, all the way down to our calf musculature. If you can imagine all of that back line being super powerful, what that will o for your upward momentum and your ability to really connect from your fingertips to your toes, which is climbing. That whole system, that kinetic chain of activation of suppleness and strength is so important for the sport we do.
I’ve come to appreciate it more personally because I was healing from that foot injury and hadn’t climbed for months. I just got back into climbing this fall. I was so pleased because I wasn’t able to climb, but the work that I did through Pilates and strength training- just focusing on strengthening this system that I’m talking about, this posterior chain and this whole core system. That landed me back in climbing at a level where I was just able to basically expedite my gains really quickly, just in the last three to four months, back to my previous level.
Neely Quinn: Oh wow.
Esther Smith: And that’s without having really been- I haven’t been climbing or training my upper extremities for climbing. No hangboarding, nothing like that. It was amazing to see one- I felt better on the wall, because I had been doing all this good hip mobility strengthening work through Pilates and strength training. My hips are open, I’m more mobile, twisty, bendy, supple through that area. I have better connection through with my footwork and my lower extremity, and I just feel like I’m a better climber as a result, and I got back into climbing and what feels like to me, a pretty rapid rate, back to my previous level because I had that foundation. It was really cool to see that. It was almost a blank slate that I was testing in a way, to see what Pilates could do for me as a climber. It got me back to climbing so fast and feeling really good.
Neely Quinn: That’s really great. A couple of things with that. I want to emphasize the fact that you really do rely on Pilates to help your clients it seems like. When I went to see you, you worked with me, and the you were like “Okay no you are going to go do some pilates”.
Esther Smith: Yeah.
Neely Quinn: It seems like something you really believe in.
Esther Smith: I do, I do. I think you have to search for providers that are really good at what they do, really care, and that are focused on a therapeutic version of Pilates, not just fitness Pilates. People that are looking at the connection of the whole body and applying it to really functional movement. Particularly for us as climbers, there are some keys in utilizing Pilates to help us be better climbers.
I partnered with Eva Kaufman for all the self-treatment videos. Every video on selftreatment.com has Pilates as the foundation for the therapeutic movement- the strengthening and a lot of the mobility work is all Pilates derived. You’ll see in our Climber’s Kit, we focus so much on the core and the hips- strengthening this area that we are talking about today, for our Climber’s Kit. It’s not all about the upper extremity, and we have to consider the cross training, and let’s call it the antagonist training of our lower half. Not just to prevent lower half injuries, but to also prevent our more common injuries of our shoulder elbow hand and wrist, and to improve our performance efficiency.
Neely Quinn: And you see it be pretty successful with your people?
Esther Smith: Yeah, yeah. I think it’s incredibly successful, and that’s why I did the teacher training myself, so I could know the method for my own body, but also to help apply it every day as a clinician. We work closely with all of the instructors at Streamline. We are getting into a new clinic space next month, and that clinic space is designed to have Pilates at the center of the clinic. And, to hopefully really dovetail physical therapy and Pilates, and all these other awesome healing modalities like acupuncture, massage, bodywork, nutrition, all happening for everybody. We feel that the body needs to be treated in that holistic way. Pilates is just amazing for stretching, for strengthening, and kind of this idea of uniform development. For everybody, not just for climbers, but for all of us. It’s a modality that’s resonated with me, and I’ve seen it be so successful in my own body and clients, so I can’t help but want to blend it more and more.
This project with the self-treatment videos is a testament to that. People all over the world are buying these videos and using them. They’re getting better, feeling better, and they’re helping themselves in places in the world, or this country, where you don’t have access to the best Pilates studio, or the best instruction, or whatever. It can really be a resource for people who don’t have access like we do. You have amazing access in the Denver-Boulder area.
Neely Quinn: Well that’s what I was going to say. I don’t know why, but it seems like in my mind, yoga and Pilates are sort of similar. Yoga seems very accessible to me, but Pilates, when I’ve looked around it’s way more expensive than yoga. I don’t know if I should be having one-on-one instruction for Pilates. It seems like that would be a good idea, because when I went to your clinic, it was very hands on. I was doing things very wrong until she could really subtly change my movements.
Esther Smith: Yeah.
Neely Quinn: So it seems like that is the kind of thing where you need one-on-one instruction. What do you think about that?
Esther Smith: We can be more general with it. We can say, well we applied the method, and coaching and videos and it’s not one-on-one and we feel that’s valuable and successful too, right? But ideally, when I want sometime to be introduced to Pilates, I suggest that they do two or three private sessions. You have somebody who is a movement expert who is watching, coaching, and assisting you for an hour over those sessions, for your peculiarities, your individualized needs and imbalances. Then you can really blend right into a mat or equipment class. The reason why it’s usually more expensive than yoga is that a lot of times the classes are much smaller. If you get into an equipment class they’re much smaller for sure, and you’re utilizing this equipment that is really specialized and helpful and requires more attention from the instructor and participant. I think in the end it can be a little more specialized and more individualistic, and that’s a little bit more of what you’re paying for.
To me, it transfers to function so beautifully, whereas I didn’t, in my own body, feel that so much from yoga. There is a lot more attention to alignment, detail, and structure that way, that to me I feel like you are more apt to find through Pilates. I advocate it strongly, but I think yoga is super valuable and awesome too. Just as a PT and somebody who is helping people rehab from injuries, I’m way more confident in suggesting that somebody create a bridge from injury back to sport or just back to life via Pilates.
It’s not more of, but it’s just an amazing therapeutic modality, and the equipment is just incredible when you get into using that. You can see things, you can asses for dysfunction, imbalances, and individual issues in a body via the equipment. You can also assist somebody into beautiful, well development movement with these springs, pulleys, and all of the apparatus that we get to use there. It creates this little mini gym, that’s like a minimalist gym. In my rehab facility, I don’t need all of this crazy equipment- treadmills, weights and everything else. All I need is a reformer cadillac, a chair, a barrel. For me as a PT it simplifies the amount of equipment that I need, and it simplifies it for people with home use too, I think. I love it for that reason.
Neely Quinn: That’s a really good endorsement, and something that nobody’s ever really talked about, except for you, on this podcast.
Esther Smith: Good, yeah. Worth checking out in your community, and the online resources for it can be pretty great. There’s Pilates Anytime, which is a pretty cool thing that you can plug in and do some little classes via coaching in your own home. And of course all the Self-Treatment videos. I think it’s worth exploring, and it’s not understood. Yoga is much more a part of our every day, and I think Pilates has a few more stigmas, barriers. I think people don’t quite understand what it is and what it can do from them. It does seem a little more expensive, and all I can say is that I think you’re getting what you’re paying for- if you go to a good studio, absolutely.
Neely Quinn: Okay so moving backwards to hip injuries. I’d love to talk more about the injuries that you had talked about, and then what people should do about them. Also, how people can figure out what is wrong with them.
Esther Smith: Yeah. Okay. We looked at the hip injuries, either joint based or musculature based. Sussing out what’s wrong with you in this area is tricky [laughs]. It really is. If you at all can find a provider in your area that can help you sort through a good diagnosis at your hip, I think that’s pretty important. It’s hard to self-asses because there are so many different variables in the hip. It could be lumbar spine, it could be SI joint, it could be ball and socket. It could be joint, or it could be muscular. It’s a lot to sort through on your own.
With the joint issues, you’re going to find a little bit more of a distinct range of motion problem, as you move your hip forward, back, side, side, rotational. You might feel clicking, pinching, grabbing, and lots of motion stiffness or pain under those conditions. A muscle thing, you would feel your pain more under the use of the particular muscle, right? So it would be like a contraction thing, not a passive range of motion thing, or a scouring of the joint. I think those two can be differentiated that way. But again, I think a physical exam is so important. Having somebody help you with that would be crucial.
In the joint issue side of things, the thing that every joint wants is to be balanced within the actual ball and socket situation, and to have relative decompression. A lot of joint issues come because we are really tight around our hip musculature, and our joint is basically sucked up and in and it’s quite compressed. There’s not a lot of space, and so you are getting a lot of bumping and grinding going on. Things that you can do to decompress the hip joint and give it space, i.e. a lot of self-massage around the hip musculature can be awesome for that. If you bust out a foam roller and self-massage all around the different aspects of the hip. Maybe you can find a way where you can almost pull traction on the hip. You want to pull the leg out long from the socket. Literally someone can pull on your leg and that might feel really good. Devise some way that you feel like you can traction that area.
One thing about a lot of the Pilates exercises is that we call for this oppositional energy, and this standing out of our joints. A lot of energy is directed at decompressing our joints by actually energetically reaching out from out center, out to the periphery, or out through out long extremities. If you were to participate in our Healthy Hip video, you’ll find that we are constantly cueing for that kind of decompression through movement, through the exercises that we are doing, or through the stretching. That can be awesome for joint issues.
A lot of times, even if you have a labral tear, or osteoarthritis within the joint, it can be managed conservatively if you bring balance to it. Part of that then is strengthening all of the aspects of the hip, particularly the side hip musculature, our glute minimus and medius, and our back-hip musculature, or glute max and it’s association with the hamstring. Then the deep hip rotators of the hip are a lot like our rotator cuff of our shoulder. There is a bunch of muscles deep under out buttock musculature that rotate the hip inward and outward, and having control and strength in those guys is super important for a healthy hip.
Everything you do around a joint problem of the hip is also similar to what you would do for a musculature problem around the hip, like these chronic hamstring strains, or hip flexor strains, or groin strains. You’re self mobilizing, you’re stretching in a 360 degree fashion, and you’re strengthening in a 360 degree fashion. One of our bigger problems as athletes in general and as climbers, is that we are really dominant and strong in our front line musculature. We tend to be really short and tight there. Our hip flexors, our quads musculature, our soaz- all those muscles that live on the front of us are short, tight and strong, because that’s what we choose to use. We sit a lot, we do these other sports that kind of keep us imbalanced that way, so we are really strong and short in the that front line. The most beneficial stretches and strengthening exercises in general are ones that open our front line and strengthen our back line.
Neely Quinn: Okay. That’s a lot to go on.
Esther Smith: I know. So ideas for strengthening the back line would be things where you are laying on your back and doing bridge work. You lift your legs up from the ground, your feet are on the floor, and you’re in that bridge, that incline slant board on your back. Maybe you are lifting one foot at a time, or maybe you are keeping in that bridge and you’re walking your heels out from you and back in. Or you are putting your feet up on a chair and lifting up into a bridge and then slowly lowering with one leg. All of that back line, where you feel your back hips, your hamstrings, your calf musculature engaged- those are so powerful, particularly for people with hamstring problems. They’ve been injured heel hooking, or they’ve popped their calf musculature heel hooking or toe hooking. You really want to be developing that muscular strength in the back side.
Other ways of getting at that would be laying on your stomach, or hands and knees, and doing leg kicks back behind you, or those fire hydrant type hip strengthening exercises that way. Squats can be amazing, because if you do a squat really well, you can feel your hip-hamstring muscles work and not just your quads. A lot of it is redirecting your effort and where that’s coming from.
Imagine if you are really strong through your backside, what that’s going to do when you put your toe on a hold and you want to push up. You’re going to do it via extending your hip, and pushing through your hip. Rather that just pushing through your knee to strengthen your knee, you want to push through your hip.
Then you have the side hip muscle strengthening, which are like the clamshells or the monster walks, getting those little guys burning on the side. That’s super important for anyone who has a hip injury, whether it’s joint or musculature. Then that goes right down to the knee. Really, most knee rehab protocols go right back up to strengthening the hip, loosening up our tight hip musculature, and balancing all of that so that the knee kind of gets to be off torque. It’s not getting all of the stress, strain, and overuse problems. It’s a lot like our shoulder and it’s relationship to the elbow. If we want to take care of an elbow tendinitis issue, which is an overuse stress-strain problem at our elbow, we need to go back up and take care of our shoulder problem, right? Imbalances there, tension problems, weakness problems, and then our elbow feels so much better- the elbow is the little weak link in the system. Same for our lower extremity. The knee gets overworked, overused, torqued and twisted because our hip really is not fully mobile, or not fully strong.
Neely Quinn: Okay. I have a couple of questions. One is you said a while back that you should find a practitioner to help you diagnose these things. People I’m sure are wondering who is that? Do I got to a physical therapist first? Do I need a referral from an orthopedic doctor to go to a PT? Do I got to my general practitioner? Who do people go to?
Esther Smith: Well, a little bit depends on the system that you’re in- the insurance system, what’s happening in your state, or in your country, if you’re international. In the States, most states allow direct access to physical therapists, and most insurance companies will allow you to go directly to a PT. In my mind, if you have what you think is a musculoskeletal problem, an orthopedic problem, a good physical therapist should be your first stop. We can do a physical exam, try to identify the issue, and see if you then need to be referred to a more advanced specialist, or go get imaging and see a medical professional outside of our scope of practice. So much can be accomplished in that initial musculoskeletal physical exam from a physical therapist. It just depends if your insurance allows for that, the PT that you are seeing, and where you are.
That would be where I would go first, unless like we talked about in the spine podcast I think, if you’ve suffered any trauma and you’re worried about a fracture or unremitting pain, or really extreme levels of pain. Anything around that, of course, just go right into a doctor or into imaging and make sure that nothing really bad has happened. Never be shy about seeking appropriate care if you feel like you’re dealing with a severe injury. But, if you feel like it’s something that you’ve been dealing with for a while, it’s kind of an overuse thing, I think that a physical therapist would be super appropriate.
We’ve had this talk before about chiropractors and they can be awesome- such a great resource. I just think you really want to find one that does a physical exam and is trying to tailor treatment to you. Some of those chiropractic offices are more of a factory line, where they will for more of a chiropractic manipulation and not so much of a physical exam. I think it’s just finding those providers that really invest their time into understanding the source of the problem, and then maybe you’re building a little bit of a team. Once you’ve seen a PT and get a diagnosis, they hopefully can refer you to a massage therapist, or a Pilates instructor, to that chiropractor, to that acupuncturist.
Sometimes the PT should be viewed as a little bit of the center of the wheel, and then there’s all these spokes of different treatment providers that can stem off of that, including MDs, physicians, sometimes surgery. A physician, if you have a good family practice physician or orthopedic physician, they would be ideal to see first. It’s just a matter of seeing who is accessible more quickly, and who is more affordable or whatever, or who works with your insurance I think. Does that answer that question?
Neely Quinn: Yeah totally, that’s really good. A lot of times in the past I’ve been like, I have this injury but I don’t think I should go a physical therapist first, I think I should go to an orthopedic and get an MRI so I know what to tell my PT when I go in, like this is what I have.
Esther Smith: Yeah, that’s true. But in the big scheme on things, in our medical system, MRIs are really expensive and they don’t necessarily tell us what’s going on. Information garnered there doesn’t always change your rehab. In certain schools of thought, unless you think it’s traumatic, and like you said in the case of severe injury, or something that you just feel like you want to know what’s going on and you want that medical diagnosis, that’s totally a good pathway. I think what we are trying to do is really base more of our interventions and more of our prognosis and plan of care on the physical exam. That can’t be replaced by an MRI. But, MRIs are great when we need to know, or you’re failing treatment after just a couple of visits, you know? So, totally valid.
I just encourage people to listen to their body and to not be shy. If you have to, spend some money to get it figured out. It’s the most important thing you have going is you health and you human machine. It’s kind of amazing how shy we are sometimes about investing in our body, and into this injury that we might have. I think we often wait a little too long, and it’s so much easier to deal with injuries when you nip them and get at them right away, in every case really. I think the faster that people can get that diagnosis, understand the nature of the problem and get on a good plan is the best way to go.
Neely Quinn: Yeah. So speaking of a plan, I have questions about the order in which people should attack their issue. If I have pain in my hip- which I do- and it has the clicking and popping, and it makes so that some positions are really uncomfortable. Do I just start doing exercises to strengthen it? Do I do self-massage? Do I stretch it? What do I do and in what order?
Esther Smith: Good question. First order would be to try and figure out what’s going on. If you can’t do it yourself, trying to find your provider that will help you sort that is number one. Otherwise, you could be wasting your time, right? But if you are willing to take more of an exploratory pathway with it, you’re going to do self-assessment basically, through your plan, then I would do it a little bit all in conjunction. You just mentioned self-massage, stretching and strengthening. I think that all three need to be happening around a hip problem or knee problem.
Let’s say you bust our your foam roller or little massage ball, and you’re taking a little tour around your hip. You are feeling and assessing for what areas feel really tight and sore. Can you scratch your itch that way? That’s always curious, because come people will roll around on the massage thing and will be like “It’s way too deep, I can’t put my thumb on it”. When somebody tells me that, I’m suspicious more of a deep seated joint problem. It’s pain that’s just being referred to the area, but you can’t put your finger on it. That’s something to think about. You’re doing this self-assessment, and then maybe you’re choosing a selection on three or five stretches that work the big guys. A front hip flexor stretch, you’ll figure out a way to stretch your side hip musculature, the IT band stretching type stuff. Maybe you’ll do a figure four stretch and stretch into those deep hip rotators in the piriformis, and then you’ll pull your knee across your chest and stretch your glute.
Again, you’re assessing and you’re asking does it feel like there is a target muscle or region that I feel like feels better with opening, stretching, and also the massage? Kind of that putting the pieces together for yourself. Then you go into some strengthening, and you’re going to work on some of those things on your back, where you are going to do some hip lifting and bridge work. You get on your side and do some side planks and some side leg kicks. Then you get onto your front, or you work through some squats and work the front musculature. All the time you are screening, assessing, and figuring it out. Like “Oh, my hip strength in these positions is weaker or stronger”, or “I feel really weak in my hip extensors but okay in the front or side guys”. Then you can zero in on what’s deficient, what’s imbalanced and what’s dysfunctional that way.
It’s not unlike what I would do with you if you showed up in my office- trying to look at all the components of a problem. A lot of it is what’s tight, what’s weak, what’s really kind of sticky and gummy in terms of the myofascial work that you might be doing with your self-massage. You just address all those variables, and a lot of time you restore health to an area or region by bringing balance to strength, flexibility, mobility, and more general myofascial tension patterns that might be more regional or global. That’s how I would go about it. If I get a tweak, I’m kind of going through that in my own body.
The part that’s cool about seeing a specialist for a physical exam is we have what’s we call special tests, where we can try to provoke your pain via very specific testing. Then we can say “Oh, it looks much more than muscular than joint because of these fve things”. Unfortunately, I can’t dispense that to you because it’s too challenging to offer that. That’s why we go to school for all the time that we do, to be good diagnosticians.
To be your own body mechanic and your own diagnostician, that’s how I would do it. You take a little tour, and go through all those components of wellness in an area. Like I said, the strength, the length of tissue, the mobility, the flexibility. You see what’s up, you see what’s limited, and you try to restore it via this sequence or system of exercises that you choose and you see if you start feeling better. We have a video called Healthy Hip and one called Healthy Knee, and that’s what we are doing. We’re going through all these different foundational components and we are helping and coaching you to do them really well. Just take self-assessment and see in the end if you achieve more of a balanced, uniform development around that area, and you are decompressed, and you are supported. That’s what makes joints really happy, is to be balanced, supported, decompressed, and positioned well within their own little situation.
When you are getting clicking, popping, and discomfort in various positions Neely, that joint sounds like it’s disturbed. It might have that kind of tissue displacement within the joint- the derangement problem. But you could be feeling a bit of a labral tear. It’s hard to know. What I would say is try to restore the joint to it’s most healthy position supported baseline, and see if you can function from there. You want to see if the exercises make you feel better, because they should. If it’s not working within a couple of weeks or so, you’re either going to switch it up or try to find somebody. And then making sure it’s not something from a neighboring joint, like your low back for instance, causing an influence on the hip, or a problem there as well.
Neely Quinn: Yeah. All of these things are really hard to do on your own. Basically what this interview is telling me about hips and knees, or at least hips so far, is that it’s really, really super helpful to have somebody working with you on it who is an actual expert [laughs].
Esther Smith: Yeah, and that’s where maybe in your area you don’t have an awesome PT, but you have a really good Pilates instructor. Maybe that’s somebody who can just help you right out of the gate with this injury. I don’t know. The hip and knee isn’t dissimilar from what we have encouraged people about in the shoulder too. The shoulder is just as, if not more complex than the hip. But yet, people who have listened to the podcast that we’ve done and have maybe checked out the self-treatment videos or whatever, have gotten better. You’ve heard that feedback. Yes, it’s so helpful to have people working with you, but if you are at a loss for that in your area, that little sequence and that self-awareness and assessment, and avoidance of the things that piss it off- that’s probably also maybe the number two strategy.
Really look at those movements, positions, see how they could maybe be faulty. How can you make them better, the ones that are making you hurt? Or avoid them for a certain period of time, modify, that can do so much too. If your hip pain is always happening when you sit, that’s probably telling you something about how much you are sitting or how you are sitting, and what could you do to make sitting better? If it’s always happening when you are standing and walking, then how can you strengthen the musculature in a way where you are more supported in a standing walking position. That’s really how I end up answering these questions, when people are right in front of me- it’s just that you have a partner in it and it’s way easier. But for people that don’t, I think there is a lot that you can do.
Neely Quinn: Okay, so we only have about ten minutes-ish left, and I don’t want to leave the knee out here. There are a lot of different knee issues that people have. People are like “I have this pain on the inside of my knee on sort of the back side”, or they have it on the outside of the knee, or right in the center of the knee. Can you talk about what those pains might be coming from?
Esther Smith: That’s absolutely common. That’s what people come and tell me too. We go back to what we talked about, those original most common injuries. Anywhere around the knee that you are pointing to that might hurt, the question is, is it coming from the joint structure, or is it coming from more of the external musculature? The joint, in climbers we see that derangement, that displaced tissue- the meniscal tears or meniscal strains on the inner aspect of the knee. Then the same is true for those collateral ligaments on the inside more than the outside, because a lot of the forces that we have with climbing are more drop knee type forces. Whether you are drop kneeing or not, you’re still pivoting your knee in that direction and putting more stress on your knee that way than you are to the outer structures.
The same is true, like I said about the hip, you have to try and decompress the joint, bring balance to it. The knee is interesting because it’s a joint where, like our hip in a lot of ways, there is musculature coming from above and below that attaches to different joints, like the ankle, or the ankle or above at the hip. You get these pulls and torques on the musculature that then pulls and torques at your knee. A lot of times when people are pointing to those areas, if you can identify that you feel like it’s actually a distinct muscle or little group of muscles, then you can say, well that muscle- does it need to be stronger? Does it need to be longer? Does it need to be massaged out? You’re basically going to that same system we talked about. Do that self-massage around there, try to break up knots or adhesions, stretch all the musculature 360 around the knee. A good calf stretch, front chin stretch, quad stretch, inner thigh and hamstring, check all those out.
Then you want to strengthen around the knee. A lot of that can be accomplished via the hip strengthening. So the things that you do at the hip- the bridging, the bird dog, the planks, the squats. They all positively affect the knee, as long as you are hinging your knee really well. One thing we see among athletes in general, you look at them stepping off a step, or coming out of a squat. We see that there is this joint, our knee, that is supposed to function like a door hinge- which is basically the hinge front and back. But what we see in people who have problems is that the knee is diving inward or outward, or your arch is collapsing in your ankle and that’s affecting your knee, or your hip is doing something funky and your knee is under some weird torque where the hinge just doesn’t get to work perfectly in the front-back plane of motion.
If you are having knee pain, it might be because of that. It might be because the mechanics and how you are tracking your knee, hip and ankle isn’t great. You’re constantly wearing, tearing, stressing and straining across that joint. Making sure that you understand how the body is supposed to be used and how those joints are supposed to work- again we go over all of that in our videos. We are kind of trying to disseminate that information so people can be their own body mechanic and figure it out a little bit. Look at yourself when you do those things and correct for them.
If your knee hurts every time you squat deeply- and that might happen on a hold, where you are going into a low froggy squat and powering up or lowering down- look at how the hinge is being used and see if you can make it feel better by using it more appropriately. Then in the knee, I think we get muscular strains, like calf strains, because of heel hooks or toe hooks- these events where we feel a pop and a failure of tissue. I think it’s important any time you have a hamstring or calf tear or strain, where you feel that sudden onset of injury, that you immediately rest and don’t use it. It would actually be a lot like if you felt a pulley pop in you finger, same type of deal. Stop climbing, stop moving, give it a week or two to see how bad it is and asses the severity of your injury. Gentle mobilizing, active stretching, ice, all that initial inflammatory phase therapies are really important for those injuries. Then, slow graduated progression to baby strengthening and getting whatever muscle was involved in that stress, strain or pop, just slowly reconditioned is really important for those injuries.
I think for prevention, if you want to avoid those, we need to be doing those things for our hips and knees as a maintenance program, and as part of our climbing warm up at the crag or gym. Making sure we aren’t climbing cold and going into some big high step and then boom, we pop our hip flexor, or our first heel hook of that day and you feel our hamstring go. Maybe we could have done one or two things before we got on the wall where we warmed up our musculature, and then we don’t have that problem. Then we stretch really well, we do self-massage, and then we keep long and strong through that lower half and we are gong to be way less susceptible to injury there.
Neely Quinn: Can you name a couple of things that people can do to warm up their hips and knees at the crag?
Esther Smith: Just air squats are awesome. Just standing there, hinging your knees in that front-back plane, they’re living just above your first and second toe, not going too far over your ankles. You can go into side lunge positions, and kind of go back and forth and mobilize your hips that way, and your knees. Even just a decent hike up to the crag is nice, and a lot of times we don’t have long approaches so we don’t get warmed up that way. Doing things to just circulate and warm up, whether it’s as simple as jumping jacks, air squats, lunges, maybe a sun salutation sequence that you would do in yoga. Just go through some of those lunges, stretches and hip openers, those are fabulous. In our Climber’s Kit we have a ten minute warm up at the start of it that goes over my favorite warm up strategies, and includes all of these nice hip centric, knee centric things, as well as what we need for our trunk and upper extremities as well.
Again, I was at this Eva Lopez workshop, and she did her favorite warm up routine. It’s as simple as move every joint. Move your neck, move your shoulders, move your elbows, wrists, hands, fingers. Do side-side of your trunk, left right rotation, and then do some squats with your hips. Open your knees out, do some froggy, squatty, lungey stuff. Do heel toe raises, just circulate, move, get every little bit of your body ready. Then you are good to go. Start hopefully on some warm up climbs that actually prepare your body a little bit before you get on your project or something that’s hard. It doesn’t have to be too complicated.
I think we have shorter approaches maybe, we get out there and it’s a little bit cold, we haven’t done anything and then we go get on a climb, and that’s where injuries happen. Or they happen when we are fatigued and we are on that last move, or last heel hook, and that tissue fails. Either way, we probably could have prevented that by being better with our general maintenance, just every day as climbers. Appreciating that the whole body needs to be maintained, strengthened, balanced, stretched and mobilized. Then certainly when we are approaching our climbing day, what can we do to do a really good warm up to just prepare our tissue. And, realize that our performance will improve if we have stronger cores, and our hips are part of our core- it’s part of that powerhouse. If we can really pay attention to our footwork and our lower extremity movement, our mechanics and development will offset our more common upper extremity injuries as well. That goes to the warming up and the maintenance at the crag, or just in general. If we are better at that we will be less prone to injuries all over.
Neely Quinn: Nice, I think that about covers it, unless you can think of something we didn’t talk about.
Esther Smith: Gosh, I think we covered a lot of it.
Neely Quinn: Yeah. There’s a lot of different injuries with hips and knees, but it seems like the main prescription is the same. You do some things to strengthen, you do some things to stretch, you warm up, and you do some massage, whether by yourself or having somebody else do it.
Esther Smith: Yeah it’s very true. Look at what’s weak, look at what’s imbalanced, and look at how you are using your body. You can’t just lay there and stretch and strengthen and massage. I you don’t go and functionally use it better. I think maybe part of that gelling for people is to make sure that when we are actually doing our exercises, or climbing, that we are transferring what we learned and what we know to function, and to using our parts like they are designed to be used. That’s just a thing that people can explore by going to workshops and seminars, observing really good movers, finding a Pilates provider, working with different providers in your community- coaches, trainers. They’re going to help you understand that, and if we can do that, that is part of the prescription. It’s not just the arbitrary slapping on of those various exercises, or those parts of fitness. It’s also really how we end up using our body and avoiding this wear and tear problem that we get as athletes, particularly climbers. So yeah, that’s a good sum up.
Neely Quinn: Where can people find you on social media and online?
Esther Smith: We are @grassrootsphyiscaltherapy on Instagram and Facebook. Online we are grassrootsphysicaltherapy.com, selftreatment.com has all of those sixteen videos for the whole body and sports specific for climbers. Hopefully more to come with you Neely, and maybe some articles and things coming out on your blog. I hope to contribute to that as well. Maybe we can tackle some of these topics and subjects that haven’t really been flushed out for our sport quite yet, and continue to try and search for answers for us.
Neely Quinn: Yeah. Well thank you for your knowledge, thank you for your well spoken wisdom, and thanks for being on the show.
Esther Smith: Yeah, thanks for having me again and for all that you do.
Neely Quinn: Yeah, you too.
I hope you enjoyed that interview with Esther Smith. If you are in the Salt Lake City area, or if you are willing travel, I highly recommend going to see her and working with her. You guys are super lucky in Salt Lake [laughs].
Coming up on the podcast, I did an interview recently with an alpine trainer and guide, who’s name is Zahan. He goes by “Z” as well. That should be coming up in the next week or so. I think that’s it. Like I said in the beginning, please, please send me your input about what else you want to hear about on the podcast, and how I can help you with this podcast. My e-mail is firstname.lastname@example.org. That’s N-E-E-L-Y. Another quick reminder that you can give gifts to your loved ones and friends who are climbers through training beta. If you want to give them a training program, just go to trainingbeta.com. You can find all of our training programs there, and at checkout you’ll find a box you can check that says this is a gift. Otherwise if you don’t want to deal with that, you can always e-mail us at email@example.com and we will make you a gift certificate or whatever you want so that you can give the gift of training.
Thanks for listening all the way to the end, and I’ll talk to you soon.