The Short-Foot Exercise for Stronger Feet

Foot/heel/Achilles issues have given me trouble over the years. The same issues are the scourge of many a runner. Plantar Fasciitis, Achilles tendon pain and metatarsalgia are a few of the problems one can experience as a result of faulty foot and lower-leg mechanics.

The causes of these injuries are often multi-faceted and thus are the solution(s). It seems that weakness of the foot muscles may be a prominent issue. One idea on the mechanism of plantar fasciitis is that the intrinsic foot muscles do a poor job of controlling forces going through the foot. If the stresses of running and walking aren’t distributed adequately then we may overstress the plantar fascia and that may trigger pain. We then need to find a way to unload the stressed tissues. (Please note that this may or may not be what causes plantar fasciitis. There are a lot of questions on how this and other lower-limb pain develops. This study discusses the poor understanding of plantar fasciitis and the difficulty in measuring foot mechanics.) If weak and underperforming foot muscles are part of the problem then how do we bring them back on line?

Lots of muscles and joints in those feet.

Among many strategies to address foot pain is an exercise known as the short-foot exercise or foot doming. As the name implies, this exercise has you using the intrinsic foot muscles to create a dome by pulling the metatarsal heads (balls of the toes) toward the heel, which shortens the length of the foot.

The short-foot or foot dome exercise.

More than anything this is a brain exercise. Chances are that when you first try this exercise you won’t do it very well. You’ll struggle, steam may come out of your ears and you’ll get frustrated. Don’t be a baby and give up immediately though. This is a new skill and it takes focused attention and time to develop skills. Keep at it. It likely won’t take you very long to figure it out. For me, the challenge of mastering this exercise is nothing compared to the frustration of being sidelined by foot pain.

Also, try the exercise on your non-hurting foot. If you’re like me, you’ll find that it’s easier to do which again may be an indicator that the source of your pain are muscles that aren’t doing their job correctly.

You may experience cramping. That’s fine. It means you’re doing the exercise correctly. You can either relax the foot muscles and try again or do what I’ve done and hold the short foot until the cramping passes. It hurts a bit but I’ve found the pain to pass quickly.

The muscles involved in this exercise aren’t given to being big and strong. We need them to work a lot for a long time, so we need to condition their endurance. Therefore we need to hold the short foot position for time and we need to do the exercise often throughout the day. The good thing is you need no equipment to do this and you can do it anywhere. You don’t have to take off your shoes either.

I think this video does a good job of describing the exercise:

More Hip Mobility From GMB

I’m a fan of mobility. I put a premium on my clients and I having a large “movement database.” I’m not just talking about flexibility mind you. On that note, I like Dr. Andreo Spina’s words on mobility vs flexibility:

“By my definition, mobility and stability are intimately related. Mobility, which is often confused with ‘flexibility,’ can be defined simply as the ability to move or to be moved freely and easily. Another way to think of it is the ability to actively achieve range of motion. Flexibility by contrast is the ability to passively achieve range of motion. It is therefore possible to be very flexible, however have limited mobility. The former implies that you can passively achieve a particular range, while the latter implies neurological control of a particular range as it is being actively attained.”

I’m also very interested in the concept of movement variability. What is “movement variability?” Todd Hargrove of Bettermovement.org discusses it as such:

“Good movement is not just about harmonious interaction or coordination between the different parts of the body. It is most fundamentally about how the system interacts with the environment, particularly in response to unexpected changes. In other words, good movement implies a quality of adaptability and responsiveness to a changing environment.

One can imagine building a humanoid robot that can walk with flawless symmetry and grace. But if the robot cannot adapt its gait pattern to accommodate changes in the terrain, it will fall each time it steps on a rock, and its movement skill is essentially useless. True movement intelligence therefore doesn’t exist so much in the movements themselves, but in their interaction with the environment.

The graceful stride of the deer isn’t useful unless it can be modulated to jump a log and avoid a wolf. A soccer player who can execute technically brilliant ball handling skills in solo practice does not face the real test until she performs those moves in a game situation against an opponent who is trying to steal the ball.

We would not say that someone is fluent in a language if they have only one way to communicate a particular thought, regardless of how perfect that particular communication is. Similarly, one is not fluent in the language of movement unless he can accomplish the same goal in many different ways.”

Why do I mention movement variability? My last blog post was about hip mobility and in it were several different hip mobility drills. This post is also about hip mobility and it features a bunch of different drills. Which ones are best? Who knows? With regard to movement variability, I think it’s probably a good idea to do a lot of different mobility drills and frequently experience novel movement.

Recently I discovered GMB.io. (Yes you read that right.) I’m not sure what GMB stands for but I have enjoyed looking through their content which is very much mobility-centric. Their 8-exercise hip mobility sequence (below) is great! I’ve been using myself and with my clients. Lately I’ve been alternating between this series and the series in the prior post.

More Achilles Tendon-itis/-osis/-opathy (or Whatever It Is)

About three weeks ago I went for a run in the snow. Part way through I felt some irritation in my left Achilles tendon. Like anyone who loves/needs to exercise, I kept running and I tried to convince myself that it wasn’t too bad, that it would probably go away soon or maybe if I changed my stride slightly it would resolve during the run.

I was wrong! I really irritated the thing and had to walk about a mile. This was the latest flare-up of a years-long lingering issue. (I’ve discussed the Achilles here and here, as well as left heel pain/plantar fasciitis here, here, here, here, here and probably in some other places… You’d think for someone who’s considered this issue so much that I wouldn’t have it anymore.)

Prior to this Achilles flare-up, I’d had some of some old familiar heel pain. It wasn’t debilitating but it was a signal that something wasn’t as it should be. Again, I ignored it to a large degree and figured it would resolve. I should’ve paid closer attention to it. Essentially, it wasn’t a problem until it was a problem. Time to get back to work on this thing.

Tendon injury: A complex issue

Why do we get injured? How do our tissues (like tendons) become damaged? If we administer the right amount of stress and then recover we get a positive adaptation–we get stronger. In contrast, if we administer too much stress and we don’t recover then we get some type of injury. Thus too much stress delivered too often and/or too fast has been my problem. I need to increase my tissue tolerance to the forces of running.

A recent article from Alex Hutchinson is titled Pro Tips on Treating Tendon Injuries. This article covers a debate among members of the Canadian Association of Sports and Exercise Medicine in Ottawa. Several top sports physicians and therapists were asked: Which therapy should the squash player try next? (I’m not a squash player but I have the injury they discussed.) If you’re dealing with this issue it’s definitely worth a read. It discusses several methods: eccentric strengthening, nitroglycerin patch, dry needling, cortisone, and platelet-rich plasma.

There wasn’t 100% agreement on anything much, but Hutchinson’s concluding statement was this (emphasis is mine):

“So what should the poor squash player do? In the question period following the debate, most participants conceded that strengthening exercises are the path to long-term health. Depending on the specifics of your tendon injury, other techniques may provide relief to allow you to exercise, but they’re not permanent cures.”

Cures I like. I have no interest in simply treating symptoms. Thus I decided it was time to implement something with which I’d been familiar but which I knew wouldn’t be very exciting at all: the eccentric strength protocol.

Eccentric strengthening

First, what does “eccentric” mean?An eccentric contraction is one in which the muscle is contracted but it’s also lengthening. Think of doing a bicep curl. You know the part where you yield to gravity and lower the weight? That’s the eccentric portion of the movement. (In contrast, the concentric portion is where you overcome gravity and bring up the weight.) For this particular protocol, we want to fight against the lowering action and lower very slowly.

I found a very thorough resource for this project from Jeff Gaudette at RunnersConnect.net. It’s titled The Ultimate Runner’s Guide to Achilles Tendon Injuries: The Scientific Signs, Symptoms, and Research Backed Treatment Options for Achilles Tendonitis and Insertional Achilles Tendinopathy. (The title of this thing just screams ACTION!! doesn’t it?) You can download both the Injury Treatment PDF and the Injury Prevention PDF. As the title suggests, this is a thoroughly researched guide to dealing with tendon injuries. I appreciate very much that there is both a treatment and prevention strategy. I won’t go into the whole thing but here are the basics:

The strength protocol consists of two exercises: a straight-kneed and a bent-kneed
eccentric heel drop. The protocol calls for three sets of fifteen heel drops, both bent- kneed and straight-kneed, twice a day for twelve weeks.

Standing on a step with your ankles plantarflexed (at the top of a “calf raise”), shift all of
your weight onto the injured leg. Slowly use your calf muscles to lower your body down,
dropping your heel beneath your forefoot. Use your uninjured leg to return to the “up”
position. Do not use the injured side to get back to the “up” position! The exercise is
designed to cause some pain, and you are encouraged to continue doing it even with
moderate discomfort. You should stop if the pain is excruciating, however.

Once you are able to do the heel drops without any pain, progressively add weight using a backpack. If you are unlucky enough to have Achilles tendon problems on both sides,
use a step to help you get back to the “up” position, using your quads instead of your
calves to return up.

The eccentric exercises are thought to selectively damage the Achilles tendon, stripping
away the misaligned tendon fibers and allowing the body to lay down new fibers that
are closer in alignment to the healthy collagen in the tendon. This is why moderate pain
during the exercises is a good thing, and why adding weight over time is necessary to
progressively strengthen the tendon.

You do these exercises for 3 sets of 15 reps, twice daily. There are photos showing these exercises including a modification if you have what’s known as insertional Achilles tendonitis. Again, read the whole thing if you want the full rundown of this protocol.

More thoughts

Part of why I haven’t done this in the past is that it is slow and tedious! Three sets of 15 slow reps makes time crawl like some sort of crippled tortoise. It ain’t fun! Plus I’ve never cared much for doing calf work. That said, I need to fix this problem. This process seems to be the best way to go about it, so I’m on board.

Something else I realize is that if I’m prone to this injury and I want to avoid it then I need to do the preventive work. That means setting aside time throughout the week and during my workouts to do some of this stuff.

I’ve been doing this work for about the past three weeks and I am getting better. I’ve done a couple of short run/walks and I’m not in the clear just yet. The only option I see is to continue doing what I’m doing.

Update

I just went on a run of a little over two miles and the Achilles feels fantastic. No pain! Felt like I could’ve run all day–which would’ve been stupid of me. This protocol is working for me right now.

Activity is Better Than Rest for Overcoming Lingering Pain

I’m glad to see Outside Magazine delivering a message that may be very useful to anyone suffering from pain. (This is from 2009, but I just saw it.) The article mirrors my recent experience with my ACL rehabilitation. The Real Heal: Overcoming Athletic Pain says two things essentially:

Rest usually doesn’t cure what hurts us. (In fact, too much rest makes us deconditioned and contributes bad feelings in general.)
Moving and using our sore parts–confronting the pain–is essential to getting rid of pain.

The writer discusses his journey following a bike crash which hurt his knee (an acute injury). He rested and took pain medicine. He states (emphasis is mine):

“It turns out my belly-up approach was dated. New research is proving that the best way to treat nagging pain is to eschew pampering in favor of tough love. Doctors at the University of Pittsburgh are doing ongoing research showing that stretching irritated tendons actually reduces inflammation. And the principle extends beyond rickety wiring. Every expert I spoke with told me variations of the same thing: ‘Rest and ibuprofen cure few injuries,‘ said Dr. Jeanne Doperak, a sports-medicine physician at the University of Pittsburgh. ‘During rest you’re in a non-healing zone,‘ offered Dr. Phelps Kip, an orthopedic surgeon and U.S. Ski Team physician. ‘The body was designed to move.'”

Pain is very much a psychological thing. I can relate to this:

“And it just so happens that tendinopathy chronic tendinitis is the most diabolical of recurring injuries. Give me a broken foot over tendon trouble any day when something snaps, at least you know what you’re in for. My injury dragged on into winter, deep-sixing my mood. This is not uncommon: The link between pain and depression is so well established that sports psychologists use a tool called a Profile of Mood States to monitor injured athletes. (This is a graph evaluating tension, depression, anger, vigor, fatigue, and confusion. People in pain score extremely high in every category except for vigor.) I was five years removed from being a college athlete and I was Long John Silvering it up stairs at work. Strange questions crept into my head: Could I consider gardening exercise?”

I like the overall message of the article but I don’t agree with all the information:

The writer says, “… or imbalances in the body’s kinetic chain of movement (a weak core can cause lower-back pain).”

Though this is a popular concept, there is significant evidence that “core strength” (which can be defined and measured in a multitude of ways) has nearly nothing to do with back pain.

For runner’s knee, the writer suggests this: “Lie sideways on a table, legs straight, and slowly raise and lower the upper leg ten times. Do three sets. Easy? Ask your PT for a light ankle weight.”

I think this might be part of an effective strategy to address runner’s knee (if the problem is rooted in the hip which it often is; however it could be rooted in poor control of the foot and ankle), but there are several dots that I think need connecting between this exercise and full-on running. This exercise is very different from running in which the foot impacts the ground and the runner must control motion at the foot, ankle, knee and hip. If this is the only exercise given to a runner’s knee patient then I’m skeptical that the runner will fully overcome the issue.

A caption under a photo reads, “Preventive Measures: Recovering from a nagging injury? Next time you go for a run or a ride, try taking ibuprofen beforehand. As long as you’re cleared for activity by your doctor, inhibiting swelling prior to a workout can dramatically reduce post-exercise inflammation and pain.”

This is an interesting idea but I have strong reservations. Pain is a signal that should be respected. Even though pain doesn’t equal injury it’s still a message from our brain that there is a perceived threat that needs to be addressed. The pain could be signaling a threat related to poor movement control and tissue stress is leading toward injury. By taking a pain-blocking drug, we might simply be turning down that signal as we continue with what may turn into an acute injury. I would compare this to driving a car with a damaged muffler that needs replacing and instead of replacing the muffler, we turn up the stereo loud: No noise!!–but have we fixed the problem?

On the other hand, I understand that even if the movement problem is addressed, we may still feel pain. Taking a drug may help the brain experience the new, better movement in a painless way which might help break the chronic pain cycle. I’m curious to what degree this has been method has been investigated.

For me, as a personal trainer, I would never suggest someone take a drug and just keep going. Rather, I would speak with the person’s PT. If he or she OKs it, I would then advise someone to move and work below the pain threshold or at a very manageable level of pain.

Pain, the Brain and ACL Recovery

A few weeks ago I had a very interesting experience regarding my ACL rehabilitation. It’s very similar to an experience I had with Achilles tendon and heel pain. Here it is.

A perceived setback

I had ACL reconstruction on May 1, 2014. I have been very aggressive with my rehabilitation and I felt it was going very well. My PT and I agreed on a strategy and he approved of the process in general. I knew that sitting and resting was not the right way to go if I wanted to regain full function. For people like me, laziness wasn’t a problem; an overly aggressive approach might be though.

I knew that I could be in trouble if I did too much work too fast and stressed the knee too much. I worried that I’d drifted into this territory when at almost nine months I experienced more pain than I expected. I had a final appointment with my surgeon and she expressed some concern at my symptoms. We agreed that I should back off my activity and rest a bit. Seems perhaps I had reached the point of “too much of a good thing.”

I backed off lifting, running a cycling. I didn’t stop my activity completely but I cut it back significantly. After a couple of weeks I realized the knee wasn’t feeling much better. I continued to experience frequent pain; not debilitating but somewhat worrisome. I decided a visit to the PT was in order. I wanted to get some guidance and make sure I hadn’t damaged the graft.

The long and the short of the visit was this: The graft and my knee were fine. I needed more strength in the leg and around the knee. I needed to do more work, not less! Eureka! (My previous PT had moved on to another position and I had to meet with a new one. Unfortunately, the “bedside manner” of this PT left much to be desired. Right off the bat she was rude, dismissive and she interrupted my answers to her questions. I became very frustrated and it was work to keep my yapper shut and listen to what I needed to. Fortunately I got the information I needed.)

From here, I was ready to rock ‘n’ roll.

Goodbye fear. Hello confidence!

My experience was a very clear experience of what modern pain science has been finding recently. Here are some important points:

1) Pain doesn’t equal injury: In Reconceptualising Pain According to Modern Pain Science, neuroscience researcher Dr. Lorimer Moseley has made several points about pain. Two are pertinent here:

pain does not provide a measure of the state of the tissues
The relationship between pain and the state of the tissues becomes weaker as pain persists.

Yes I had an injured knee and yes I had surgery in which part of my patellar tendon was cut out in order to make a new ACL. This was all very disruptive to parts of the knee and was clearly part of the pain I was feeling. It takes about six weeks for the graft to heal. The reconstructed ACL is pretty much healed at six months which would’ve been October for me. In other words, my knee was/is healed and any pain wasn’t from tissue damage.

2) Fear is a significant obstacle that must be addressed: Fear is a powerful part of our pain. Overcoming that fear is major part of a successful rehab and return to activity. The pain in my knee caused me to worry that I’d re-injured it and it led me to avoid a lot of activity that I enjoyed. This condition is known as fear-avoidance. The International Association for the Study of Pain (IASP) describes fear-avoidance this way:

Psychological factors play a key role in the development of chronic musculoskeletal pain, in particular dysfunctional beliefs about pain and fear of pain. Fear of pain leads to avoidance of activities (physical, social, and professional) that patients associate with the occurrence or exacerbation of pain, even after they may have physically recovered. Whereas this response is adaptive in the acute phase—rest promotes recovery—it leads to disability and distress when avoidance behavior is continued after the injury has healed.

“Fear-avoidance model” by LittleT889 – Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:Fear-avoidance_model.jpg#mediaviewer/File:Fear-avoidance_model.jpg

When I learned that my parts were solid and strong and that I wasn’t broken, I felt the fear drain away like water down a toilet. I was a happy dude!

Another of Moseley’s points is important here: that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.

Big words. What does that statement mean? I’ll let Moseley explain (emphasis is mine):

“First, there are other central nervous system outputs that occur when tissue is perceived to be under threat, and second, that it is the implicit perception of threat that determines the outputs, not the state of the tissues, nor the actual threat to the tissues.“

In even simpler terms, we may feel pain absent any damage but we feel pain when our brain perceives a threat–even when there is no threat. I compare this to a car alarm that is set off by the wind. There’s no break-in occurring yet the alarm signal is going off due to the alarm sensing a threat.

3) Patient education is vital: Very interestingly, an effective strategy in treating chronic pain is patient education. This strategy of patient education is supported in several studies that are discussed in a review in the Archives of Physical Medicine and Rehabilitation, and it’s further discussed in an article titled Can Pain Neuroscience Education Improve Endogenous Pain Inhibition? Literally, knowledge of pain processes can reduce pain. (Pain is weird!) I believe that my experience supports this phenomena.

(To be clear, it’s not that I received education on how pain works. I received the message that my knee was solid, not injured and that it could be worked very hard.)

Keep this in mind.

Dr. Moseley discusses pain education in Pain really is in the mind, but not in the way that you think. I like what he says here:

“The idea that an inaccurate understanding of chronic pain increases chronic pain begs the question – what happens if we correct that inaccurate piece of knowledge?

We’ve been researching the answer to this for over a decade, and here’s some of what we’ve found:

(i) Pain and disability reduce, not by much and not very quickly but they do;

(ii) Activity-based treatments have better effects;

(iii) Flare-ups reduce in their frequency and magnitude;

(iv) Long-term outcomes of activity-based treatments are vast improvements.”

Most of us outside the medical community probably still equate pain to damage. Many inside the medical community still think that way too. (Blame Rene Descartes.) We now know better. Rather than address pain from a strictly biomechanical approach, therapists would be well advised to study and adopt what’s known as the biopsychosocial model for pain. This model is explained very well here and discussed in-depth here. We patients will be well armed in a fight against pain if we understand this model too.

What I’ve Learned: Principles of Movement & FASTER Global – Part IV

I’ve been discussing movement, exercise and how to make traditional exercises more applicable to real-life and athletic activities. I’ve discussed going from two feet to stepping. From there we can progress to a variety of hops and jumps.

Progressions

2 feet to 1 foot
stationary to stepping to jumping
jumping from two feet to two feet
jumping from two feet to one foot
jumping from one foot to one foot
stepping and jumping may occur in saggital, frontal or transverse planes
add weight

Other things to think about

We could focus on “sticking” the landing and maintaining perfect balance and control or we might focus on moving very quickly from one hop/jump to the next.

We might emphasize a very long or very high jump/hop or we might emphasize short and fast hops/jumps.

Here are some videos featuring tri-plane jumping and hopping with all sorts of arm driver activity. These are in no particular order and I’m not showing a progression. These are just a few combinations.

There is a nearly endless galaxy of these types of exercises. Any number of implements can be used (Core Momentum Trainer, dumbbells, sandbags, kettlebells, nothing at all). Trainees can either stay stationary or move in any direction.

I’m in the advanced stages of ACL rehabilitation and I’m using a lot of these types of exercises in my own workouts. I’m using them with a lot of my clients who are athletes as well as clients who don’t consider themselves athletes. These exercises can be a lot of fun, feel very challenging and are useful in stimulating the metabolism for those wanting to lose weight.

What I’ve Learned: Principles of Movement & FASTER Global – Part III – Lunge and Reach

In the previous two posts, (here and here) I discussed what I’ve learned by going through the FASTER Global coursework. (If you’re a fitness professional who wants to truly become an expert at movement, then you need to do this course. This has been the most comprehensive movement education I’ve had in nearly 20 years of working in the fitness field.)

I believe I’ve made the case for why we should train with tri-plane movement. Further I believe that I’ve illustrated why traditional gym exercises like squats and deadlifts may not be the best way to develop all-around movement skills or strength. (For the record, I’m not saying traditional squats and deadlifts are bad. I use them in my own workouts and with my clients. To be clear, I believe that there are infinite variations that can and should be used to condition people in the most comprehensive way.)

In the previous post I showed a bunch of lunge and squat variations. Here are some more lunge variations this time with arm reaches.

Lunging and reaching

While lunging, we can drive motion from the upper body by reaching up, down, across, overhead, etc. We can reach with one or both arms. The way in which the trainee steps drives motion from the upper body up through the rest of the body. As he or she reaches, motion is driven down through the body toward the ground. The reaching affects balance and creates a wide range of slightly different body positions which look a lot like any number of athletic activities, for example, look at the baseball pitcher and basketball players.

Lower body motion plus upper body motion.

Saggital plane anterior lunge with same-side posterior arm reach… Or something like that. Lots of stuff happening.

Kobe executes a type of lunge and reach down.

Resistance can be added to these in numerous ways: weight vest, dumbbell(s), sandbags, kettlebells, etc. Cables or tubing positioned at any number of angles can speed up or slow down the lunge.

Remember though, if someone can’t control these exercises then he or she should be regressed to something that is controllable, safe and manageable.

Here are a few examples of lunges combined with reaches in various directions. I’ve shown an anterior lunge and a lateral lunge but we could add any of these reaches to any type of lunge. The combinations are nearly infinite.

Next we can progress to jumps and hops, all done in any number of directions, all with feet and arms in any number of positions. I’ll show some of those in the next post.

What I’ve Learned: Principles of Movement & FASTER Global – Part II

From gym work to “real life.”

Athletic endeavors and typical daily movements are rarely symmetrical. We’re often stepping from one foot to the other in any of several directions, swiveling and/or bending our bodies, reaching, moving with a load on one side of our body–all potentially at the same time. If we think of the SAID Principle (discussed very thoroughly here by Todd Hargrove of Better Movement) then it stands to reason that some of our training ought to resemble our chosen athletic or leisure activity, both in movement pattern and energy system usage.

A squat by any other name…

A lot of conventional exercises–squats and
deadlifts for instance–keep the feet planted against the ground in a symmetrical stance. Fine, but how much should we expect those exercises to translate to something like skiing? Yes skiing uses two legs and it sort of looks like a squat but there’s a lot more going on during a ski turn than just moving the body down and up.

We could say something similar about basketball where there’s a lot of jumping,

landing and movement into positions which look a good bit like a deadlift–but clearly doesn’t look like the standard deadlift.

Here’s a very interesting video on how to take a squat and add some flavor to it:

These are the types of movements that more closely resemble many sports and recreational activities. These can be used as part of a warm-up for a workout or they can be used as the workout itself.

Ground reaction forces

At some point we need to consider ground reaction forces. A foot or feet hitting the ground creates a whole different set of circumstances compared to planted feet. Enter the lunge.

A lunge creates a ground reaction force (GRF) as the foot hits the ground. A series of events should ideally take place in a certain sequence at the following joints: mid-tarsal joint, subtalar joint, talocrural joint, knee, hip and on up through the spine and even out to the shoulders and beyond!

(BTW, a lunge can be any distance or depth. If someone can’t lunge far and deep then it’s completely appropriate to simply take a step. I often ask my clients to go as far and/or deep as they can only so long as they can maintain control of the movement.)

There are a lot of variations on the lunge. We can step in any number of directions. Our world is a three-dimensional place so we can step forward or backwards, side to side, or in a circular or twisting type of motion.The purpose in doing this is to allow us to experience a wide range of joint angles and different ground impact scenarios. We can see if an athlete is able to move into his or her sport position. We might be able to expose a movement pattern that is unstable and which the athlete may want to improve for performance and safety.

Lunges for all occasions

Here are a collection of lunges done in an assortment of directions. Each type of lunge creates a different reaction throughout the limbs and joints.

Not pictured are lunges in which the trainee steps up or down off of a step. Any of these lunges can be done in this way. It’s a good way train for something like a hike (if for some reason a hike can’t be undertaken) or to simply add variety and new skills to the workout. Next you’ll see lunging in conjunction with reaching.

What I’ve Learned: Principles of Movement & FASTER Global – Part I

I spent much of the Summer and Fall going through the FASTER Global Specialist in Functional Performance and Specialist in Functional Therapy courses. It’s been a fantastic experience. At times it was incredibly challenging but such is life with anything worth learning and doing. I’ve come away from the experience with a tremendous movement analysis skill set, and a systematic way of thinking that I didn’t have before.

Sometimes I think I know something, that I’m a fairly knowledgeable trainer. Then I’m exposed to new information and I think, “I don’t know anything!” Whenever I dig into something new I have my old beliefs challenged by new concepts. That’s very much my experience with FASTER.

In this post I’m going to cover a few things I’ve learned. I’m going to try and keep it concise. I could meander all over the place….

The Specific Adaptation to Imposed Demand (SAID) principle is always at the top of the FASTER thought process. We consider the client’s or athlete’s goal(s) and then we build a program that very closely resembles that goal. If we’re working with a skier then joint motions and body position should look a lot like skiing. Similarly with a bowler, kayaker, runner, rock climber, pitcher, someone who has trouble waking up and down stairs–whatever. So with that we start with some questions.

Two big questions & another question:

Can the athlete get into the position required by the activity?
Asked another way: Does the athlete have the range of motion for the task?
If yes, can the athlete control that ROM?The above two are big. If we get two yeses then we ask:
Can the athlete control the ROM at the speed required of the sport?

Look at these activities. Lots of interesting poses here. Notice how the bodies are positioned. Notice the knees, hips, trunk, arms and head. Take note of all the angles between the joints. Here’s a question: Do any of the exercises you see or do in the gym look anything like any of these? How much of what you do in the gym puts you in an athletic or “real life” position? Does a standard squat, deadlift, kettlebell swing, sit-up or any type of machine exercise fit the bill?

In my exercise toolbox I now have the observational skills and knowledge to address those previous there questions with my clients and athletes. I know how to progress people from very simple movements to far more aggressive movements. I feel confident in my ability to help my clients solve their own movement problems via what I hope are fun, challenging and safe exercises.

(BTW, this also applies to anyone who “just wants to work out.” If he or she has no athletic goals but wants to feel like they’ve worked hard, I can instruct them on exercises that will be both challenging and safe. If I think a squat is the type of exercise that will satisfy his or her requirement to “feel” a workout, then I still will ask those questions.)

In following posts I’ll discuss progressions and variations on traditional exercises. By playing with joint angles, foot positions and hand/arm positions, and by employing impact (stepping, hopping, jumping) we can create an infinite number of exercises that closely resemble sporting activities. With this process we can probably better prepare for sports than if we simply employ traditional exercises like squats, bench presses and deadlifts. Don’t worry if you don’t consider yourself an “athlete.” These exercises tweaks can be a lot of fun, very challenging and never boring.

For effective management of persistent pain, provide a clear understanding of the factors that drive pain, develop graduated strategies to normalise and optimise movement patterns while controlling pain, and couple these steps by prescribing sports specific conditioning and a graduated return to sport. Addressing psycho-social stressors and unhealthy lifestyle factors is part of this process, especially where ‘central’ pain features are dominant. Magic bullets don’t exist, so don’t promise them.
– Dr Peter O’Sullivan, Curtin University, West Australia

Tiger Woods received a lot of coverage earlier this month for withdrawing from a golf tournament due to back pain. Tiger mentioned back spasms in interviews and made the following statement:

“It was a different pain than what I had been experiencing, so I knew it wasn’t the site of the surgery. It was different and obviously it was just the sacrum,” Woods said. “The treatments have been fantastic. Once the bone was put back in the spasms went away, and from there I started getting some range of motion. My physio is here. If it does go out (again), he’s able to fix it.”

So the implication here is that the sacrum can in fact pop out and be put back in place. And that once the sacrum is back where it belongs–presto!–the pain was gone. This is the type of statement that perks up the ears of numerous therapists, coaches and trainers. This is also the type of information that grabs the attention of multitudes of back-pain sufferers. There’s hope! A magic treatment is at hand!

First, can a sacrum pop out? For that question, I like these words from UK physiotherapist Adam Meakins aka the Sports Physio:

“The notion of anyone’s sacrum just ‘popping out’ is complete and utter nonsense, let alone the sacrum of a fit athletic professional male golfer without any past risk factors or history of significant trauma…

SACRUMS DONT JUST POP IN AND OUT…

All that white webbing-type stuff are ligaments. Very strong stuff. The sacrum is underneath it between the hip bones at the bottom of the spine.

For starters the pelvis is an incredibly strong and stable structure with many, many strong ligaments and muscles across it. The sacroiliac joint does have some small amount of movement, and yes some have more or less than others, but the variation is minimal and the ridiculous belief that many therapists have in thinking that they can 1) feel this joint move 2) decide if it’s in the right or wrong position and 3) adjust it with manipulations is just again complete and utter nonsense based in pseudo science and nothing more than palpation pareidolia as I have discussed before in my previous blog here and on the assessment of the painful SIJ here and its management here.”

So why did Tiger think his sacrum had ‘popped out’ well there are two possible reasons.”

One very competent and observant trainer is Boulder’s Mike Terborg. He sent me an informative article from the British Medical Journal Blogs called Common misconceptions about back pain in sport: Tiger Woods’ case brings 5 fundamental questions into sharp focus. It was written by physiotherapist Dr. Peter O’Sullivan. I won’t go into every detail of the article but I’ll summarize the big pieces. (Emphasis is mine.) O’Sullivan lists five quotes related to Tiger’s pain and then asks questions of those observations. He cites research to support his answers. Go to the article to read the whole shebangabang.

“Tiger has a pinched nerve in his back causing his pain.”
What is the role of imaging for the diagnosis of back pain?

O’Sullivan: “Disc degeneration, disc bulges, annular tears and prolapses are highly prevalent in pain free populations, are not strongly predictive of future low back pain and correlate poorly with levels of pain and disability. (Deyo 2002, Jarvik JG 2005).”
“Tiger had a micro-discectomy for a pinched nerve which had lasted for several months.”
What is the role of microdiscectomy for the management of back pain?

O’Sullivan: “The role of decompressive surgery (micro-discectomy) should be limited to nerve root pain associated with progressive neurological loss (e.g., leg weakness)… (O’Sullivan and Lin 2014). Micro-discectomy is not a treatment for back pain.”
“My sacrum was out of place and was put back in by the physio.”
What role do manual therapies play to treat back pain?

O’Sullivan: “Passive manual therapies can provide short-term pain relief. Beliefs such as ‘your sacrum, pelvis or back is out place’ are common among many clinicians.

These beliefs can increase fear, anxiety and hypervigilance that the person has something structurally wrong that they have no control over, resulting in dependence on passive therapies for pain relief (possibly good for business, but not for health). These clinical beliefs are often based on highly complex clinical algorithms associated with the use of poorly validated and unreliable clinical tests (O’Sullivan and Beales 2007). Apparent ‘asymmetries’ and associated clinical signs relate to motor control changes secondary to sensitised lumbo-pelvic structures, not to bones being out of place (Palsson, Hirata et al. 2014). In contrast, there is strong evidence that movements of the sacroiliac joint is associated with minute movements, which are barely measurable with the best imaging techniques let alone manual palpation (Kibsgård, Røise et al. 2014).”
“I need to strengthen my core to get back to playing golf again.”
What is the role of core stability training?

O’Sullivan: “’Working the core’” has become a huge focus of rehabilitation of athletes and non athletes in recent years.

Recent studies have also demonstrated that positive outcomes associated with stabilisation training are best predicted by reductions in catastrophising rather than changes in muscle patterning (Mannion, Caporaso et al. 2012), highlighting that non-specific factors such as therapeutic alliance and therapist confidence may be the active ingredient in the treatment – rather than the desired change in muscle.“
What should clinicians do? The paradigm shift required for managing a complex multidimensional problem like back pain.

O’Sullivan: “Firstly, clinicians need to realise that back pain does not mean that spinal structures are damaged – it means that the structures are sensitised…There is growing evidence that low back pain is associated with a combination of genetic, pathoanatomical, physical, neurophysiological, lifestyle, cognitive and psychosocial factors for each domain. The presence and dominance of these factors varies for each person, leading to a vicious cycle of tissue sensitisation, abnormal movement patterns, distress and disability (O’Sullivan 2012, Rabey, Beales et al. 2014).”

O’Sullivan makes these recommendations to clinicians:

To adopt this new approach clinicians require at least two things:

Change of mindset: Abandon old unhelpful biomedical beliefs, and embrace the evidence to change the narrative to help people with pain understand the underlying mechanisms linked to their disorder.
New and broader skills for examining the multiple dimensions known to drive pain, disability and distress. These assessment skills need to be complemented by the skill of developing innovative interventions that enhance self management, allow the patient to engage in relaxed normal movement. The clinician also needs to encourage the patient to adopt healthy lifestyles and positive thinking about backs (O’Sullivan 2012).

The change he advocates for is sloooowly happening in some areas of health care. The strictly biomechanical model (pain = injury) is still king.

Denver Fitness Journal

All Things Health and Fitness by Kyle Norman, MS, CSCS, FMS, RRCA Running Coach

Injury Rehabilitation