Treat Back Pain Without Surgery

treat back pain

If you found this blog article after going down a deep rabbit hole of investigating how to treat back pain without surgery, I hope you found us first. The adage “opinions are like assholes…everyone has them” originated after the first person searched “relieve back pain” on google. There’s a lot out there and from an experienced clinician’s educated opinion, most of this is all bad advice and information. The tips in this article can advise you on how to treat back pain without surgery.

The positive thing to glean from all this is that you’re not alone. Low back pain is the number one cause of disability globally. In fact, 70-80% of people will experience low back pain in their lifetime and continues to be one of the most common and most profitable health problems in primary care. No, I’m not expecting that to magically get rid of your back pain forever; however, there’s certainly more truth to that than when you typed “magic back pain fix” in your YouTube search earlier. In fact, many studies have found that health information on the Internet varied highly in quality, reliability, accuracy, and readability.

For context, we’re given a blog topic to write on with many of the top-ranking results for the topic. We found an article by John Hopkins Medicine that even spread misinformation about chronic back pain being “age-related”. If this was the case, every person of age would have chronic back pain which is not true at all. We must watch studies being biased even as they are heavily funded by specific groups to illustrate points in their favor.

Fear not though! We’re only funded by ourselves and the clients that we work with daily who experience low back pain, among many other ailments. In this post, we are going to cover a lot of topics including how low back pain is more than just pain and how we might classify various kinds of low back pain. Another topic includes treatment interventions with their success rates. The most important is how your provider should be speaking to you about your pain. I’m going to be very explicit with you. This may take a while to read because quite frankly, low back pain isn’t simple. Treating back pain is not simple and neither is experiencing back pain. Read at your own pace. We certainly hope you learn more from this, but even more so, inspires more questions.

What Is Low Back Pain? – Much More Than Tissues & Your Body

I don’t think we need to spend much time on where our low back is. The low back is defined as “the area below the lower ribs and above the gluteal folds”. The issue we’ve run into over the last few decades is how we present low back pain to the general population. Fear mongering and misinformation has created this image that low back pain is a disease that couldn’t be more wrong. Low back pain is a symptom, not a disease. Depending on your situation, you can treat back pain without surgery. Read that one more time. The clinician’s job is to provide educated information, inspire confidence, and provide a plan to navigate through these symptoms. There are plenty of solutions – it is possible to treat back pain without surgery.

Commonly, for worse more than better, most people are presented with pathoanatomy6 meaning “what’s wrong with you and your body”. The problem with this is exponential in that it creates a mindset of learned helplessness (“I’m sick and I’ll always have chronic back pain”), devalues someone’s self-worth (“I’m weak and I’ll never live up to being the best person I can be now”), and fragility (“I have to be very careful, or I will throw my back out”). We include these phrases because I hear them all the time. Clients have been told many things from past practitioners they’ve worked with.

Imagine having an electric shock device that’s attached to you for the rest of your life and you’ll never know when someone is going to press this imaginary button to shock you. You would live in fear too. In one study, they concluded that “For the vast majority of people with low back pain, it is currently not possible to accurately identify the specific nociceptive source”. Translated that simply means, we have no idea what is causing your pain. Pain can manifest from more than just bones, muscles, tendons, and ligaments. You’ve surely had that “gut feeling” when you’ve either done something you shouldn’t have or possibly felt symptoms of anxiety. Low back pain is a symptom. You may be able to treat your back pain without surgery.

A practitioner that works with you should follow a model of care called the Bio-Psycho-Social model of care meaning that they take not only what they find on a physical exam into consideration but also genetic factors, comorbidities (do you have something else that may lead to having low back pain), psychological factors (your identity to yourself and mental health), and social factors (your identity to others and societal values). You can find a great illustration of this here.

We will get further into detail about further classifying low back pain later, but statistically speaking, <1% of cases in primary care are a specific spine pathology, ~ 5-10% are radicular syndromes, and an overwhelming ~ 90-95% are non-specific low back pain. You can find this illustration below in figure 1. Before we start thinking we are clearly in the <1% category, let us talk in the next section about more defining features and that if you’re reading this, you’re likely in the 90-95% percentile.

Figure 1 (Bardin et al., 2017)

Classifying Low Back Pain – Complicated to Simple

We’ve all heard terms like Sciatica, disc herniation, disc degeneration, stenosis, bone on bone, chronic back pain, and subluxation with virtually no context to what they mean and if they apply to you.

Most stories we hear are you’re given this diagnosis with either no explanation at all or you’re given a very inaccurate example of a jelly doughnut spilling everywhere or your X-Ray with lines and circles everywhere that looks like Post Malone’s face tattoos put up next to the “perfect posture” with fine lines. You leave feeling weak, defeated, and broke because you were told that the only person that can fix you is the “Doctor” (or a cult leader) standing across from you that wants you to refinance your house, rename your firstborn to Aligned, and leave your job so you can come in 4 times a week for a month, 3 times a week for the next two months, and 2 times a week for the rest of your life. Just remember, you may be able to treat your back pain without surgery.

You can clearly tell that this fires us up. Below, let’s cover each triage category we stated above, what we see with each, and how this can’t always define our back pain.

Specific Spinal Pathology – The <1% Group

We want to reiterate that this population is less than 1% of people with low back pain. A clinician’s job is to rule you out of this group rather than ruling in. To do this we have what are called red flags. One might have these in their dating or personal life as well like, “if they act like a serial killer and they look like a serial killer…they might be a serial killer, so we should move on”.

For the diagnoses, we see in this group: vertebral fracture, malignancy, spinal infection, axial spondyloarthritis, and cauda equina syndrome. These are some (meaning not excluding others and if you feel you need to seek a professional medical opinion, please do so) red flags we like to rule out to make sure you’re in the right clinic. Keeping in mind that 80% of acute low back pain have at least one red flag but less than 1% have a serious disorder.

  • Change in bowel or bladder habits
  • Unusual bleeding or discharge
  • Prolonged corticoid steroid use
  • Severe night pain or inability to rest
  • Unexplained weight loss
  • History of cancer/malignancy
  • Severe trauma
  • Fever/chills
  • Perineal numbness or saddle paresthesia
  • Older age (>65 years for men, >75 years for women)

Again, these are just some red flags. Simply because you’re a 67-year-old male doesn’t mean you have one of these diagnoses. Your clinician should look for a combination of signs and symptoms that increase their suspicion. Less convincing evidence of cancer or fracture, typically a suggestion for a trial of therapy for 1-2 weeks with review.

Radicular Syndromes – The ~ 5-10% Group

This group commonly involves nerve root irritation and involvement. This is where we find people who ACTUALLY have sciatica compared to pain referral. Sciatica is extremely overdiagnosed. Let’s break down the three different subsets of radicular syndromes.

  • Radicular pain – mainly on one side and specific dermatomal-dominant pain location (pain following a specific pathway), positive nerve tension test (straight leg raise with pain at <45 degrees), leg pain typically worse than back pain, and pain increases with cough, sneeze, or strain4
  • Radiculopathy – nerve root irritation involving numbness commonly in a distal dermatome (meaning feel it in my leg but the problem is higher up), weakness or loss of function (like drop foot), sensory loss in the same pattern, weakness of muscle strength along nerve root and reduced reflexes. These symptoms can often accompany a radicular pain problem which makes them more confusing
  • Stenosis – often bilateral leg pain or cramping with or without low back pain, commonly exacerbated by extended postures (like standing or walking for long periods) and relieved by flexion (like sitting, bending forward, and recumbent posture), neurogenic claudication (meaning compression of the spinal nerves)

This was a lot to digest, but your clinician should be looking for these things during their examination. Even with testing being positive, research shows a very favorable prognosis for all three of these when managed conservatively. If symptoms are disabling and persisted longer than 6 weeks or seem to be progressing or more severe, referral to a spine surgeon is warranted.

Here is where pain gets weird.

We often use imaging (commonly X-Ray first, and if there are radicular symptoms or no signs of improvement after several weeks of a trial of care, advanced imaging ex. MRI) to further diagnose specificity. However, a study found that radiological signs of disc wear and tear (ex. degeneration 91%), bulges (56%), protrusion (32%), and annular tears (38%) are also common in pain-free patients.

Another study found there is “no agreement on what defines “normal” and “stenotic”, stenotic images can be seen in asymptomatic subjects, and there is limited correlation between anatomic findings and symptoms”. Bringing this back to when your Chiropractor or therapist throws up that X-Ray of yours. Now you know there is little correlation that dictates your pain. In fact, this might make your recovery harder. Mainly because we can’t even diagnose a disc bulge from an X-Ray in the first place. Are you frustrated yet? Let’s talk about where most of us fit into.

Non-Specific Low Back Pain – The ~90-95% Group

If you’re familiar with numbers and how they work, one can clearly see this is most people who experience back pain. There are no identifiable features for NSLBP and is mainly a diagnosis of exclusion from the previous two categories. We can treat this back pain without surgery.

We don’t actually like to use the term Non-Specific Low Back Pain even as most people want a name, and that term is unsettling meaning “we don’t know”. At Modern Movement Clinic, we treat back pain a bit differently than what you may have experienced before. We often call this ‘Mechanical Low Back Pain’ describing a simple example of load versus capacity.

Think of a teeter-totter or an old-school weight scale and how they work. On one side we have load defined as how much stress, volume, and intensity we are placing on an area like your low back. On the other side of this proverbial scale or playground equipment, we have capacity. The definition of capacity is how much load can this area tolerate. This is where the Biopsychosocial model can interplay as well.

If you’ve been gardening a lot (high load in a short period of time) with no exercise or strength training to adequately equip you to tolerate this load (aka increased capacity), it would make sense that your low back hurts. Additionally, if you’ve been stressed at work, haven’t been sleeping well, or anything that adds to your plate instead of taking away, this is load just as much as gardening for hours is. Therefore, sitting down and having a conversation with our practitioner to rationalize these things is important instead of going straight to “your bones are out of place” or “your scoliosis is the reason for your pain”. No one on earth is symmetrical and the overwhelming majority of people have increased curvature in their spines. You can read more about load and capacity here.

When working with someone with NSLBP or mechanical low back pain, the initial goal should be straightforward: what feels good and what doesn’t feel good. Pretty simple right? See how the medical system has drastically overcomplicated low back pain? We commonly put this in categories like “flexion intolerant” or “extension intolerant”. Here we also find areas we might want more mobile or build capacity in other areas. We find this doing functional movement testing. These are all ways we can treat back pain without surgery. Above all, education for all of these categories is paramount, including if we are not seeing a response and what the next steps are.

If you’re a clinician or clinician to be, or if you are just simply a curious person who wants to know further how to categorize NSLBP, refer to figure 2 below on how we categorize acute and persistent (also called chronic) low back pain.

Figure 1 (Bardin et al., 2017)

Not Responding to Conservative Care? – What’s Next

There’s a multitude of reasons why you may not be responding to conservative care. People have different response times to care. In fact, if you’re a great clinician, you don’t ever claim that you get anyone better. They get themselves better and the research proves that. A systematic review found that “responses seem to follow a common trend of early rapid improvement in symptoms that slows down and reached a plateau 6 months after the start of treatment, although the size of response varied widely”.

This same study by Artus and their crew found that “variation in treatment responses did not appear to be explained by different types of treatment”. This means that it didn’t really matter what the clinician did; they all saw similar responses to care.

The rationale behind this includes a few factors at play.

People commonly seek care when pain is worst and logic would serve that symptoms following treatment would reduce, especially with time. We call this the ‘natural history’ or ‘clinical course’ of pain. When you sprain your ankle or get a cut, it gets better with time. We promote optimism in many forms at Modern Movement Clinic. Not only through treating back pain but pain relief, in general, to make pain manageable.

If we spent our time talking about how hard something is going to be, your first thought might be “this on top of everything else in my life right now?!”, clearly making things seem insurmountable. For example, if losing weight was the goal and we started out by telling you how overweight you are, how much you’re going to cut out in life and diet, it might seem pointless to even make the effort and you forget the reason why we had the goal in the first place.

Other factors they found in the Artus study were “nonspecific effects of treatments”. “Some of these factors relate to characteristics of the pain problem or to the patients themselves such as their beliefs, expectations, and experiences with other illnesses, previous episodes of the illness or with previous use of the current treatment or other treatments”. Breaking this all down means what does the patient know thus far or what have they been told along with what treatments have been done to them prior if having previous experience and what was the overall outlook and effects of that?

See how pain gets complicated?

This is why dry needling has become such a popular therapeutic intervention along with cupping and compression wrapping, yet there is not a lot of sufficient evidence of their effectiveness. Remember, these are all ways to treat back pain without surgery. This is not to say they can’t be effective for someone; however, we often claim these modalities as the reason for success or recovery. “It can also be influenced by factors related to the practitioners providing the treatment such as their previous experience with the use of the treatment and their expectation and knowledge of the clinical course of the illness”. We can loop this back to the dating red flags example, if your clinician can’t give you evidence-based reasoning for what they’re doing, red flag.

We’ve talked about all the ways one might get better with care but not everyone finds success initially. We referred above to how then you might be referred for advanced imaging. You might also be referred to a spine specialist or pain management specialist for consultation as well. Their goal should be to treat back pain without surgery… If it is a possibility to do so under the presenting circumstances. We will not cover every intervention available; however, we will be covering two with transforaminal epidural steroid injections and lumbar fusion surgery along with what the research has shown in their effectiveness.

Transforaminal Epidural Steroid Injections

These are commonly the next step for radiculopathy or radicular pain and not responding to around four weeks of conservative care. One goal in treatment for this presentation is working on ‘centralizing’ the pain; this meaning the pain down the leg or distally comes closer to the center or origin. Steroid injections or TESIs “contain contrast material, local anesthetic, and steroids and target the inflamed nerve root under fluoroscopy guidance”. This same study that provided the definition found moderate evidence for short-term relief; however, long-term was unclear. This was just the steroid injection alone. They went on to find that about 65% needed a second injection where we commonly have the option of around four.

Of all the patients involved, 16% fell into the group of being completely resolved, and close to half had pain centralized and pain was significantly less. These groups received the injections in conjunction with Mechanical Diagnosis and Therapy (MDT). This refers to the “what feels good” and “what does not feel good” during our assessment where we may provide a repeatable motion or position to get into the centralize the pain.

Lumbar Fusion

This is not the only invasive surgical procedure but one we wanted to cover as the evidence shows that there is no real evidence of effectiveness of lumbar fusion compare with conservative treatment.

This procedure is becoming less and less performed as surgeons are becoming well versed with modern surgical procedures. The most common fusion is a posterolateral fusion with or without screw or bone fixation and also anterolateral interbody fusion using bone transplant. Most of this means what direction are they coming from and what are they using to do the fusion.

This same study concluded “Previous systematic review on the topic have been unable to draw strong conclusions on the effectiveness of LF. This is understandable as it is not possible for any review to reach a robust agreement by analyzing the results of four high-quality studies in a situation when one study reports that intervention as effective, another reports worsening of the outcome and two studies suggest that intervention does not have any effect”.

The problem with any additional intervention however is, is whether it addressing the cause of the person’s low back pain in the first place. This same study did not find any evidence of fusion being more effective in reducing perceived disability related to chronic low back pain compared to conservative care. Even in the TESIs study by van Helvoirt et al, the 15 patients who did not respond favorably to steroid injection who underwent surgery to treat back pain reported “statistically significant positive effects for pain in the leg and back but not for disability, anxiety, and depression after the TESIs”.

How do we work on disability, anxiety, and depression? This takes us to our final section (pause for applause), how should someone manage you and your low back pain. The things that can treat back pain without surgery.

Managing the Person with Low Back Pain – Why n = 1

I’m reluctant to say this because this entire blog post has been about providing evidence through studies and care… We live in a data world where we haven’t fully accounted for the human condition. We see a lot of people where they’re immediately given muscle relaxants or pain medications. They are told to go on anti-inflammatory diets because of processed foods. People are advised to lose weight or get nerve stimulation or whatever the latest local tv ad is. Even worse they are just given a handout of exercises with virtually no instruction or examination to see if this person fits into these movements. “Fix Your (Insert Body Part or Perceived Flaw) With Just This”.

We can’t always blame the practitioner as the insurance model of care has become harder and harder to manage quality care with the patient. Reimbursements rates from insurance companies are so low at clinic and hospital levels. They have to choose quantity of patients over quality meaning most are high volume where you have 15 minutes or less to spend with the person in front of you. A person going through years of low back pain can’t possibly summate everything they’ve experienced and are experiencing in that amount of time.

It’s hard for the clinician’s too, believe us because we’ve been there. You have to meet quotas of number of patients in a day. Of these patients, you won’t be able to do their notes during the visit because you’re working with them. Notes start to mount up. Insurance companies want to see improvement in something as preposterous as 4 visits for a person who has had pain for many years. The therapist goes to work from sunup to sundown, eating food and going to the bathroom when they can (which they can’t ever), only to go home and must work on notes. We’re not saying all this for you to feel sorry for the therapist. We are saying this because it is the reality and why working outside of insurance commonly provides a higher quality of care for everyone, clinician and client/patient.

In a study by Darlow et al, they worked on comparing the clinical effectiveness and cost-effectiveness of an approach called Fear Reduction Exercise Early (FREE) with general practitioners. Typically the first place one might stop with low back pain. This FREE approach provided evidence-based education and advice to the GP. It encouranges them to suggest activity, work participation, integrating a biopsychosocial approach and discouraging interventions with low beneficial value. This resulted in “significant reduction in patient fear avoidance at 2 weeks in”. In addition, “nonsignificant trends for reduced imaging and reduced specialist referral were also observed”. They did not find improvement in disability or pain outcomes more than usual care; however, this study was not done in conjunction with therapeutic intervention with a physical therapist or evidence-based chiropractor. Simply changing the mindset but of the General Physician can alter the track of the patient’s mindset to recovery.

What else is important to the person in front of us? A study by French and colleagues looked at just that by arranging a study, polling experts in the field and consumers and cross comparing the two. Experts considered remaining active, reassurance that back pain is a normal experience and not necessarily related to serious harm, how to identify features that may indicate more serious pathology requiring expert assessment, and avoidance of unnecessary imaging to be the top four messages. Consumers however prioritized being able to identify more serious pathology and principles of managing the pain and messages about avoiding imaging to be least important.

One statement that really jumped out to us in this study was, “In general, it seemed that people with low back pain placed emphasis on gaining knowledge of “what can you do for me,” whereas experts placed emphasis on “what can you do for yourself”. Can we as clinicians really blame you? We live in a world where you take this to fix that. The problem is that side effects of that means you must take this thing to work with that. On social media, there are endless videos of “Fix Your Low Back Pain with This” among other click bait videos claiming to have solved and worldwide problem.

To Conclude: Treat Back Pain Without Surgery

Thus, we bring it back to the rabbit hole you may have crawled out of… Watching endless hours of people jamming hard objects into their intestines. They are saying you need these specific shoes or lifts or orthotics because your leg is short, stretch this magic muscle that might fit onto your Daily Wordle, and go on and on and on. Our best advice is to find someone that resonates with you. Someone that listens to you and what your goals are. Above all someone that provides the education and optimism you need for recovery. Our hope is that they are evidence-based but above all, leave you feeling more confident about who you are and what you need to do to get better. All of this with a focus to treat back pain without surgery. After all this reading, you’ve found that nothing gets you better but you. Just make sure you have someone to help facilitate that for you.


Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Hoy, D., Karppinen, J., Pransky, G., Sieper, J., Smeets, R. J., Underwood, M., Buchbinder, R., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., van Tulder, M., … Woolf, A. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356–2367.

French, S. D., Nielsen, M., Hall, L., Nicolson, P. J. A., van Tulder, M., Bennell, K. L., Hinman, R. S., Maher, C. G., Jull, G., & Hodges, P. W. (2019). Essential key messages about diagnosis, imaging, and self-care for people with low back pain: A modified Delphi Study of consumer and expert opinions. Pain, 160(12), 2787–2797.

Artus, M., van der Windt, D. A., Jordan, K. P., & Hay, E. M. (2010). Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: A systematic review of randomized clinical trials. Rheumatology, 49(12),2346–2356.

Bardin, L. D., King, P., & Maher, C. G. (2017). Diagnostic triage for low back pain: A practical approach for primary care. Medical Journal of Australia, 206(6), 268–273.

Genevay, S., Courvoisier, D. S., Konstantinou, K., Kovacs, F. M., Marty, M., Rainville, J., Norberg, M., Kaux, J.-F., Cha, T. D., Katz, J. N., & Atlas, S. J. (2018). Clinical classification criteria for neurogenic claudication caused by lumbar spinal stenosis. the N-class criteria. The Spine Journal, 18(6), 941–947.

Stynes, S., Konstantinou, K., & Dunn, K. M. (2016). Classification of patients with low back-related Leg pain: A systematic review. BMC Musculoskeletal Disorders, 17(1).

van Helvoirt, H., Apeldoorn, A. T., Ostelo, R. W., Knol, D. L., Arts, M. P., Kamper, S. J., & van Tulder, M. W. (2014). Transforaminal epidural steroid injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. PainMedicine, 15(7), 1100–1108.

Saltychev, M., Eskola, M., & Laimi, K. (2014). Lumbar fusion compared with conservative treatment in patients with chronic low back pain. International Journal ofRehabilitation Research, 37(1), 2–8.

Darlow, B., Stanley, J., Dean, S., Abbott, J. H., Garrett, S., Wilson, R., Mathieson, F., & Dowell, A. (2019). The fear reduction exercised early (free) approach to management of low back pain in general practice: A pragmatic cluster-randomised controlled trial. PLOS Medicine, 16(9).

Keep Hands Warm While Running

keep hands warm while running

If we haven’t noticed, especially if you experience ACTUAL cold weather, it’s winter time. If you have been running outside in the elements or if you plan on starting your training program soon, it might be a good idea to purchase some running gloves to stay warm and prevent cold hands from preventing your PRs. Fear not! We are here to provide some good ideas for you to implement to help keep your body heat working and to keep a steady blood flow. Below we will speak on ideas like gloves and hot hands hand warmers along with other specifications you might need to consider. 

Choosing the Right Gloves 

You may be newer to an area that experiences elements like snow associated with winter. We often think any glove will do but there’s many factors to consider. When wearing gloves, we don’t want to go the route of cotton as this typically retains moisture and thus doesn’t keep your hands warm once they start to sweat.  

That being said, if the temperatures are 32 degrees or above, you have a little bit more leeway to be able to wear more knit gloves from Nike or these lighter gloves from Asics.  

However, if the cold air is blowing with temperatures below 32 degrees, we need to keep the hands warm while running while you move them back and forth as you run. You will want to go with something warmer like the Salomon RS Pro Windstopper Gloves or the Salomon RS Warm Gloves. When temperatures drop below 32, we run the risk of limiting blood flow to the extremities. This occurs as more of your body heat is being applied to the trunk and torso area. 

With more extreme weather events like below freezing or subzero temperatures along with windchill, layers are key. You may consider using the knit gloves as a liner to absorb moisture while putting the Salomon’s on top to blow the wind and precipitation. This will create a layer between your gloves that can stay warm. 

Regarding fingerless gloves, mittens, touchscreen capabilities, and anything else, these are all personal preferences. Clearly, when it is that bad outside, the last thing on your mind will be what should be the playlist you want to change it to. Let’s chat next about hand warmers. 

Upping the Ante for Warm Hands Using Hand Warmers 

Some people have circulation issues or simply it is THAT cold outside that we must add another option to keep our hands warm. HotHands hand warmers can really increase your comfort level with some lasting anywhere from 12 hours to 18 hours based on doing some investigation. These are considered chemical hand warmers and are air activated warmers. This creates a long-lasting heat you can carry with you on your run. You may even carry them at other events like hunting, fishing, and sporting events. You just simply give these a shake and stick them inside your pocket. Some gloves even have a dedicated pouch you can stick them in. 

We hope this helps give you some ideas of how to keep those digits warm as you carve through trails and roads during the wintertime. If you’re looking for other ideas in regards to clothing to wear in the winter time, we suggest checking out our blog post on that here

Benefits of Outdoor Running

the benefits of outdoor running

Let’s all just be frank with one another, runner to runner. Does anyone REALLY like running on a treadmill? Sure, the elements sometimes move us to running indoors or possibly time doesn’t allow us to travel to a trailhead but I’m not sure I’ve ever worked on a runner that was vocal about loving the treadmill over road or trail. Plus, there are many benefits of outdoor running.

At Modern Movement Clinic, we do a lot of running assessment and analysis where we like to put someone on the treadmill mainly because we like the controlled environment to analyze someone’s running biomechanics and manipulate speed and slope for either modifying symptoms or seeing if this alters their gait. Nevertheless, we realize the treadmill has major “womp womp” energy coming from it. 

In this post, we’re going to explore some of the benefits of outdoor running and what differences we might run into with running on a treadmill versus a run outdoors. 

The Science Behind Treadmill Vs. Running Outside 

Treadmill and running out in the fresh air have different benefits both physically and mentally. Regarding the physical aspects, treadmills tend to have a higher load on the Achilles tendon in peak force, loading rate, and cumulative force per distance of continuous running.  This research from the university was conducted by Willy and colleagues.1  Because of this, we want to possibly wait to hop on the treadmill or do analysis with a runner who is dealing with achilles irritation to tolerate running outside first.  At the knee, they noticed no difference between running indoors (on a treadmill) and outside regarding load. 

Some other aspects we notice between treadmills and running outside are that ground reaction forces (think forces that come back into your body as you step) are indiscernible. This is widely thought that running outside, especially on pavement, is “bad for your joints” compared to the treadmill.  

Running outside is associated with increased stride time, length and decreased stance phase (think how long the foot is on the ground) and there tends to be less vertical displacement of the center of gravity (think how high you’re coming off the ground).3,4,5  

As one can see, you can get heavy into the science about the differences between the two environments. Let’s now explore a little more of some of the benefit you get strictly from running outside. 

Benefits of Running Outdoors 

It’s a rarity that your running coach will program your runs to be on the treadmill, especially on the long run (I’ve done 2 hours before and let me say…it was no fun). Before we get into the benefits of strictly outdoors, just know that running is a great form of exercise and provides great health benefits to your heart health and mental health. Regardless of where you’re running, you’re gaining benefits. 

That being said, we found a study by the University of Exeter stated, “Compared with exercising indoors, exercising in natural environments was associated with greater feelings of revitalization and positive engagement, decreases in tension, confusion and anger and depression, and increased energy”. They also found that it manifested greater enjoyment and satisfaction as well. Another study at the University of Michigan found that being in nature improves your memory and attention span as well. 

Aside from our mental health, there are some additional benefits of outdoor running. Because we don’t have control of the terrain, running outside gives a runner a varied load that would better benefit the body to adapt to the stresses with running. Experiencing this personally, what is a better way to explore a city or trails around you than to go for a run? You’ll be burning more calories while also getting familiar with a new place over the long term. Lastly, what more do you need for running outdoors other than a pair of running shoes and some athletic wear that accommodates to the climate and weather? Therefore, as the years pass, running continues to pick up more and more athletes. It’s a much cheaper sport than others that require a lot of equipment. No gym membership needed. 

We hope this gives a bit more clarity that although either space is fine for running, that you have plenty of motivation now to lace up your running shoes and grab some fresh air. 

benefits of outdoor running science
  1. Willy RW, Halsey L, Hayek A, Johnson H, Willson JD. Patellofemoral Joint and Achilles Tendon Loads During Overground and Treadmill Running. J Orthop Sports Phys Ther. 2016 Aug;46(8):664-72. 
  1. Kram R, Griffin TM, Donelan JM, Chang YH. Force treadmill for measuring vertical and horizontal ground reaction forces. J Appl Physiol (1985). 1998 Aug;85(2):764-9. 
  1. Schache AG, Blanch PD, Rath DA, Wrigley TV, Starr R, Bennell KL. A comparison of overground and treadmill running for measuring the three-dimensional kinematics of the lumbopelvic-hip complex. Clin Biomech (Bristol, Avon). 2001 Oct;16(8):667-80. 
  1. Nelson RC, Dillman CJ, Lagasse P, Bickett P. Biomechanics of overground versus treadmill running. Med Sci Sports. 1972 Winter;4(4):233-40. 
  1. Dal Monte A, Fucci S, Manoni A. The treadmill as a training and simulator instrument in middle- and long-distance running. J Sports Med Phys Fitness. 1974 Jun;14(2):67-72. 

Ankle Stretches Before Running

Ankle Stretches Before Running to Prevent Injury

Runners and ankles have been in a perpetual battle with one another for years much like the Hatfield’s and the McCoy’s. Perhaps you’ve dealt with an ankle sprain while on a run before, or you may have put up with an ongoing bout of plantar fasciitis. It’s even possible someone told you your “calf muscles are tight and you need to do calf stretches”. (Slow eye roll)

Your foot and ankle are the closest to the ground during your run. By proxy, they take the most ground reaction force during the foot making contact, roughly 10-12x your body weight. This slowly dissipates as it moves up the body, but due to the forces involved, we need our feet and ankles to be strong and adapt to the loads involved with our training plan. A couple of studies from Steinacker in 2001 and Taunton in 2003 concluded that collectively, the foot and ankle make up over a quarter of running-related Injuries (RRIs) of the lower extremity.

We know how you get when you’re injured and running is sidelined for a bit (take cover!). Let’s break down ankle mobility in general and diver deeper into stretches or mobility you can do to ACTUALLY see results. More specifically, how and why we would want to progress towards strength and warm-up drills to keep them in mint condition. 

Ankle Mobility – What Is It? Does It Matter or Not? 

With many of our running clients, we believe education helps remove a lot of the doubt and scary stuff when it comes to an injury. After all, the more you know (say it with me) the more you growwww. We often see that ankle dorsiflexion and ankle plantarflexion are the two main range(s) of motion that runners need to work on and perhaps are limited. One rule of thumb is not necessarily searching for a magic number (this changes based on body type and age). Instead, it looks for congruency between your right and left sides.

An easy way to assess this is by simply using a door or wall to measure your dorsiflexion. This looks very much like a calf stretch, and we call this the Ankle Dorsiflexion test (duh). This range of motion test is a nice way of seeing if your problematic side needs some mobility attention. Many times with ankle sprains, dorsiflexion gets compromised the fastest and therefore needs immediate attention.  

Plantar Flexion

One of the ankle stretches (or motions) used during running is plantar flexion. Plantar flexion can be done in a couple of different ways. In an open-chain assessment (meaning your foot is not in contact with the ground and non-weight bearing), you can sit on the ground with your legs straight out in front of you. With your feet side by side, you can point your toes forward, both at the same time to notice any difference in tension, and independently to note any difference in mobility. You can do this in a closed chain position (weight-bearing) by simply doing a Calf Raise test (in double leg and single leg) to see if there is a difference there as well. Keep notes on what you find. This way you are able to trace your way back to what you need to work on. 

Ankle dorsiflexion comes into play during the swing phase of the running gait the most on the stance leg. All that fancy terminology means is that the leg that is in the air is swinging forward during the run. As that occurs, the body is also moving over the foot that is on the ground and creating dorsiflexion. Plantar flexion happens during the toe-off phase of gait where the foot is pushing up and forward off the ground to keep you moving toward your next mile split. 

Don’t Forget!

In saying all this, we also want to consider the big toe, notably great toe extension. In that toe-off phase of gait, we also have the big toe bending to put tension along the plantar fascia and the bottom of the foot. This happens even more so if you are a forefoot runner. We want to measure this as well actively and passively on both sides making notes on both. 

You may find some differences between the two. Let’s put our objective measures now to work. 

Measuring Your Ankle Mobility Video 

Ankle Mobility Video 

Creating Ankle Mobility – Stretch or Strength? What If We Could Do Both? 

For years, others tell runners everywhere they need to stretch not only before their run but after as well. What if I told you that you might be wasting your time? I’ll wait for the uproar to die down and I may have to dodge some rotten tomatoes but it’s possibly true. Before I explain why, let me say, that if you (yourself) like stretching or find a benefit with it, do it. If it is not aggravating your symptoms or taking up time you could dedicate to something else, then how is that hurting me? The rationale as to why I would suggest loading the area or doing more strength instead is simple.

Running injuries either involves a tendon or a bone or both. Since we can’t stretch a bone that just leaves tendons and tendons inherently don’t like to be stretched. They are highly innervated meaning there is good communication with the nervous system; Nerves DO NOT like to be stretched. We commonly find a lot of runners coming in frustrated either because other practitioners (physical therapists, chiropractors, trainers, massage therapists, etc.) tell them to stretch till the cows come home and haven’t seen any results OR have been told to and aggravate the area more. 

Eccentric Strength Training

If this sounds familiar to you, let me present another option that will save you time and possibly a large hole in your drywall. The concept is called eccentric strength training. Without going too deep into physiology, this means strengthening the area as it is put under a stretch or elongation.

Another good example of ankle stretches to do before running would be a calf raise off a step as you drop below the level of the step. As a result, you are elongating the calf musculature and Achilles tendon under load. The body often responds well to this compared to just stretching alone. The reason being is the body adapts to the load or demand you place upon it. It’s why you might have previously been more flexible but now after running, are perhaps less flexible. The body prioritizes that flexibility is not a need considering running is a mid-range of motion sport and thus adapts to the demands with running, and not being flexible. 


Take a deep breath because that was a lot of information! Watch this video and start trying out these movements if you feel ankle stretches before running has got you either nowhere or further in the “pain cave”. 

We would be remiss if we didn’t take a quick second to why you might progress these too. 

Ankle Warm Up Video 

Ankle Stretches Before Running

Progressing Your Ankle & Calf Work 

In an ideal scenario, we want our training to be pretty sport-specific. In the context of running, running is a plyometric sport and therefore we should have our training work towards plyometrics. Read that carefully. Work “towards” meaning we don’t just jump (pun intended) right into plyometric training. 


Plyometrics, by definition, is a form of training that involves a stretch and contraction sequence involving muscle and tendon fibers to generate strength at a high speed. Because of this, this creates a much higher load on these tissues. We want to work up to this otherwise, we could be compromising our running training. 

A good example is how we do this with our runners at Modern Movement Clinic. We start with something like eccentric calf raises and isometric holds at the top of the calf raise. It is important to allow a couple of weeks to work on the body adapting to this. Not only to adapt but also to get your groove of feeling more confident with balance and coordination. We would then move to unilateral training meaning doing this on one foot compared to two feet. This emphasizes working on discrepancies between your right and left sides (remember how we measured both together and independently earlier?). Finally, we would move more towards pogo jumps (for reps initially then time) and jump rope (time-based). 

Try It Out

The foot and ankle don’t have to be this mysterious area. In fact, with just a little explanation and concepts, you will see a vast improvement in your prevention of running injury and performance in running with a few simple ankle stretches before running. 

How to Dress for Winter Running

dress for winter running

Whether we like it or not, it’s getting darker earlier and temperatures are dropping. Depending on where you live, cold days may have different translations along with what your terrain may look like. Either way, cold weather running is here for the foreseeable future over the next training block. We are here to help you with how to dress for winter running. 

Check Your “Local On the 8s” Weather Report! 

Whether you are a runner in the Denver/Golden area or anywhere else, running in the cold requires winter running gear, period. Before learning how to dress for winter running, here is the best rule of thumb for running when the temperature drops. Try adding 10 to 20 degrees to the outside temperature to calculate your running temperature. This comes down to what your workout out is, what the weather forecast says regarding wind chill and “feels like” temperature, how cold you feel when you are under these certain circumstances and time of day as well.

For a shorter, more easy-paced run, add 10 to 15 degrees to the outside temperature to estimate your running temperature. However, if you are doing a long run, harder workout, or your engine is always “running hot”, add 20 degrees to the outside temp. For example, the report says 40 degrees outside with a wind chill so feels like 30 degrees. If you’re doing a hard effort, it’ll feel like 50 degrees outside based on the wind chill temperature of 30 degrees. 

One trick with wind chill and running, run into the wind on your way out for your workout and the wind at your back when returning. This helps avoid running into the wind when you are wetter and sweatier, naturally making you colder. This brings us to our next point. 

Layers, Layers, Layers!


Winter running gear is imperative that it can be layered. Layers do a few things for us as runners. They give us a small pocket of air between each layer that is warmed by your body heat and keeps you that much warmer. Additionally, it is simply functional meaning if you’re heating up more than you thought, take a layer off. You can always take layers off; however, when you’re trail running and it’s snowing, you can’t add layers then and there. You can always stand outside your place to dynamically stretch or warm up for five minutes to see if you’re within a good range of layers before taking off on your winter run. 


Avoid cotton layers, especially as your base layer, as they absorb moisture quite a bit as you sweat and thus make you feel colder. Asking local coach Andrew Simmons of Lifelong Endurance and Peak Performance, he suggests wool for most things, especially socks. A lightweight baselayer shirt with a high neckline allows you to keep the heat in and cold wind out. A wool, poly blend, or fleece-lined exteriors allow for a full range of motion and keep you staying warm. 


To break this down better, think layers of three. Your base layer needs to be sweat-wicking since this is the closest to your body and can be short or long sleeve depending on the elements and temperature. A mid-layer is next where this can be wool or a poly blend being light or mid-weight but is suggested for long sleeves. Lastly, the outer layer can be one or many obviously depending on the temperatures but revolves around a jacket or vest. One key piece for the outer layers is to make sure they are reflective. This is to make sure people not only see you but see how badass you are for running outside. Let’s wrap things up by going from head to toe on what to wear. 

Top to Botton – How to Dress for Winter Running

We will address each area on how to dress for winter running where you can find hyperlinks to possible suggestions. 


You’ve got a face that people love and if you think differently, they at least like the way you think. Because of this, wearing a headband, sock hat, or face mask that is breathable and sweat-resistant fabric with a comfortable feel is imperative especially if there is a wind chill. Sheryl Crow said, “the first cut is the deepest” and as we all know, she was referring to the wind out there when running. 


For layers around the torso, we described above the layering concept. When it comes to a jacket, local Denver trail runner, Mountain Endurance Coach and influencer, Margaret Spring, couldn’t stop talking about finding your perfect jacket. She notes finding one that is water and wind-resistant, reflective for when it’s hard to see out. It also has thumbholes or longer sleeves to allow gloves to fit over and not have any breaks between you and the outside. Pockets can never be underestimated as well, especially if there are inside pockets to store your phone or fuel. Vests are another viable option depending on the temperatures. 


Do not forget about gloves! We will say the same for socks as well below. Your extremities naturally have less blood flow because of how far they are from your heart and thus are cooler by nature. This goes for ears, hands, and feet in even “cool” temperatures. Gloves you may want some touchscreen-compatible fingertips to allow you to control your phone better as well. 


Tights are perfect for really all-season running. You can pair them with t-shirts in warmer weather and layered during colder temperatures. Tights should be moisture-wicking and seams being comfortable. They are made with different weights and thicknesses as with some being fleece lined or special fabrics. 


Socks and shoes are closest to becoming the wettest during your run and are often overlooked. Wool socks don’t absorb sweat and therefore keep the tootsies warm. Aim for socks that are ankle height or higher where you can even tuck the tights into. You don’t want to double up on socks because this could compromise the fit of your running shoes so pay up for better. For running shoes, commonly, you might decide to wear trail shoes out when on the snow. These have a better outsole for slippery elements. Some trail shoes even have GORE-TEX material on the upper that allows for water resistance. If the trail or area where you run is slippery, don’t forget your spikes to strap on your shoes that go by Yaktrax or Nano spikes

We hope this helps bring more of a method on how to dress for winter running. If you’re running into other questions with your running, you’ve come to the right spot. Holler at us and let’s link up! 

Yoga for Runner’s Knee Pain – Can It Help?

yoga for runner's knee pain

If you’re a runner with previous miles under your feet, you’ve likely experienced a running injury before. One of such injuries may have been Runner’s knee also known as patellofemoral pain syndrome. The majority of running injuries are typically around the knee, roughly 50%. You may seek professional care from a physical therapist or a yoga instructor for Runner’s knee pain. And you may even seek a movement professional like Modern Movement Clinic that can give you a more accurate diagnosis but even more so rationale in how you got the knee injury in the first place. 

At times you may be told to stretch tight muscles and strengthen weak muscles and thus be given stretches and rehab exercises and told: “you need to stop running”. Maybe you even hear things like “running is bad for your knees”. We’re glad you found this article because we are here to set the record straight. We will break down what ACTUALLY is runner’s knee, how it can happen, how yoga can SOMETIMES help (what you can do as an alternate), and how to possibly even KEEP RUNNING while injured. Let’s begin. 

Runner’s Knee – What Is It? 

There are some common symptoms we have with this diagnosis. Pain on the front of the knee or anterior portion around the patella that can be either dull or sharp depending on how acute this may be is a common identifier of PFP. Outside of runners, cyclists and athletes who do repetitive jumping can experience this as well due to the forces involved with sport specificity.  

With running, you may notice running downhill is more painful along with taking the stairs (going down). You may also notice speed or running on your forefoot may make the pain worse. This is one of the most common running injuries endurance athletes face especially if they have either previously injured this area or are new to the sport. Fear not though, with a little explanation on how this happens and some better planning for moving forward, you can get back to pounding pavement soon enough. 

How Does Runner’s Knee Happen? 

When doing research on this article, we looked at a few different articles and they got complicated quickly. Patella’s not fitting into their trochlear groove, not tracking correctly, muscles pulling patellas every which way. You leave thinking your body is a hot mess and there’s no way you’ll ever overcome.  

You want to see someone who sees the whole picture and doesn’t treat for just symptoms. This may be something you’re experiencing. You may be getting a litany of things that are “wrong” with you like “your hip flexors are short”, “your hips are tight”, “your glutes are turned off” with virtually no explanation to how this came to happen (this can’t happen, by the way, it’s B.S. terminology some therapists use because they lack the capacity to explain things effectively) or what to do about it all. 

Truth be told for how popular this injury is (runner’s knee), hardly anyone has a structural problem. You’ve been built the same way since you started walking upright. Your body ADAPTS to what it receives. I always explain to my running clients that we never wake up on day 1 of our running career saying “well…I guess it’s time to go run a marathon”. We all know that wouldn’t go well. We train UP to that and our body ADAPTS.  

Consider two terms: load and capacity. At this current time of your training, your knee experiences loads of running and whatever else thrown at it. The body needs recovery periods to build something called capacity. Think of capacity like the endurance in your lungs. Some runs are easier than other days and others you feel you are really huffing and puffing. The knee can behave much the same way. Muscles are going to be tight; they’re adapting to the stress you’re giving them and trying to make you stronger.

To be clear: 

✅ Runner’s knee has little if anything to do with your patella tracking in any certain way. That’s old school and prehistoric mentality that has no research validity. 

✅Has more to do with how well your body is recovering (capacity) from your training or life’s stressors (load). 

✅“Tight muscles” are tight because they protect your body from the load applied with running and inherently getting stronger. Your tendons actually get thicker the more you run. How cool is that?! 

✅Running doesn’t require much flexibility because it is a mid-range of motion sport. You’ll likely have a harder time running if you’re very flexible. This is because there is an element of controlling this range as you land with each step. 

Yoga for Runner’s Knee Pain Can Help…Sometimes 

We do general mobility assessments with our runners, and we see common themes. Most are not what the general population would consider flexible. Whether they can’t touch their toes or squat with perfect form, it doesn’t matter.

What matters is: 

✅Are the right and left sides relatively close in range of motion and function? 

✅Does the affected side illustrate a difference (in flexibility or strength) compared to the other side that we find important? 

You’ve watched Paralympians and Special Olympians along with Olympic-level runners perform before. They all have tight muscles here, prosthetics there, asymmetries here and there and all perform at an awe-inspiring level. What we are saying is, before you go stretching everything with yoga, know why you’re doing it so you’re not doing more harm than good or even worse, wasting your time. 

Yoga can have the benefit of building some flexibility or mobility under the circumstances. Even more so, the element of how relaxing yoga can be has the biggest benefit.  

We tend to do our mobility routines IN our strength program. If you want to relax then we suggest finding a good vinyasa style-based class at your local yoga studio where you move around much more as opposed to holding a stretch for a long period. With running injuries, holding a stretch for a long period (commonly seen in the hip flexors) can make the pain worse. This is not to say you can’t do restorative yoga for Runner’s knee pain or you shouldn’t stretch. Everyone is different, but we know from our long working experience with runners what we typically see which is why we like our mobility more dynamic and at times even loaded (with weight).  

Here’s a YouTube video of some of the common movements we use for mobility along with some stretches you can use to improve mobility and performance. Let’s talk about how we can gauge if we should keep running, adjust our running, or stop for the time being. 

Can I Keep Running? – Running With Knee Pain 

Stop me if this sounds familiar. You get hurt, you decide to see a therapist or an ortho.

They tell you one of two things: 

❌You should stop running. 

❌Running is bad for your knees. 

Is this creating PTSD flashbacks for you? You’re not alone. We see a lot of runners who have been told that they don’t need to stop at all or simply just need some program modification. Here are a couple of good rules of thumb to see if you should stop completely: 

Are you noticeably running differently to compensate (aka limping, hobbling) for your run? Is someone saying “Franny…what the hell is wrong with you”? 

Are you continuing to hurt into the next day or 24 hours after? 

If you said yes to these then perhaps you should take up walking for a bit as it can still build tolerance in the tissues as we never really want to rest completely. Mixed with cross-training, getting care from a qualified therapist, you’ll be back running very soon. 

If the pain is manageable and you’re able to run through a small amount of pain that usually goes away that evening or the next day, you can continue to run but might suggest modifying your program to have less volume, fewer downhills, and possibly even some walk: run intervals. 

One last really good suggestion is modifying your cadence or how many steps you take per minute. Cadence typically dictates how long your feet are on the ground and how long your stride length is. Studies have shown that a 5% increase of your cadence can have a positive effect up to 20% at the knee. This requires some practice so check out this video on Youtube on how to properly do this to find out what your common cadence is now and how to modify it. You can also use Spotify playlists to find songs that have common beats per minute to match the cadence. 

We hope that after reading this you realize that having runner’s knee or knee pain is not a death sentence. You can train through with a little intelligence and modification, such as our take on yoga for runner’s knee pain! We’re happy to help elucidate this even more if you’d like as we work online as well with lots of running clients. Feel free to reach out and let’s see how we can get you back to conquering miles again. 

Do I Need a Referral for a Chiropractor

do i need a referral for a chiropractor

At Modern Movement Clinic, one of the more common questions we get is, “Do I need a referral from an MD to see a Chiropractor?”. The short answer to the question is “No”. In fact, not just in the state of Colorado, but in all 50 states, Chiropractors are considered portal-of-entry or direct access, meaning that we are considered primary care providers and don’t need a referral to be seen.

This does not mean that you won’t have a referral by another practitioner.  In the greater Denver and Golden areas of Colorado, Dr. Riley and Modern Movement Clinic often get referrals from Orthopedic Doctors and Primary Care Medical Doctors for acute and chronic pain, with a high prevalence in running and endurance sports injuries where overuse injuries are popular. When working with another practitioner or group of practitioners, keeping them updated on the progress of your condition is paramount in keeping success rates high.

Sometimes You Need a Referral

Other times, Modern Movement Clinic may have to refer you to another practitioner. If we feel another pair of eyes or care that is outside our scope of practice is necessary. This may include advanced imaging, pain medication or injections, or simply just confirmation of diagnosis. Most of the therapy done in-house revolves around passive and active therapy. For example, joint manipulation, active release therapy, or dry needling are more passive with mixing in active therapy and rehab that may include resistance bands and weights. We also offer 15-minute phone consultation. We will review if you are a great fit for Modern Movement Clinic. Otherwise, a referral is necessary first. The next time you ask yourself if you need a referral for a chiropractor, call us. If a referral is necessary, we’re happy to help provide you options.

You can also work with someone you have in the past that you know and trust.  This article from American Chiropractic Association can help answer many other frequently asked questions as well.

In Conclusion

Modern Movement Clinic helps people feel better about themselves. They focus to help people get back to leading a more productive and active lifestyle. Combining the movement and sports expertise of our practitioners with the knowledge and companionship of other professionals. The Medical Doctors and Orthopedic Specialists together make the ultimate therapeutic alliance.

No need for a referral, call us or visit our website today to get back to doing what you love.