Illustration by Vidhya Nagarajan
I enter the St. Louis Bread Company near Washington University School of Medicine, glance around, and start to fret. All these healthy young people? My expert won’t see any problems here…
Dr. Greg Holtzman, associate professor of physical therapy and orthopedic surgery at the med school and associate director of clinical practice at its p.t. clinics, joins me. Sipping sweet tea, he spends the next two hours observing the gait and posture of everybody who walks through the door. Granted, he has no chance to examine these people or learn their history. This is parlor-game diagnosis. But it’s startlingly revealing.
“We move in ways that are efficient,” he says. “but not always optimal. Think about a swayback posture, where somebody locks their knees and kind of sways their shoulders farther back than their hips. They’re resting on passive structures—the knee and hip joints—and they don’t have to use muscles to stabilize themselves, so they’re not using much energy. It’s efficient. But it’s not necessarily effective from a joint perspective, especially over time.
I nod, still worried that he’s not going to see any problems here, in this mecca of health and supple youth. Turns out he already has.
“That set of girls that just left? One was standing with her legs crossed in a big X, one hip dropped. Again, she was resting on passive structures, maybe the iliotibial band on the side of the hip. It can hold you up—but that’s not optimal. You start to get changes in muscle strength and length. I imagine if I tested her gluteal muscles, they’d be weak. If she doesn’t run or do a lot of stair climbing, she’ll be fine for a long time. But if she’s a runner, and that standing position is typical for her, I’d predict she’s running with a narrow stance, and tensioning that band on the outside of the hip to give herself some stability. If she has pain, it will be lateral hip or lateral knee pain.”
I glance over to her table, worried for her. “The body’s fairly resilient,” he assures me. “A lot of what I view as potentially harmful is, for that particular person, probably fairly innocuous at the time. It’s a low-level stress. But if it’s repeated daily, year after year, it weakens muscles and wears joints, and it becomes a degenerative stress on the body.”
He slides down in his chair, legs outstretched, instantly transformed from earnest professional to insolent, slovenly teenager. “Kids do this a lot in school. Well, those muscles are adapting. The hamstrings get stiffer. The abdominal muscles get weaker. These are the people who when they stand up will often hyperextend [lock] their knees.”
He sits upright again. “The two girls that were standing at the counter a minute ago were very different,” he remarks. “One was really underdeveloped—no butt, a really flat back—and that swayback posture. The other had very large, muscular thighs, and her core didn’t balance them very well. Obviously, I can’t feel her back, but I would expect her to have excessive curve; she’s arching it a little because her legs are heavier than her trunk can support. The body likes to take the path of least resistance. If your thigh muscles are heavy, or your legs are stiff, then instead of moving the leg fully forward, you’ll rotate your back a little. And that’s too much movement in the lower back.”
“What about that guy?” I ask, indicating a heavyset man who’s walking with this feet pointing out at 45-degree angles. “Turning your feet out can be perfectly normal,” Holtzman surprises me by saying. “It just depends on the structure of your hip. The problem is, some people try to change it—particularly if their feet turn inward, they’ll try to force themselves to walk straight, and that puts their hip in a potentially bad position.”
A skinny, sweet-faced young med student in a hoodie grabs his cappuccino. “His backpack is so low, it’s almost pulling him down,” Holtzman whispers. “He has to compensate for that, so he’s hunched forward, and that thrusts his head forward, which puts a lot of stress on his neck. If hunching becomes a habit, the muscles in the middle of the spine start to get long and can’t support you very well, so you’re hunched over more and more often. Now you’re looking down, and you don’t want to do that, so you try to stand up tall, but you don’t have the muscle strength, so you arch your lower back. Or you hunch over but bring your head up, and that shortens the muscles in the back of the neck, which can lead to tension headaches.
“For this guy, one simple change is just raising his backpack. That lady in the gray striped shirt, she has a really hunched middle spine and forward head. She’s basically lost her neck. That weakens the muscles in the front of the neck and puts more stress on the cervical vertebrae, because they’re compressing and shearing each other.”
You can compress and shear for years without feeling a thing. “So you develop habitual postures and patterns of movement,” he says. “And the ways those habits develop are fed by what you do on a daily basis—and what you don’t do!”
A guilty flush warms my cheeks as I remember his bio: Holtzman started Wash. U.’s running clinic. “It’s not good to start running in middle age, right?” I blurt. “Hard on the joints.”
“I get a little frustrated when I hear that,” he says with a sigh. “Yes, running is stressful for the joints, and if somebody is having pain, it’s very easy to tell them not to run. If my clinic were structured on the premise that you just need to stop running, I could certainly get people to be pain-free. But running is actually a very economical form of exercise. There’s no question it’s high-impact—that’s sort of the point. What you want is to get good form, so there’s not as much stress on the body. And you should start slow, alternate with walking or cross-training. The Couch-to-5K program’s a good one.”
A young woman in a puffy purple jacket crosses in front of us. “She doesn’t have a lot of strength in her glutes,” he remarks, “so her hips drop—foom, foom—as she walks. That can put stress on your back, your hip, your knees. We neglect our glutes because we can take over with other muscles. I would tell her to actively squeeze her glute muscles when her feet hit the ground—my hope is that from heel strike to foot flat, those glutes are coming on to prevent the drop. And the other cue I give people is to imagine they are walking uphill, tilted slightly forward.
“I focus a lot on how people perform functional activities during the day,” he adds, “because if I give somebody a functional exercise and they go through 10 squats but every time they go up a step, they move incorrectly, the exercise isn’t doing them any good.” He confides his dream: that we’d all learn proper movement and posture as children, the way we learn good dental hygiene, and we’d have a physical therapist evaluate our movement maybe once a year. Making that the norm would require insurance reimbursement. But it would head off a lot of problems.
He borrows my notebook and draws a “Physical Stress” diagram, starting with a baseline of “maintenance.” Above it is “adaptation,” where you use your muscles enough to strengthen them. Above that is “injury and tissue death,” so the key is to know just how far to push yourself and when to stop.
Then the chart gets interesting: Below “maintenance” is “maladaption and atrophy,” the circle of the inferno populated by those of us who are far too sedentary, overweight, and weak-muscled. Below that comes “injury” and “frailty,” where we are not only unwilling but unable to move.
“The body craves movement,” he says, eyes on an older woman who’s shifting from one leg to the other as she waits for her caffeine. “A lot of movement comes down to gait,” he adds, watching her grab the cup and scurry out the door. “You can see the people that have no arch support; their feet collapse inwards. Pronation. They’re walking on the inside of their feet, and you know they’re not supporting themselves very well. Or their glutes are weak, and you see their entire pelvis rotate as they walk. Or their head is jutting forward instead of resting straight on the neck.” He nods toward a young woman in sneakers. “See her foot collapsing? That’s a poor shoe choice for her, because it has no support.”
Now he’s getting downright Sherlockian. “How can you tell that? The fabric? The thin sole?”
He grins. “No, I just know the shoe. I have that shoe.
“Pronation occurs naturally,” he continues. “It’s just if you have too much of it, or you can’t get out of it. I don’t necessarily believe that everybody who excessively pronates has to be in orthotics. You can get the foot stronger. But you have to at least be aware of what the foot is doing.
“We don’t think about the way we move,” he concludes, “because 90 percent of the time it doesn’t hurt. Most of the people I commented on today might not even have pain.
“But they will.”
