If you haven’t read part one, please do so now, especially the part about anaerobic versus aerobic exercise. You need to understand the difference between anaerobic and aerobic exercise for many of my recommendations in this post to make sense.
To very briefly summarize, anaerobic exercise occurs when you are forced to start breathing through your mouth and can no longer comfortably carry on a conversation while exercising. If you're out of shape, even a brisk walk or climbing one flight of stairs can quickly put you into anaerobic.
Now how is anaerobic exercise related to pain and performance? Excessive anaerobic exercise physiologically increases inflammation and the generation of damaging free radicals in the body. Anaerobic exercise also leads to a breakdown in exercise form.
Just notice what happens to your running, cycling, or swimming form when you start breathing heavily through your mouth (a marker for anaerobic exercise). A breakdown in form increases your risk of injury. All of a sudden your body weight is abnormally shifted more to your feet, resulting in common conditions like plantar fasciitis, or to your knees, back, neck and/or shoulders.
If you play sports like tennis or basketball, pay attention to what happens with your performance. Playing sports predominantly in the anaerobic zone produces leg fatigue, a breakdown in form, and deteriorating hand-eye coordination, leads to more missed shots. If you were more aerobically fit, it would take longer for you to reach the anaerobic zone of performance breakdown.
In elite athletes where skill levels are fairly level at the top, it's often the fitter athletes who prevail because they can maintain their high level of performance for longer. Think Roger Federer in the 5th set of Grand Slam finals, easily outlasting younger opponents due to supreme aerobic fitness.
Poor form and anaerobic exercise produce a vicious cycle. When you exercise with poor form, and inadequate strength, you enter anaerobic zones more quickly which in turn breaks your form down even further.
Can You Sit “Indian Style” (aka Lotus position)?
I remember when I was younger and attended various Indian cultural and religious events, I would notice kids and younger adults sitting cross-legged (aka “Indian style”) on the floor while more senior folks and/or those with disabilities would sit in chairs along the walls or the back row.
Now when I attend these events, I find most kids, teens and young adults (especially men) unable to sit cross-legged. I used to be like this too until very recently. Even when I did sit cross-legged, because my hamstrings were so tight, my upper back would be hunched.
I know many female readers may think sitting cross-legged is easy, but keep in mind that the female body, specifically female pelvic anatomy, was designed to allow the safe passage of an infant through the birth canal. Most men are not naturally blessed with such flexibility, and behaviors like prolonged sitting tend to have a much more adverse impact on our posture and flexibility. This is why men need to work extra hard on flexibility and engage in activities like yoga rather than just doing cardio and weights.
As I reflect on my grandmother and other elderly relatives, they had the ability to sit on the ground in various postures for prolonged periods cooking a full meal while maintaining a remarkably erect posture. Full meals would also be eaten off a banana leaf or steel plate on the ground. Chairs were minimally used in my ancestral home in India.
Not only did my relatives sit on the ground effortlessly, but they were also able to get up from the floor with relative ease, and interestingly the ability to rise from the floor with little to no assistance is actually a diagnostic test called the sitting-rising test or SRT, which can predict your risk of death.
This study from the European Journal of Cardiology showed that individuals who scored fewer than eight points on the test were twice as likely to die within the next six years compared with those who scored higher.
Those who scored three or fewer points were more than five times as likely to die within the same period compared with those who scored more than eight points. Each point increase in the SRT score was associated with a 21 percent decrease in mortality from all causes.
I strongly recommend you take the SRT and below is an excellent video to teach you how to score it. It is a deceptively difficult test to get a perfect score on, but I smile as I think of how my late grandmother in her eighties could have easily outscored my average 30-year-old desk bound Silicon Valley engineer!
The inability to sit comfortably on the floor with a relatively upright posture is one of many signs of our deteriorating form, posture and flexibility, while having difficulty rising from the floor also indicates a deficiency in leg strength.
Signing up for long distance running events, boot camps and complex workout classes when your body is in no shape to take on such activities puts you at risk. Yes, we often “get away” with our weekend warrior activities, but over time for most modern adults, some form of injury is on the horizon.
My clinical practice is focused on lifestyle practices to prevent and reverse insulin resistant conditions (diabetes, heart disease, cholesterol disorders, obesity, etc.), but I also encounter so many people suffering from needless pain and injuries because of a lack of basic strength and flexibility which can easily be gained by performing some simple exercises. When my patients get injured, they become sedentary and their metabolic numbers (cholesterol, blood glucose, etc.) deteriorate rapidly along with their mood.
So although I'm not a certified personal trainer, I am passionate about prescribing exercise to my patients (and readers) in a way that maximizes enjoyment and minimizes injury. The following sections are a compilation of what I think are some of the key fundamentals of posture and strength that can help you achieve most of your physical goals with the least risk and pain. Some of these exercises have helped me personally overcome nagging injuries and have done the same for my patients as well.
Prioritize These Muscles to Improve Performance and Reduce Pain
Working out for many of us is an exercise in vanity. We want to feel good, but we also want to look lean and strong. As a result, many of the exercises we choose as part of our workout involve muscles that are easily visible like anterior or front-facing muscles…think bulging biceps and strong chest, especially for men.
However, the real muscles that give us true power and protect us from common injuries are less visible and usually neglected. These are what we refer to as our “core muscles” which wrap around the front and back parts of our torso as pictured in the image below.
“Core strength” is probably the most overused term in modern exercise, but I have to admit that it is the absolute foundation for optimal posture, performance in virtually any sport, and injury prevention.
If I were a physical trainer I would absolutely require that each of my clients develop a strong core before they engage in virtually any type of exercise or activity, from running, to lifting weights, to participating in nearly any high intensity exercise or bootcamp style classes. This would dramatically reduce the number of aches, pains, strains and serious injuries and maximize long-term fitness and enjoyment.
This is because your core muscles are the central engine from which strength and power originate, while your arms and legs are the peripheral levers that perform a particular exercise. When your core is weak and not engaged in an activity or exercise, you apply significant force to the levers (arms and legs) and their joints (shoulders, knees, hips, etc.). Over the short term you can injure the levers and their joints, and over the long term you can wear out your joints, leading to degenerative arthritis.
Although there are multiple muscles that make up your core (see image above), there are just a few key exercises you need to perform to condition your core. The following are my favorite. They have helped eliminate many of my joint aches and pain (low back, upper back, and plantar fasciitis). I've included relevant images and links and exercise goals where applicable.
This is the most fundamental of core exercises and should be mastered by everyone unless they have a physical limitation. Below is an image of a proper forearm plank position. You can also plank on your hands like the top of a pushup position, but I prefer the forearm plank
Some Additional Tips:
- Tighten your abs and draw your belly in
- Keep your buttocks and thigh muscles tight
- Keep your knees locked
- Keep your head/neck relaxed
Basic Plank Targets and Variations:
- Aim for a basic plank time of between 90 seconds to 2 minutes. There is no need to surpass that. Instead do the variations below. Longer is not better when it comes to plank time and if you are trying to set a record, you need to beat 8 hours, 1 second which is the current record to date! If you cannot do a basic plank, you can drop your knees to the ground and do a “half plank” instead.
- Single leg plank: So once you hit a goal of 2 minutes, you can start challenging yourself with single leg planks where you lift one leg off the ground, hold it for maybe 5-10 seconds and then alternate
- Single hand plank: Now try single hand planks where one hand is on the ground and the other reaching forward
- Single hand-single leg: This is where you reach forward with one hand and then raise your opposite leg (right hand forward with left leg raised and vice versa).
2. THE SIDE PLANK
I especially love the side plank because it immediately identifies asymmetries in strength based on differing hold times and allows you to correct asymmetries. For example, my right side plank used to be stronger than my left but now both sides are more even after some extra work on my left side. See the image below which I like since it labels the various core muscles that are engaged:
Some Additional Tips:
- Like the standard plank, keep all your muscles contracted, especially abdomen, buttocks, and quads. Your body should be a straight line
- Keep you belly button pointing straight ahead of you, not up or down
- If you can't do a standard side plank, drop your knees to the ground for a half side plank
- A target time for side plank can be between 45-60 seconds. Once this is achieved, start doing challenging modifications like lifting your top leg in the air and holding for a few seconds.
Once you get your front and side plank down, there is a whole world of different exercises you can do to challenge yourself. Check out this workout by my colleague, Reena Vokoun, who worked in the heart of Sillicon Valley for many years, and is now the owner of Passionfit. Sign up for her free videos here
3. SWISS BALL EXERCISES
If you don't own a swiss ball, I highly recommend getting one. This takes core exercises to the next level and I find them more fun to do as well.
- Stir-the-pot: This is one of my all-time favorite core exercises. It works all of the major core muscles in one shot. If you've mastered the plank (can do 2 minutes), stop wasting time doing longer planks and start stirring the pot! Watch the video below:
I now do a variation of stir-the-pot where I draw out the entire alphabet with the swiss ball. So the swiss ball is like a giant crayon and then I trace out “A-B-C-all the way to Z.” This makes me move the ball in various directions working my core in myriad ways. It's an incredible workout. Maybe you'll start off tracing 3-4 letters with your “core crayon,” but pretty soon you'll be doing the entire alphabet.
4. WORK YOUR GLUTEUS MEDIUS
I call this the magic muscle since it can be linked to so many different pain conditions. Working and conditioning this muscle I think was key to eliminating my plantar fasciitis (common, painful heel condition), knee pain and low back pain. It also helps you run faster (as does a conditioned core).
The gluteus medius is located on the upper outer part of your buttocks as highlighted in red in the image below. It is technically part of your core muscles, but I thought it deserved some special emphasis since many people doing more common core exercises may still have weakness in this muscle if they don't target it more specifically.
The gluteus medius muscle keeps our pelvis stable during activities like walking, preventing our leg and foot from crashing down onto the ground. Essentially, when you lift your right leg to walk, the gluteus medius on the left side will contract to keep your pelvis stable, and enable a more controlled lowering of your foot to the ground.
If your gluteus medius is weak, each of your steps imparts significantly more force to your feet, ankles, knees, hips and lower back. This study shows how strengthening the gluteus medius helps knee pain in patients after knee surgery, while this study shows how it helps patellofemoral syndrome, which is the most common cause of knee pain in individuals without injury. I have many sedentary patients who complain of knee pain and when I ask them to develop their gluteus medius, their knee pain magically disappears.
Plantar fasciitis is a very common cause of foot/heel pain in modern humans. The typical regimen to heal it usually involves a variety of interventions like calf stretches, rolling the foot on a frozen water bottle, etc. but my plantar fasciitis (and that of many others) never fully healed until I combined these standard measures with exercises to strengthen my gluteus medius. This is a good article that explains the connection between your core muscles/gluteus medius and pain in the foot/ankle joint.
Finally, since we're discussing common painful conditions, what about good ol' fashion low back pain which most humans will suffer through at least once in their life. It's so common that I dedicated a separate post on it here, where I do mention the gluteus medius. Below is a section of the image graciously shared by back pain guru, Esther Gokhale which very clearly shows what a developed gluteus medius (I circled it in red marker) looks like in real life.
So bottom line is if you are experiencing a painful condition (especially involving your feet, ankles, knee and/or hips) that isn't going away with standard exercises, I would consider focusing your energy on developing your core with an emphasis on your gluteus medius.
Hopefully I've convinced you that the gluteus medius is truly a “magic muscle,” and now it's time to teach you how to develop it and hopefully eliminate some of your aches and pain, in addition to improving your exercise and athletic performance.
Some great exercises that target the gluteus medius include the following:
1. Hip Abduction Exercises: These are exercises that involve moving your leg away from the center of your body and can be done while you are standing or lying on your side. You can do it without additional resistance when you start, but then you can add in resistance bands or ankle weights to make it more challenging. Below are some examples. I usually do these exercises while pushing my thumb against my gluteus medius muscle so I feel it contracting/bulging against my thumb during the exercise.
2. Glute Bridge Exercises: These exercises are done on your back and involve your pelvic thrusting upward while you tightly contract your core and buttocks. You can start with both feet on the ground and then progress to single leg glute bridge (see images below).
5. THE SQUAT
Squatting is an essential exercise that our ancestors used to do well, but that we no longer do thanks to the modern chair. Squatting maintains leg strength and hip mobility. Below is an old video instructional I did on squatting which includes modifications for seniors also. I do squats throughout the day as a break from sitting to maintain leg strength and flexibility in my hips. Set a timer and do a few squats every 20-30 minutes while you sit at work or in front of the TV.
Once you master the regular squat, try single leg squats like my favorite, the Bulgarian split squat. Start without weights and as you get stronger you can hold dumbbells while doing this.
Few Words on Flexibility
Sitting for a living has multiple adverse effects on our body which I can't summarize in one blog post. If I were to recommend one area to focus on for flexibility, it would be on improving hamstring mobility.
Tight hamstrings throw off the biomechanics of your entire body, causing your low back to arch and strain, your upper back to round forward like a turtle, which in turn pushes your 10 pound skull forward, exerting force on your neck. Tight hamstrings also transmit pain down into the soles of your feet, predisposing individuals to conditions like plantar fasciitis, which we discussed earlier.
There are multiple ways in which you can improve hamstring flexibility and most of these involve you reaching with your hands towards your toes. This link has some great hamstring stretches. One key for me personally was keeping my back straight and bending from the hips rather than rounding my upper back. This simple modification completely released some residual tightness I had in my lower back.
I am also a big fan of using yoga straps with handles like below.
Another key tool for loosening taut hamstrings is by rolling your hamstrings on tennis balls like below. I often put tennis balls under my hamstrings even while I sit in my office chair, rolling back and forth to loosen tight areas. Even rolling your feet on tennis balls while standing not only provides a great foot massage, but also helps loosen hamstrings as well.
We covered a lot of ground in this 2-part series on exercise. Just want to summarize a few key points:
- From part 1, use some form of heart rate monitoring to determine your aerobic and anaerobic zones by applying the Maffetone formula (180-Age). See the post for details
- Build a strong aerobic foundation and then layer on a couple of anaerobic workouts each week. Don't make anaerobic your exclusive or predominant form of exercise, especially if you lack a strong aerobic base
- Assess your basic core strength and flexibility with some standard tests: Take the sit-rise test (SRT), measure your front and side plank times, assess your hamstring flexibility. Work on improving these first before you ambitiously sign up for a race or a high intensity exercise class.
- Question any trainer who fails to emphasize perfect form with exercises, or who continuously puts you through high intensity workouts that leave you mostly in pain with little recovery time
Nearly every exercise I've discussed in this post can be done without visiting a fancy gym or fitness center. You can do them in your office, at home, or a hotel room while you're on business. Exercise should never feel like torture. If it does, then you have either chosen the wrong exercises or are doing them incorrectly.
If you work every day for even a few minutes on strengthening your core (don't forget the gluteus medius!) and hamstring flexibility, you can eliminate multiple areas of pain and take your fitness and athletic performance to another level, while reducing your risk of chronic health conditions.
I also love the adrenaline rush of doing high intensity exercises and the “pumped up” feeling of lifting heavy weights, but nothing compares to the feeling of having a stronger core power all of your everyday activities and fitness pursuits, combined with improved flexibility that gives you the freedom to live and move without pain.
-I strongly encourage you to check out the blog post and especially the videos at the end made by my good friend and colleague, Dr.Peter Attia here. I've planned to do a similar set of videos for a while, but am now happily postponing that project thanks to Peter's masterpiece video shorts with posture guru, Jesse Schwartzman.
–Esther Gokhale is a dear friend and global posture guru helping people all over the world overcome chronic back pain. Check out her work here
-Check out the growing library of videos and resources at Passionfit
-Kelly Starrett is a renown PT and sports trainer with revolutionary approaches to improving performance and preventing/reversing pain. Check out his Youtube channel for innovative, high energy and often entertaining videos on healing common aches and pains while improving form.