Stop “Hanging Out” on Your Joints

thoracic and neck posture

Growing up, our parents and teachers nagged us to sit up straight. And they were right to do so. I see people hanging out on their joints all the time, instead of utilizing their postural muscles to keep them upright. Improper posture not only puts excessive stress on your joints but also your ligaments and muscles, too. Over time, this could result in damaged joints, increased pain, or poor movement patterns. Although we know it’s important to have proper posture, why is it so difficult to do? Our lifestyles and technology work against our efforts to have better form. In this post, I’ll focus on our lifestyle choices that impact our joints and will post a follow-up blog post on how technology impacts our joints.

Shoes Impact Foot Muscle Development

We start wearing shoes before we can walk causing us to never develop the muscles in our feet. The benefits from the support provided by our shoes is offset by the lack of development in our foot muscles resulting in flat, unresponsive feet. Collapsed arches can occur through “hanging out” on the arch to hold your body weight up. This will stretch the ligament supporting your arch, eventually resulting in a flat foot. This why a lot of people are not ready to transition to “barefoot” running or a minimalist shoe because they can’t control their feet.

foot posture collapsed arch

Knee and Pelvis Lockout

At the knees, a person can lock their knees out into hyperextension causing posterior knee pain. I commonly see people hang out on their hips to the point of pain or discomfort and then when that occurs they switch over to their other hip until that one hurts.

knee posture hyperextension unlocked

In addition to their knees, people also lock out their pelvis in an anterior tilt thinking this is good posture until their back hurts, or they posteriorly tilt, sitting on their sacrum (a non-weightbearing bone) until their back hurts. Our lifestyle of sitting in our car, at desks or in front of the table at dinner time coupled with improper posture can lead to hip and back pain. Moving up to the thoracic spine where people hunched over and it looks like gravity is just beating them down. Since everything we do is in front of us, we let our shoulders fall forward, which perpetuates the issue at the thoracic spine, followed by protruding the neck and extending at the base of our skull just to look forward!

hip posture

Improve Your Posture Today

Although it’s easy to fall into bad posture patterns, there are many exercises that can help people of all ages improve their posture, awareness, and to combat the technology and lifestyles we have been enjoying. Here’s an exercise you can do today to improve your posture:

posture ergonomics kona hawaiii

  • Find a bare wall and place your low back flat against it, bringing your feet away from the wall to make this easier.
  • While holding the low back flat, bring your shoulders and head to the wall. Do this by bringing the shoulders down and back and performing a chin tuck at the neck.
  • Holding this for a count of 10 seconds for 10x is a good way to turn on the postural muscles and place you in a better position.

Read this post to find out how to make free and cheap workplace ergonomic improvements. Give us call or email us if you would like to work on your posture and we would be more than happy to assist you on your journey!

Don’t Slack on Your Balance!

slacklining balance training physical therapy

Including balance training in your daily routine is just as important as brushing your teeth. Life is constantly challenging us in ways that may increase our chance of injury if we are not prepared. Daily activities such as walking (especially on uneven surfaces), climbing stairs, and even getting in and out of your car might increase your fall risk if you slack on your balance maintenance.

Speaking of “slacking”, have you ever cruised by a park, only to have your attention captivated by a group of seemingly circus-like individuals walking across a thin line between trees, much like a tightrope but with less tension? If you haven’t seen or heard of it before now, welcome to the world of slacklining. This activity, which started as a general off-season activity for rock climbers, has developed into an increasingly popular outdoor activity aimed toward developing advanced balance skills while also encouraging a deeper connection with nature and the community. Much like other athletic pursuits, slacklining boils down to a few general components that are essential in everyday life. In addition to a focused mind, proper body awareness, and relaxed breathing, it is absolutely impossible to walk the line without good balance.

There are three general systems that work together to create a properly balanced body and can be developed with the help of a physical therapist. These include:

  • EYES: When we close our eyes, the whole world changes. Our vision gives us important feedback about our immediate surroundings, allowing us to plan accordingly. Have you ever tried to stand on one leg while closing your eyes? Taking one’s vision out of the picture will automatically make balancing more difficult, but it also makes the body work harder to use the other two systems which will only become stronger with time.
  • INNER EAR: Inside each ear, we have three small canals coated with a waxy substance which is home to tiny crystals. These crystals are sensitive to our bodies’ movements and respond any time the head turns or the body’s position changes, such as doing a somersault underwater. Without proper function, this particular movement would cause the world around you to spin!
  • PROPRIOCEPTION: Our position in space is constantly being assessed via tiny receptors in our muscles and joints called proprioceptors. This system is challenged by changing one’s base of support, such as standing on one foot, stepping onto uneven ground, or even a thin/shaky slackline hanging mid-air. When our proprioception is challenged, we rely on our vision and inner ear more; thus, a slackliner must gaze forward to focus his/her eyes on a stable spot while maintaining an upright head position despite the constantly moving body.

When you initiate your own balance training, you’ll be amazed at how challenging yourself daily can lead to significantly noticeable benefits.

So if the moment presents itself, get out and try something new and challenging, like slacklining! Or come up with your own home balance training practice to improve your balance skills. Meanwhile, be sure to check with your local physical therapist for a comprehensive movement and balance assessment to give the best of yourself toward whatever your passion may be.

Annual Assessments By Physical Therapists – Why Should You Care


Nobody waits until their teeth are rotting out to see a dentist. It is ingrained in us to see a dentist twice a year for a routine checkup because the health of our teeth is connected to our overall health. But what about the health of your musculoskeletal system? You use it every moment of your life from sitting to sleeping. With a yearly analysis of your movement patterns you can stop injuries in their track.

In today’s world, we see a pandemic of chronic neck, knee, shoulder and back pain.  Most patients who come to see us did not experience sudden injuries – they have suffered from slowly growing chronic pain. Most often these problems are either preventable or largely correctable by changing the way someone moves: sitting, standing, bending / squatting.

Chronic pain can easily result from lots of little injuries that add up during the day from moving incorrectly. If left uncorrected, improper movement can greatly accelerate degenerative changes within one’s joints leading to further pain and debility.

Don’t wait for degenerative changes to occur. See a physical therapist every year to discuss any minor aches and pains, correct any flaws in your movement patterns and benchmark your movement patterns over time.

Continuous Rehab: Sitting, Standing and Bending Properly To Avoid Neck and Back Injury

proper posture

Ok so rehab exercises are good for chronic neck and back problems but what about the other 23 hours of the day…?

This brings up a good point, exercise only works if you are making a habit of increasing your body’s awareness and posture.

Proper Posture and Biomechanics

For instance, exercises to help someone recover from a “slipped disc in the neck” are probably minimally efficient if the sufferer does not also change the way they use their neck.  I am a strong proponent that exercises for chronic neck and back pain only are effective if ergonomics and biomechanics are also changed to load the spine more evenly.

Unfortunately most studies within the field of physical therapy discuss in one form of treatment versus another, usually contrasting a particular set of exercises versus is leading different set of exercises to see which is more effective. Posture and proper biomechanics are highly regarded yet not widely studied necessarily when it comes to chronic neck and back pain.  This is probably due to the fact posture my mechanics would be difficult to study within a population of people going about their normal daily routines.

We in the physical therapy community has gotten fond of saying “some conditions can’t be treated, they have to be changed”.  I have seen many patients over the years that have tried seemingly everything to lessen their pain; – everything except for change the one thing that is probably causing the pain to continue.

I can’t say it enough, posture and proper movement – using the body how it is designed to be used is incredibly effective.

It seems strange in the advanced information age that we as adults have to be taught how to sit, stand and bend properly.  However – what we must remember is that the human condition has rapidly changed with the onset of the industrial age allowing for modern conveniences and repetitive stresses that are both detrimental forces for reshaping our bodies.

Anthropologist tell us that we are designed to stand, squat, and lie down.  We are not designed to sit in chairs.  This idea might sound far-fetched but in thinking of it, our closest relatives monkeys, apes and chimpanzees never sit on their rear-ends. They  squat or lie down.

In short, the body does not come with an owners manual and most injuries that come through our doors are either entirely preventable or at least somewhat preventable with the proper application of biomechanical principles.

Know Pain, Know Gain

Pain is the number one reason people seek out medical services, but how much do you know about your pain? As a medical community, I believe we are good at describing pain (acute, chronic, burning, aching, the dreaded 0-10 scale, etc), but how good are we at actually helping patients understand their pain? Pain is a subjective experience, meaning each person experiences pain differently. This is probably obvious, but how much thought have you truly given it? Pain has been proven to be impacted by many things including diet, stress, emotional state, physical activity, past experiences, setting, and beliefs. For example, most people would agree that if you sprain your ankle it will hurt, but what if you sprained your ankle while crossing a busy intersection or running from a dangerous animal? Your brain essentially makes a decision very quickly that it does not care about the danger signal from your ankle, because you are about to get hit by a car or become a meal for an animal! Once you get to safety however, the brain will decide that the danger signals from your ankle are now relevant and you will have pain. Another example is how people can have pain in a limb that is no longer there, “phantom limb pain”, and there are even studies showing that you can have pain in a limb that isn’t even yours!

Basically, my point is that pain is much more complex than injured tissues. One of the main concepts that I like to educate my patients on is that pain does not equal tissue damage. Pain is a warning or danger signal, much like an alarm, that something may be wrong within the body. Your brain makes the decision if something should be painful in order for action to be taken. That action could be removing the painful stimulus like a splinter or discontinuing an activity like running or going to your healthcare provider. But what happens if the pain persists after an injury or surgery and lasts months or even years?

When you have persistent pain it can be difficult to get an answer to “why do I have pain?”. Many tests, medications, injections, and potentially surgeries are done with limited relief or explanation. Generally speaking, our bodies will heal itself as best it can in 3-6 months. When pain persists longer than this it is termed chronic pain. This is where the sensitivity of the nervous system comes into play. Many things may actually be responsible for your pain while not causing any real tissue damage, such as applying light pressure to the skin or even prolonged sitting. Sometimes your nervous system or “alarm” can become too sensitive, much like a smoke alarm going off when you’re cooking. One of the main goals in patients with chronic pain is to decrease this sensitivity of the nervous system and re-conceptualize what pain really means. There are many ways to do this, but the first one is education. Here are links to some quick videos that discuss the concepts I mentioned here and more. Please take the time to watch and comment below. If you are interested in hearing more please contact our clinic and I will be more than happy to discuss pain with you or share the multiple resources that I have available!

Lorimer Mosely TEDx Talk

Understanding Pain: What to do about it in less than five minutes?

– Tyler Patrick, PT, DPT, ATC, CSCS

Christmas & Fitness Gadgets!

Okay, so this year on my Christmas list, I put down that I wanted gold, frankincense and myrrh.
For your own personal Christmas list, I complied a fun list of fitness related products below.
~Dr. Brett Carey, DPT

1. Solo Shot 2
The 2nd edition of an already great product. Solo Shot 2 is robotic cameraman that tracks you via a receiver arm band. I own the first edition myself. It has proved to be an incredible way to improve athletic performance through visual feedback.
 2. Apple Watch

There are still lots of unknowns regarding this device. What I suspect is that with a new tool Kit development program available, start ups will flock to make an abundance of apps. The new Apple Watch will probably have a better feature set than all current wearable combined.
apple watch
3. Waterfi ipod shuffle
Are you an aquatic endurance athlete? This waterproof ipod shuffle may be just the way to keep you from getting bored during long swims and paddle sessions.
P.S. I didn’t buy this device, instead I injected silicon grease for $7 and stuck my ipod shuffle in a ballon – seems to work well – try at your own risk!
4. Rumble Roller massage ball
I wouldn’t trade my rumble ball (extra firm) for any other myo ball. The spikes keep the ball from getting high centered around areas such as the shoulders and the hips.
5. Hitcase
Turn your iphone into an action camera. I haven’t used the Hitcase myself but intend to. Your iphone already comes with a great camera, why not use the camera you already have for your action sports needs?
I love surfing big, frightening waves, those are moments I want to remember for life. This product seems like a good outlet for storing such memories.

Workplace Ergonomics: Making free and cheap changes to your workspace

The cheapest ergonomic set up that I could possibly make.  Looking forward to seeing other peoples ideas on this topic!

The cheapest ergonomic set up that I could possibly make. Looking forward to seeing other peoples ideas on this topic!

I was talking to a patient recently about proper workplace ergonomics to reduce common problems such as carpal tunnel, elbow pains such as tennis and golfer’e elbow as well as neck and shoulder pains.

My patient really wanted to change his work station to accommodate some neck pains he was experiencing. I showed him how to set up his work station in order to avoid causing excessive strain to his neck region.

One problem arose: Like many underfunded workplaces, this particular patient wasn’t given any funds to change his work station and also did not have disposable income in order to buy accessories to make his mostly-desk-work job easier on his body.

He had a Macbook laptop that he was treating like a desktop computer. His chair and desk set up were okay and what he really needed was 1: an external keyboard or second monitor (to avoid looking down all day), an external mouse (to avoid excess side bending at the wrist). I am an Apple fan myself but must admit that Apple accessories are pricey.

Later that evening, I started thinking of how I could help this man feel better at work but also not spend much, if any money. Here in Hawaii us locals pride ourselves on our DIY solutions. In Hawaii the shipping for workplace equipment can cost more than the item itself.

Below are the solutions I came up with:

1: Air Display app: Cost: $10.00

Got an old ipad laying around? This app turns your ipad into a 2nd computer monitor and allow you to use the mouse and keyboard on your laptop. Simply drag content from your laptop screen up to your ipad screen.

This Fixes? The problem of causing excess cervical strain by looking down at a laptop screen all day. Position the Ipad on top of your desk and use the laptop on the desk pullout tray.

2: Printer paper box: Cost: Free!

Buy printer paper in bulk? Good! Take the box that the paper came in, place it on top of your desk and place the ipad with Air Display App on top.

3: RC Trackpad app: Cost: free!

Use your smart phone as your mouse

This Fixes? The problem of excessively side bending the wrist to the center of your laptop. Place phone to the side of your keyboard – where you would normally place an external mouse.

4: Cut up old mouse pad: Cost: free!

Have some old mouse pads lying around? If so, cut them in halves and glue them together in order to make a nice wrist rest in front of your keyboard.

This Fixes? Numb fingers; helps to minimize pressure on the wrists (carpal tunnel region).


In terms of fixing / preventing repetitive strain injuries common for desk workers, $10 can go a long way. I know these ideas may not work for everyone – dependent upon what hardware you are using at work. However, hopefully this will stimulate some new ideas and conversations. We are constantly coming up with new cheap, easy, solutions for poor works station ergonomics. Please email us with any questions or ideas.

Footwear Wars and Gait Analysis

In recent years the footwear debate has heated up.  Battle lines have been drawn between new distinctive groups such as the “minimalist” shoe folks and the “drop heel” traditionalists.
I have had so many patients come in with bags of shoes; hypersensitive to their shoe selections.  Some bring in barefoot running shoes and big bulky shoes and have no idea which direction to turn.  In some ways patients stressing about their footwear mimics the physical therapy professionals also stressing about how to advise regarding footwear.
I am still myself sorting out evidence and peer reviewed studies regrading footwear types.  Evidence and theories change so quickly that I have become determined not to make up my mind just yet…
Footwear war aside, I think its best to shift one’s emphasis to what you stick into the shoe — i.e. your foot.  I have seen plenty of patients bring in prescribed footwear from very highly skilled shoe fitters. The problem sometime being that you have the right shoe but still run / jog wrong.
The right shoe will still let you compensate for weak muscles and inflexible or injured muscle groups. The right shoe still may cause common injuries such as: plantar fascitis, patella tendonitis, IT band syndromes, etc…
My best advice: Footwear is important, bio-mechanical assessment is even more important. When analyzing / correcting your running – be process oriented and not just goal oriented. Know that running / jogging / walking correctly takes a very dedicated effort and an open mind but has big pay offs in performance. At our clinic in Keauhou, we analyze gait / running style of many athletes such as soccer players, 5ker’s and iron men participants. We used HD cameras, imovie software and the Uber Sense analysis app in an effort to paint the most complete picture of what is happening during movement.
Dr. Brett Carey DPT

For the General Public: Using as a resource

Have you ever googled: why does my knee hurt? Try it…

You will see a bunch of random information.  Some will pertain to a particular provider advertising their practice.  Some will suggest that your pain has dozens of different potential causes without really helping you figure out why your knee hurts.

The big problem with most health related web pages is that the web page doesn’t have the ability to interact with you.  Yes you can ask a question to the search engine, but the search engine cannot ask you a question.

Therapydia’s website does well to solve the above mentioned problem.  Best of all, the website is a free resource for anyone to use.  On our site, under the “For You” green box is a section called “Research a Condition.”

For You

Ask whatever you want regarding a particular injury / problem and a physical therapist from somewhere within the United States will answer.  Maybe your problem is an easy fix such as correcting the way you sit or lift an object.  Perhaps the solution sounds more involved and the therapist recommends you seek clinical care.

Although we don’t have the ability to solve all problems online, we do have the ability to start the process of gaining useful and specific information at the point of initial pain onset.  As a medical community, we have long sat within our “walled gardens”, tucking ourselves away in clinics and limiting our exposure to the communities that we are supposed to be serving.  Our ability to advance our skills and practices relies heavily on the ability of our communities to learn more about painful and debilitating conditions.

Please use and don’t wait until your first physical therapy appointment to ask your first question.

A Hui Hou,

Dr. Brett Carey D.P.T.