Building the Ultimate Back - Stuart McGill

Below are my notes from Dr. McGill's "Building the Ultimate Back" workshop hosted by MSK+ on November 20-21, 2010. A total of 32 pages of notes were taken throughout the weekend.

Prior to reading the following, I kindly ask that you take two things into consideration:

• The notes were subject to my interpretation and therefore may not be 100% accurate
• All statements made have context. There are no absolutes and the suggestions presented depend on the context upon which each statement was made

Enjoy!

Page 1

Range of motion and strength do not necessarily correlate with recovery

• Achieving new range of motion (stretching) does not necessarily change movement patterns
• Evidence on the Transversus Abdominis is dying out
• Find motions, postures, and loads that make the individual worse. Then take it away and check again

"Build capacity within tolerance within an injury mechanism that is part of their sport"

• Injury = Load > Tolerance
• The culminating event is rarely ever the cause of a back injury
• Very rarely is a max 1-RM lift a mechanism of injury
• It's not the load that causes the injury, it's the amount of strain
• Tolerance - the amount of load a tissue can take right now
• Capacity - the sum of the work that they can do before they break into pain. Train within the capacity every day with enough rest and the capacity will increase

"The Lats activate natures 'back belt'"

• Longissimus Thoracis - The biggest back extensor is a thoracic muscle
• Most patients hurt their back in shear before they do in compression
• Fatigue is a killer of protective movement patterns. Just because they move well, it doesn't mean they will

"Scientists set up experiments in order to find what they're looking for"

• The contribution of the Rectus to flexor torques is between 10-15%
• The Rectus is not designed to change length
• Sit ups are designed to use the obliques
• Core elasticity - short range stiffness to allow the extremities to fly
• Psoas not only acts as a hip flexor but also to lock the pelvis to the lumbar spine
• Spinal Manipulative Therapy - to reset the neural system via the intertransversarii & small rotators. These are the proprioceptors as they are the most spindle rich muscle fibers
• On neuromobilization and nerve flossing - it is important that we get the bulge down prior to flossing

"The squat is a hamstring exercise until you get halfway down. Then it hits the glutes"

• The upper and lower glutes have different neuromuscular components. The lower fibers are active with a deep squat and the upper fibers with an external rotation load.
• Bent knee sit ups - 3400 N of compressive load vs. Straight leg sit ups - 3200 N of compressive load (NIOSH limit = 3400 N)
• Dr. McGill is less worried about the differences between the bent knee and the straight leg sit ups. His concern:

"What a stupid exercise!"

• Always start a painful low back in the sagittal plane to build tolerance. Then progress to the frontal and finally to the transverse plane.
• It is not only about muscle activation but also the corresponding load on the low back.

"The orientation of interspinous ligaments are backwards in English anatomy texts"

• Latissimus dorsi is important for stabilizing the upper lumbar spine
• Compressive load generally stays the same while shear loads decrease with a neutral spine
• Muscles create force linearly with neural drive
• Muscles create stiffness asymptotically (stiffness always stabilizes the spine)
• Symmetry of stiffness is important
• Stiffness can be created at relatively minimal forces in order to create co-contraction. Too much force is detrimental
• The risk of injury is present at very low and very high levels of activation...depending on the activity
• On the use of ultrasound - there is no relationship between the amount of muscle thickness and electrical activity. Muscles are found in layers, some muscles just go along for the ride
• Extending the hip with hamstrings jams the head of the femur anteriorly into the labrum. The glutes pull the femoral head posteriorly

"Building strength too soon may keep people chronic"

• There is no best stabilizer muscle. It changes all the time.
• What is a good stability exercise? Anything that creates a movement engram / pattern that creates stability...with decreased spine loading and sufficient muscle activation

"Abdominal hollowing is pathological"

• The pelvic floor and the abdominal wall have an inverse relationship. Stop a fart, create a fart
• We must divorce the diaphragm from the stabilizers. We must be able to breathe through the brace. (note: the diaphragm has two functions, respiration and posture/stability. In the presence of fatigue, respiration will always win)
• "I'm a marathon runner"..."Well good for you, because you're not a good athlete". A good athlete is someone who can be dexterous while sparing their joints
• Intervertebral discs really do not compress very much. They push on the end plate and as a result, the trabeculae compresses.
• Endplate disruption is of the transverse trabeculae
• Schmorls Nodes - are actually endplate compression fractures
• Posture will make your spine stronger by 30%. If you want to hurt your back, break form!

"The spine will break at 18% less load in the morning"

• Endplate fractures - decrease the space between the vertebrae and increase the load between the facets. This results in extension intolerance

"Stop treating your spine like a ball and socket joint"

• Degenerative disc disease vs endplate fractures. DDD never occurs at a single joint segment, you're more than likely seeing an endplate fracture so find the mechanism of injury
• Provocative testing will show you where you can and can't take loads
• From Noyes' research - ligaments avulse under slow load and tear at the midsubstance with high/rapid loads
• Disc injuries are a result of delamination. Fatigue injuries vs torn collagen. "Nuclear worms" work their way between layers over time resulting from a very specific movement pattern - repetitive flexion / extension under load

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"Nuclear worms" respond well to McKenzie techniques...if there is adequate disc height left

• Radial herniations are a result of flexion + torsion
• Limacon-shaped discs are sagittally strong - have very focal injuries
• Ovoid-shaped discs are rotationally competent - have diffuse pattern injuries

"Patterns of herniation are patterns of repeated stresses which are patterns of movement patterns"

• Sloppy pushups work...but only if they have 70% of their disc height left (for a hydraulic effect). Unfortunately, they also traumatize the facets
• Sitting is ok for the virgin spine. But not ok to a spine that has even a little bit of an injury

"There is no bad exercise...just bad form and inappropriate loading parameters"

"Do you know one world class athlete who does crossfit? I don't, because training to failure repeatedly outpaces the opportunity for repair"

• Remove the cause of their trouble before you recommend therapeutic exercise
• We must identify what is tolerating, exacerbating, and relieving
• There may be a correlation between a sports hernia and the inability to hold a side bridge for > 70 seconds
• Poor side bridge performance predicts one's sitting posture
• Instability "catches" disappear with exercise therapy and motor training
• The presence of a lumbar spine hinge often demonstrates a necessity for the latissimus to contribute to stability
• Weakness vs lack of motor control - if the brain can clean it up, it's likely a motor control issue
• Use the quadruped rockback to find out how wide you need to be to squat, get out of a toilet, etc
• Scottish hips - have a deep socket but a prominent rim
• Ukrainian hips - have a shallow socket and round hips

"The best QL training is to go for a walk"

• If you can get a nerve to floss, it will find its own pathway (but remember, we must first remove the cause of irritation
• The fundamental emphasis of the Glutes is not extension but external rotation
• Manual biofeedback - to stimulate muscle contraction, brush lightly against the grain of hair
• Know the following characteristics of pain: skin, bone, nerve, ligament, muscle, fascia, peritoneum
• The Internal Oblique and the Transversus Abdominis are twins - they almost always work together
• What is a stabilization exercise? - Anything that grooves motor patterns to ensure sufficient stability

"Follow the endurance pathway"

• The cat/camel is a mobility exercise, not a stretch. Optimal number of cycles: 6-7
• When performing the curl-up, the cue is to "unweight the head, neck and shoulders to make the scale weigh 0". Don't forget to dissociate breathing

"The curl-up really isn't a curl-up"

• The highest level of clinical vigilance will get you better. It's not just the exercise, it's owning the exercise
• In the presence of a diastasis recti, play with the pushup progressions
• Sweeing the floor in the bird dog induces new blood perfusion
• The most difficult patient won't fit in a traditional category. Therefore we must only add one new challenge at a time in order to identify what gets the better or makes them worse
• When qualifying an athlete for training - know their demands, capacities, deficits, and special risk of injuries

"Don't train the failed tests, train the reason why they're failing"

• Everyone has a limited capacity...use it wisely
• Stretching prior to performance - in some instances we may want to inhibit specific muscles
• The bench press - a grinding exercise that teaches neural capacity. Use the brain to get through sticking points

"Core strength makes the impossible, possible"

• The best spine challenging and sparing exercise for the anterior chain is a staggered pushup
• Spine Power = P = F x V. Always keep one of these at zero
• Speed comes from relaxation - you get quick by relaxing muscles
• Bracing needs to act like a dimmer switch - to tune and be ready at 20-30% MVC
• < 20 % MVC - won't get enough elasticity
• > 30 % MVC - will be too stiff and will not be able to get springy

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