How return to running can begin in acute injury rehab

An article for Inform Performance E-Magazine. (Includes brief videos for visual aid, around 1 min long).

Return to running is often discussed in sports rehab and we are getting spoilt with the metrics and objective measures that we can use now to help inform return to running. But what comes before this stage? Before we start achieving jump heights or reactive strength index scores, or even before that with endurance capacity tests like calf raises? There is often a quiet period of rehab, the rarely spoken, often ignored doldrums of acute injury. Priority is rightly focused on pain, range and swelling. But, we usually have a lot of time on our hands with athletes who are used to being busy and who like to move. Speaking from experience in football, a sport where running is vital to performance, fit players don’t often have time to work on their running because they are too busy training or recovering. Especially in youth sport, we can grab some much-needed time with athletes to work on running skills as part of their return to train.

I want to share some ideas and concepts that I have professionally borrowed (sounds better than stolen) that influence a lot of my rehab programs and pay forward when it comes to returning to running later down the line. I’m not going to discuss any particular injury, I’m going to leave that to you to work around with your own clinical reasoning. With that in mind, the order of these interventions will change depending on what tissues you are offloading. With most things that I share, these are concepts and not hard & fast rules.

Return to running

To be clear, I am not a sprint coach, but I want to demonstrate how we can bridge the gap from acute injury to some basic running drills. The main ones I want you to think about are the A-drills and wall drill variations that encourage triple flexion and triple extension.

So, regardless of the injury, we have some key goals that we can work towards in acute rehab (delete as appropriate to your injury):

• Plantarflexion of the ankle & Dorsiflexion of the ankle
• Full knee extension & mid / inner range knee flexion
• Hip extension & inner range hip flexion

I would argue that is not teaching anyone anything new. But part of rehab is to regress some of the demands and build back up. So let’s think about some of the contributing factors that will form the foundations of those movements and then using the rehabilitation progression model that Phil Glasgow and I published in 2017, demonstrate how they interact and develop into something that starts to look like running.

Break it down to build it back up

A big win for me in most rehabs is addressing the coordination and interaction around the femur, the pelvis and the trunk. Firstly, the ability to independently move one segment, in order to focus proprioception, before building to more complex movements that involve multi-segmental coordination. The ability to switch between isolated and involved movements, or your brains ability to handle that information, being called “dissociation”. Rehab is an opportunity to allow these movements to be conscious, with high repetitions, encouraging them therefore to become subconscious and more automated on a return to sport.

Femur & pelvis

This could be a massive discussion as we look at all the variations of how the femur interacts with the pelvis during movement. But let’s go back to thinking about those A-drills. Flexion and extension of the hip should be straight forward. But what about the role of pelvic tilt during that flexion and extension?

Anterior-posterior tilt exercises: https://youtu.be/5VA_ypzeeLA

And not just anterior to posterior, but often the importance of lateral pelvic tilt is ignored.

Lateral tilt? In sprinting? Surely that’s a big energy leak… well.. yes and no. This is different to a hip hitch, which can be a passive movement and demonstrate a lack of control. We can build up awareness of a lateral tilt and learn how to resist against it but also, there is possibly an element of hip extension during running that gets forgotten. The active distraction of the femur from the pelvis.

Hip distraction and lateral tilt exercises: https://youtu.be/zYW5dpw6oi0

Indulge me for a second whilst we talk anatomy.

Psoas:

Don’t worry, I’m not going to ask if you think you can palpate it or not.

Traditionally the iliopsoas (the combined tendon of the broad, flat iliacus muscle and longer thicker psoas muscle) has been considered a conjoint tendon. Recent anatomical studies have started to debate this, with potentially two distinct tendons. There is anatomical variance, what was previously discussed as a rare variant, it is now believed that the majority of cases demonstrate >2 tendons (Polster et al 2008; Guillin et al 2009; Philippon et al 2014). Furthermore, in the cases of more than one tendon, the isolated psoas tendon is significantly thicker than the accessory iliacus tendon. This is of interest in a rehab setting.

The purpose of these studies is mostly surgical, research into the roles of the two tendons in function is not as strong. However, Suzanne Scott (one of my go-to resources for movement and anatomy) believes that the thickened tendon demonstrates a role beyond simple hip flexion, instead acting in much the same way as an Achilles tendon in energy storage. The spring of the hip.

To load this spring, we have two methods:

1. Distraction of the hip
2. Extension.

In both cases, we need to create active stiffness, so this is where our dissociation comes into play. In these examples, we are looking to keep the trunk stiff whilst we load and release through the hip. (Ensuring that trunk mobility and control is addressed elsewhere in the program).

This in turn benefits our ability to “snap” into hip flexion. Adding tension into extension to spring into flexion, with consistent cues around “push the floor away” or “drive into the floor”.

With any inner range, we are inefficient in contraction ability and strength (due to shortened actin-myosin cross bridge formations), we also have the issue over space in the anterior joint, so working into strength positions in this range along with pelvic control, is going benefit that spring later on. From this inner range position, we have a greater ability to drive down into the floor as we start the reloading process of the spring all over again.

Loading the spring: https://youtu.be/EKdEDlkPaPE

Inner range hip strength: https://youtu.be/r3s4pxL7f7A

If we are looking to load that spring when running, I’m thinking here about the foot strike and push off from the ground, then this spring needs a solid frame built around it in order to maximise that energy storage. So, whilst maintain trunk stiffness and exploring lateral tilt of the pelvis, we can also look to resist against it. Our biggest ally in this is the gluteus medius. Where possible, I believe the lateral hip should be loaded as much as possible in a closed chain. I think exercises like “clams” are poorly prescribed and the rational is often flawed. This is why.

Gluteus medius

Gluteus Medius strength and function is an important consideration to running due to the role in coronal plane stability of the pelvis during the stance phase of running. It is another muscle that is grouped together and treated as a singularity, when in fact, morphologically the muscle has three distinct parts, anterior, middle and posterior, each varying in size and demonstrating separate innervation for each part (Al-Hayani, 2009). The direction of the fibres of the anterior and middle parts of the gluteus medius (and the anterior part of the gluteus minimus) suggests that they have vertical pull and initiate (key word) abduction, which is then completed by the tensor fasciae latae.

The middle and anterior gluteus medius is relatively large in cross-sectional area, has a large abduction moment arm and has fascicles that are aligned relatively vertical in the coronal plane (Flack et al 2014). On a fixed lower limb, these morphological characteristics are ideal for generating the large torques required to absorb the vertical ground reaction forces imposed on the body and to support coronal plane pelvic alignment during the early stance phase of running (Semciw 2016).

EMG analysis of gluteus medius during running was typically presented as mono-phasic, with peak activity occurring just after initial contact (Semciw 2016). One study presented a bi-phasic pattern, with a second, smaller burst of activity occurring at toe-off (Gazendam et al., 2007).

So, whilst they initiate abduction, they play a bigger role in the stance phase of walking and running. Therefore, I more interested in their role of pelvic stability. Lets flip that abduction movement around and fix the femur, the movement now begins to look more like a lateral tilt, a much smaller movement through range than abduction but one that will benefit our foot strike and our psoas spring.

Glute med exercises: https://youtu.be/OYXuh2eTuCU

“Coming together is the beginning, working together is success”

So, at differing stages depending on the injury, we have worked individually on pelvic movement, lateral hip contraction, loading the hip flexors as a spring via distraction and also in the inner range, we have encouraged active trunk stiffness throughout to support these processes. As the rehab progresses, it becomes important to move away from isolation and look to combine these drills to increase complexity and transition back to running.

Figure 1: Blanchard & Glasgow 2017 rehab progression model

The options with each progression become greater and depend on your clinical reasoning skills to add variables. The next two suggestions are very basic exercises to demonstrate that progression.

Dead bug:

There are many variations of a “dead bug” exercise but one for me that really translates into what we are trying to achieve from a running perspective. One that combines inner range hip strength, active trunk stiffness, hip extension and distraction and all mixed together into a complex dissociation exercise. A simple, low load drill that can be added to most programs either at the beginning as a familiarisation pattern or at the end to work control under fatigue.

Dead bug: https://youtu.be/M2xldzMgNTs

Hurdle step over:

From what I’ve seen, most sports will build in hurdle drills to some form of gym or warm up session. But how well is it coached? What is the aim and rationale? How passive do most athletes look when they are stepping over hurdles, honestly?

Some typical “cheating” movements I look out for in hurdle drills mostly involve flexion where its not wanted. When an athlete is lacking inner range hip flexion strength or control for example, they will flex at the trunk and drop into anterior pelvic tilt as they try to “pull” the femur closer to the body to clear a hurdle.

This is quite commonly combined with a passive flexion of the standing knee, relaxing the proximal portion of the quads to allow this movement. What benefit does this serve? I guess this depends on why the hurdle step overs have been prescribed in the first place, but if its to act as a constraint and encourage good hip mobility, good active hip mobility, in prep for running, then this cheat makes it a waste of time.

Figure 1: Blanchard & Glasgow rehabilitation program (2017)

Using our regressed exercises from above, we have hopefully provided the coordination, control and strength to perform this movement with more purpose. So, focusing on a triple extension of the standing leg, getting terminal knee extension, “pushing the floor away” or “leaving a footprint on the floor” we should also get the hip distraction, loading the spring. In turn, this cueing of the standing leg should therefore transfer into a quick, active “snap” into posterior tilt, clearing space in the anterior hip of the flexed leg and all done with a strong, stiff trunk.. looking much like our A-drills. 

Hurdle drills: https://youtu.be/2LLAAvOfpm8

On you go..

The list of exercise potential is endless, so many variations and constraints that can be added or tweaked. Most people will have their go-to list of drills that achieve exactly what I have explained here. The purpose of this piece today was to add some depth to the acute stages of injury, where we are often left wanting and adding time fillers to the program. Hopefully this has sparked some ideas or direction to where you could go with running drills even in the early days of injury. As the great Phil Glasgow says, “Rehab is training in the presence of injury” and if you can use the time to strip back complex drills knowing that the repetition and coordination will be useful on return to sport, then try and maximise your time and optimally load at every opportunity.

This article was written for the first edition of the Inform Performance e-magazine (here) which includes many brilliant contributions from the leading practitioners in sport.

References:

Al-Hayani, A., 2009. The functional anatomy of hip abductors. Folia morphologica, 68(2), pp.98-103

Blanchard, S. and Glasgow, P., 2017. A theoretical model for exercise progressions as part of a complex rehabilitation programme design.

Flack, N.A.M.S., Nicholson, H.D. and Woodley, S.J., 2014. The anatomy of the hip abductor muscles. Clinical anatomy, 27(2), pp.241-253.

 Gazendam, M.G. and Hof, A.L., 2007. Averaged EMG profiles in jogging and running at different speeds. Gait & posture, 25(4), pp.604-614.

Guillin, R., Cardinal, É. and Bureau, N.J., 2009. Sonographic anatomy and dynamic study of the normal iliopsoas musculotendinous junction. European radiology, 19(4), pp.995-1001.

Philippon, M.J., Devitt, B.M., Campbell, K.J., Michalski, M.P., Espinoza, C., Wijdicks, C.A. and LaPrade, R.F., 2014. Anatomic variance of the iliopsoas tendon. The American Journal of Sports Medicine, 42(4), pp.807-811.

Polster, J.M., Elgabaly, M., Lee, H., Klika, A., Drake, R. and Barsoum, W., 2008. MRI and gross anatomy of the iliopsoas tendon complex. Skeletal radiology, 37(1), pp.55-58.

Semciw, A., Neate, R. and Pizzari, T., 2016. Running related gluteus medius function in health and injury: a systematic review with meta-analysis. Journal of Electromyography and Kinesiology, 30, pp.98-110.

Viewing balance exercises with eyes closed

For a long time, I have questioned prescribing balance exercises with eyes closed to athletes in sport. Regular readers of the blog will know that I continuously explore the clinical reasoning behind treatments and interventions but have a particular interest in exercise prescription. I have to admit that single leg balance with eyes closed is an example of exercise prescription that just doesn’t make sense to me, how many athletes close their eyes to perform a sport related task? I’m regularly seeing discussions online about “what is functional?” and most of the debates are based around semantics without much weight behind them but provide a good opportunity for people to have a little disagreement about something. To avoid getting into a debate about “functional” I thought it best to better understand the concepts and demands behind “balance” to see if I can answer the “why” behind balance exercise progressions.

Now stay like that for 1 minute or until another player throws a ball at your face

One argument for closing eyes during balance exercises is to remove the visual stimulus and encourage the athlete to challenge vestibular and proprioceptive senses. Remove one thing and make others compensate for this deficit. In a study of track athletes, sway velocity (cm/s) increased two-fold when athletes closed their eyes during a static balance test (here) but the only significant finding in the study was the difference in centre of pressure displacement (cm) between non-dominant and dominant limb across the medial-lateral plane. So, no difference between male and female athletes and no difference between “eyes open” and “eyes closed”.

So how does this explain the increase in sway velocity? The sway velocity is the area covered in both the anterior-posterior and medial-lateral planes of the centre of pressure per second, indicating speed of correction. The fact that the displacement between “eyes open” and “eyes closed” was not meaningful suggests that the demand on the fine motor correction increases. A decent argument to include “eyes closed” in a balance program, if that is the aim.

Static balance in dynamic sports

Compared to dynamic balance tests, static tests do not allow re-positioning of the centre of mass within the base of support, so the athlete becomes more reliant on smaller corrections. Different sporting populations have demonstrated varying abilities in static and dynamic balance skills, with gymnasts outperforming in static balance but soccer players demonstrating better dynamic balance (here).

This may seem obvious given the control on the balance beam vs changing direction to avoid an opponent. But actually, perhaps where the argument becomes more broad and complex.

As with any exercise selection, it needs to be appropriate to the aims of the rehabilitation program and the demands of the sport, taking into consideration open and closed skills and linking these to fixed gaze drills vs dynamic gaze drills.

Have we gazed over “skill”?

In a given skill, experts can recognise which cues are relevant and avoid information overload (Martell & Vickers 2004). Below is a slide from my presentation “3 sets of when?” It explains the concept that following any injury, the athletes ability to perform a given skill returns (temporarily) to novice level.

Take a skill like walking. Immediately after an ankle sprain, your ability to perform that skill at an expert level is decreased. A skill that has taken years to perfect, to become automatic, now becomes a task which requires concentration. Thankfully, the return to expert level doesnt take years (hopefully!) and this is where our exercise selection becomes crucial to optimally load and sufficiently challenge. We can’t presume that the pre-injury skill level is the same post-injury. We should also consider experience of the balance task specifically. I can think of experiences where athletes are standing on one leg on a Bosu throwing a reaction ball at a 45 degree trampoline. “Oh you’re no good at that are you… we need to address your balance”

I’ve digressed slightly from single leg balance with eyes closed… and actually I still haven’t discussed “gaze control”.

Gaze control links specifically to experience of a task. Comparing those skilled at orienteering to non-skilled (here) demonstrated an increased ability of the orienteering folk (what do you call people that go/do orienteering?!) to employ a wide focus of attention and to shift efficiently within a peripheral field. The test very cleverly measured gaze control to flashing images with varying degrees of relevant and irrelevant information. What is interesting from this study was that the control group where physically active and proficient in other sports, but the “skill” advantage lay with the orienteering-iers. [shrugs and thinks “sounds right”].

I did not know that about balance!…

Elite athletes have heightened spatial awareness and processing capabilities vs their non-elite counterparts, where gaze control is cool and calm, with long duration of fixation of specific locations. This results in better body positioning end efficient limb actions (here). What better example than ballet. When comparing professional dancers to controls walking along a thin taped line, it was observed that experienced dancers focus far into space, delivering effortless and accurate movements where as controls looked down and focused on the line, moving with greater speed and less control (here). Dancers shift their neural control from somatosensory inputs and to an increased use of visual feedback, via peripheral fields and focused gaze control. Interestingly, sub-maximal exercise has been shown to increase visual attentional performance (posh words for reaction time) and a decreased time need to zoom focus of attention (here). This is useful for prescription considerations.

This efficiency has been demonstrated in other studies also, where the addition of a 4-week balance training program to Physical Education classes in school resulted in increased CMJ, Squat Jump and Leg Extension Strength (here). A time period that can’t be associated with physiological adaptations to muscles (regardless of time, they did balance exercises!) and even when a balance training program has been compared to a plyometric strength program (here). It is thought that improved centre of pressure is linked to spinal and supraspinal adaptations, due to high inter-muscular activation and co-ordination.

My question for any budding researchers out there… if there is a spinal level involvement here, can we utilise the contralateral limb at the very early stages of injury to improve balance on the injured side?

Finally, I get to my argument… balance is the output. Balance and proprioception are different entities, as are gaze strategies and balance. But they may all be interlinked via “skill.”

In researching this blog, I’ve certainly become more accepting of “eyes closed” as an addition to balance programs. But also think I’ve gained more clarity on appropriate prescriptions and the suitable progressions for individuals.

Perhaps “eyes closed” is not a progression, but a starting point!

Immediately post injury, we are looking to internalise feedback (intrinsic) and focus on local, fine movements. There are plenty of regressions within “eyes closed” balance that we can make the athlete safe from secondary injury. Graded progressions from static to dynamic, trying to keep the demands appropriate to the skill required to return the athlete to “expert”.

From here, our progressions should not be the removal of a visual stimulus, but instead optimising and enhancing gaze control:

• Focus on a stationary target –> moving target
• Head still –> head moving (repeat stationary and moving target progressions within this)
• Static balance –> dynamic balance (repeat progressions above)

Essentially, we progress through from intrinsic cues to extrinsic cues, where gradually the athlete is thinking less and less about the mechanics of balance and more about skill execution and performance. We know that gaze control components improve with sub-maximal exercise, so our ordering of our program can reflect this. It is commonplace for balance exercises to be at the beginning of the program, but if balance is our primary aim for rehabilitation, perhaps it should be later in the schedule.

I don’t think this is too dissimilar to how most people prescribe exercises, but for me at least it has given me a better thought process into the “why” which ultimately should make rehabilitation programming more effective and efficient and therefore more elite.

Yours in sport,

Sam

Compex doesn’t have to be complex

I should probably start by acknowledging that there are other muscle stimulation devices available… but I’m not employed by Compex, I just have some very good experiences using their product. This blog was borne out of frustration of seeing Compex machines gathering dust in treatment rooms or being used ineffectively as passive, plinth based modalities. I think a lot of people are missing the trick, you need movement!

While I am an advocate of its use clinically, I  want to disclose that using a Compex will not make a bad exercise good. It is a bolt-on to a rehab program and is something that can make a good exercise great. That is key. The clinical reasoning, exercise selection and placement of the stimulation all underpins an effective application, so before rolling it out to all athletes or patients make sure you can reason why it has a place in your practice.

Its all about progress

Like with any intervention, the clinical reasoning behind the application of muscle stimulation can influence its use at different stages of injury and rehabilitation. In the acute stages, it is believed that muscle stimulation may modulate pain. For an interesting read on the use of electricity and pain throughout the centuries, click here. However, as we understand more about optimal loading and mechanotherapy, we probably need to limit the time an athlete sits on the plinth watching the latest Mannequin Challenge on their smart phone while their quad twitches. It is worth considering that a Compex placed on a dead body would still cause it to twitch. The key is to get them moving and use the Compex to either facilitate movement or provide an external load. Interesting that we can use the same machine and the same settings to either regress or progress an exercise… the key is in the exercise selection.

Consider the tissues

Muscle injury: It should be pretty obvious that placing a muscle stimulation device, designed to promote contraction of muscle, on a contractile tissue with a tear or micro-damage could have negative consequences. For a second, lets forget the Compex. Respect the pathology and consider if you really need to lengthen or contract that muscle to load it. Is there a way you can work that tissue as a synergist perhaps? If the hamstring was injured in the sagital plane, can we move through coronal (frontal) planes and still load the hamstring? This could possibly be a slight progression on an isometric exercise and shouldn’t change the length of the muscle that may cause pain or further damage. Certainly more beneficial than sitting on the treatment bed though. So now consider how muscle stim may benefit this stage of injury. It could possibly help with any inhibition due to swelling or pain, perhaps be used to add an increased load to unaffected tissues that you may not be able to load otherwise.

As the healing progresses and the level of activity increases, it is quite common that we see some deficits in muscle function, especially after a long acute phase (if that isn’t a paradox?! Think post surgery or fixation). A good example is post ankle reconstruction, where you have worked on regaining plantar / dorsi flexion but when you ask the athlete to do a heel raise, it’s quite an effort. It may be appropriate to use the Compex here as a little crutch to facilitate movement and contraction. But the key thing here is it is not our cadaver that we causing a contraction in, the athlete is consciously initiating the movement. (Previous blog on internal and external cues here).

Now promise me if the Compex hurts, you will turn it down. OK?

Progressions by all definition, progress. So after working through isometric and concentric exercises, the program may require some eccentric load. This is worth trying yourself before asking a patient to do it, because a very simple exercise like a TRX squat that may have been cleared earlier in the program can dramatically increase in work with the addition of Compex. Consider a quad injury. The Compex has two phases of a cycle, a fasciculation phase that causes visible twitch and a long contraction phase (depending on the setting, the length and intensity of the contraction change). After one or two cycles for familiarisation, instruct the athlete to work against the contraction – so when the Compex wants to promote knee extension via a quad contraction, sit back and encourage knee flexion. Try this yourself for 6-8 reps and feel the fatigue induced, it usually surprises people. Again, make sure you can reason WHY you are doing this. This is usually a good bridge for someone who needs to step up their program but maybe can’t tolerate external load (confounding injuries, instability of joints, lack of technique etc etc.)

Joint Injuries: In comparison to a muscle injury, your application of Compex may be more aggressive. Because you are unlikely to affect a non-contractile tissue with the stimulation, you may use the eccentric reasoning to help reduce atrophy rates following a intracapsular injury like an ACL. Ensure you know the available range first of course.

With these injuries, the external stimulation may help with inhibition, improve proprioception lost by the ligament or capsule or it may provide stability to the joint by increasing the available contraction. Again, there will be a time and a place and it requires the clinician to reason through the application, but this may be a great addition to a program that is becoming stale.

Tendon injuries: The use of the Compex to enhance an isometric contraction or to create an eccentric contraction may be a great addition for an in-season tendinopathy as a way of managing load. The timed contraction allows clinicians to monitor Time Under Tension (TUT) which is essential for tendon management. If considering a High-Medium-Low frequency through the week, a pain free exercise that is used on a Medium day can become a High load exercise with the addition of an externally generated contraction. But consider the two things that aggravate a tendon, compression and shear. Appropriate exercise selection and range is going to be crucial, that being said, it may be that the addition of stimulation to the quads actually reduces shear through the patella tendon by changing the fulcrum of the patella (no research to back this up, just my musings).

I really like Geckos. I found this Gecko a musing

Conclusion:

I think there are many options out there to enhance rehabilitation by considering the diversity of muscle stimulation. But I want to repeat for the hundredth time, it is the exercise selection that is key. The addition of a Compex will only amplify that choice.  For the patient, it adds a bit of variety to a rehabilitation program and for the clinician it is another tool to help with optimal loading of a healing tissue or structure. I am a big fan of weight training (don’t let my chicken legs fool you) but there are injuries or athletes that for one reason or another are unable to tolerate weights. This is one tool in a very large and overused metaphorical tool-box that may bridge that gap between body weight exercises and weighted exercises. I also believe there is great benefit when complimenting this with Blood-Flow Restriction Exercise or Occlusion training… but that’s another blog.

As always, thoughts and opinions are welcome.

 

Yours in sport,

Sam

Laboring through a Labral Tear

One skill when working in sport is learning to compromise between your clinical brain (the one that tells you that pathology and injury needs to be managed a certain way) and your performance brain (which tells you that your job is to get athletes back over the “white line” in order to do their job). In an ideal world, we try and appease both of these brains where tissues heal well and performance is optimised with the lowest risk of re-injury. But there are some pathologies that cause these two brains to clash. Ones that can be “managed” until the off season where proper interventions can take place. One such injury that I’ve been trying to learn more about is the mid-season hip labral tear.

The purpose of these blogs is to encourage me to read more around certain topics, so in order to help with this I have to say thanks to a few people that have provided me with papers and words of wisdom (Erik Meira, Nigel Tilley & Joe Collins). And thanks to whoever invented Twitter because I probably wouldn’t have this access to knowledge otherwise.

The Problem..

Typically, hip instability injuries are seen in sports with high repetitions of rotational and axial load – football, gymnastics, hockey, tennis, martial arts.. and so on. The hip is widely accepted as being one of the most structurally stable joints in the body, with a deep acetabular socket lined by the labrum, which creates negative pressure within the joint to increase congruency of the femoral head. But what happens when this environment is disrupted? A recent review by Kalisvaart & Safran (here) explain that it takes 60% less force to distract the femoral head from the acetabulum in presence of a labral tear. (This review is great for explaining multiple causes of hip instability, not just labral tears, and also assessment techniques.)

Typically, a lack of stability is replaced by rigidity, where the surrounding soft tissues try to compensate for this increased translation (Shu & safran 2011 here and Boykin et al 2011 here). On assessment of an ongoing labral tear, its quite common to find increased tone or reduced range around adductors and hip flexors. Iliopsoas in particular plays a role to help increase congruency in the hip. (For tips on how to release iliopsoas, please tweet @Adammeakins) – one key thing when managing this condition is not to confuse high tone / over activity with being “too strong”. Chances are its the opposite, it more likely indicates a lack of control. Its not uncommon to see adductor tendinopathies secondary to labral tears as the the load around the joint increases – especially in sports like ice hockey where there is high eccentric load on the adductors (Delmore et al 2014 here).

The Intervention..

So, you’ve diagnosed the tear (clinically and / or radiographically) but other than being irritable, it isn’t affecting the athlete. (Note, not all tears can be managed conservatively, due to pain & some require mid-season surgical intervention – Philippon et al 2010 here). The key premise to your ongoing rehab should be to make the hip joint as robust as possible. Remember, “Stability – not rigidity”. Whats the difference? Can the athlete control the hip or pelvis while performing another task? Or do they lock into a position and rely on passive structures like ligaments and joints.

Consider the demands of the sport. Don’t just fall into the trap of working through what I’d call the “action man ranges” – true anatomical flexion, extension, abduction and adduction. Watch training and competitions of nearly all sports and you’ll rarely see these truly sagittal or coronal movements. They tend to be combinations accompanied by transverse movements of the body in relation to the limb. Make sure this is replicated in your rehab.

UNIONDALE, NY – MARCH 05: Nik Antropov #80 of the New York Rangers warms up before playing against the New York Islanders on March 5, 2009 at Nassau Coliseum in Uniondale, New York. (Photo by Jim McIsaac/Getty Images)

Using the three examples above, consider the role of the hip musculature throughout these movements. We don’t always have to replicate abduction in an open chain movement, sometimes its necessary for it to be closed chain and for the body to move relative to the limb. Note how none of these tasks fit the “action man ranges” but all involve some degree of traverse rotation, combined flexion and abduction or extension and adduction etc etc.

No I can’t bench press, but my squats are awful.

Delmore et al (here) and Serner et al 2013 (here) describe some excellent exercise interventions for the adductors here. These include some good low-load isometrics for those early stage reactive tendons – with isometrics appearing to down-regulate pain associated with this acute pathology (Koltyn et al 2007 here; Rio et al 2015 here to name just two resources) . Moving forward through rehab, I’ve discussed exercise progression at length before (here), I’m not dismissing exercises that involve pure flexion, extension etc but as part of a progression, its important to combine these movements. For example, start with a single leg dead lift – can the athlete control their trunk through hip flexion and through extension back to neutral? No? Then here’s a range to work on, using regressions to help improve technique and control. Yes? Then add a rotational component at different ranges of flexion – rotation away from the standing leg will increase the demand on the adductors to control the pelvis in outer ranges. The leg itself hasn’t abducted, but relative to the trunk it is hip abduction.

Remember the bigger picture

Its important not to just focus on the affected structures. For those interested in groin pain, a summary of the 1st world conference on groin pain is here – one key message from that conference was that anatomical attachments are not as discrete as text books make them. Consider what else contributes to the hip and pelvis control. We have mentioned iliopsoas control, but also rectus abdominus. Its not just a beach muscle. Eccentric sit ups can help improve control of the hip flexors, along with some lower load exercises like dead bug regressions – a little imagination or some quick youtube research can turn this one concept into hundreds of different exercises.

We have addressed the issue of controlling abduction through range with the adductors, but also remember to maintain that abduction-adduction ratio with some external rotator & abductor muscle exercises (queue Clam rant here – clams to me are like psoas release to Meakins). Possibly the best piece of advice I was given when doing this research was from Joe Collins, who told me to consider hip joint pathologies like you would a rotator cuff injury in the shoulder. Don’t neglect those smaller, intrinsic muscles around the hip. The exercise below is an anti-rotation exercise working through ranges of hip abduction-adduction.

The athlete is tasked to resist the rotation of the femur into external rotation while slowly moving through hip abduction and back to adduction. (This example is done with a shorter lever to improve control and the bench provides feedback to keep the hips in neutral or extension, rather than the favored flexion). Anti-rotation exercises can also be incorporated into trunk / core control exercises (for any instagrammers – follow ETPI who post some great videos and snaps of golfers working on rotational control). Progress from anti-rotation into control through rotation. Some examples here:

anti-rotation plank with sagittal control

Anti-rotation plank variation with weights

Anti-rotation plank with traverse control. Encourage the athlete to keep the pelvis still when moving the upper limb.

Single leg bridge with arm fall outs. Can be regressed to a normal bridge if the athlete lacks lumbo-pelvic control.

Side plank with arm tucks – an example of controlled trunk rotation while isolating the lower body to stay stable. Can be combined with the adductor bridge mentioned in Serners paper to increase load through proximal adductors.

 

These are just some ideas of how to manage a labral tear mid-season; working on rotational control, analgesia via isometrics, improving congruency in the hip joint and overall hip stability via strengthening – Stability, not rigidity! The exercises mentioned here are by no means an exclusive list and I love learning about new drills and ideas, so please share any that you find useful.

 

Your in Sport,

Sam

Rehabbing teenagers can be awkward! – sensorimotor function during adolescence

There is a bit of a buzz phrase in rehab about “individualising programs” and while it is something we wholeheartedly agree with, it is a phrase that is very easy to say and yet very difficult to implement. Especially when you work with a population where said individual changes rapidly through time, like a teenager! It is a common sight on a training pitch to see a star player in their age group suddenly tripping over cones or developing a heavy touch where there was previously effortless control. Side effects of the adolescent growth spurt, where the brain is now controlling a much longer lever. It’s like giving a champion gardener a new set of garden sheers when for the past year they have used little hand-held scissors and asking to them maintain their award-winning standards. (My garden embarrassingly needs some attention and it’s affecting my analogies).

The control and precision between these two instruments is influenced by the lever length of the handles…

…Similar to a rapidly growing femur and tibia which is still being operated by muscles that have length and strength suitable for shorter levers.

 

 

 

 

 

 

 

 

Alongside the performance related issues, there is suggestion that this period of growth may coincide with increased risk of injury (Caine et al 2008). We believe that bone grows quicker than soft tissue, so we are asking a neuromuscular system to control a new, longer lever using prior proprioceptive wiring. Imagine our gardener again, for a long time he has been able to keep his pair of scissors close and controlled, now with his extra long shears the load is further away from his body, his back and shoulders are starting to ache. Not sure what I mean? With one hand hold a pencil to the tip of your nose. Now, with one hand hold a broom handle to your nose. The longer lever is harder to control. **I promise it gets a bit more sciencey than gardening and broom handles. **

Managing these growth spurts is something we have talked about before and recently contributed to a BJSM podcast on the topic (Part 1 & Part 2) and a complimentary BJSM blog about “biobanding” during periods of growth and development (here). This particular blog was inspired by a recent (2015) systematic review looking into exactly which sensorimotor mechanisms are mature or immature at the time of adolescence by Catherine Quatman-Yates and colleagues over in Cincinnati (here). The following is a combination of their summary and our examples of how these findings can influence our rehab programs.

Tailoring the program:

We have so many options for exercise programs, that’s what makes the task of designing them so fun. It challenges our creativity. When working with a teenager with sensorimotor function deficits, let’s call them “Motor Morons” for short, we don’t have to totally re-think our exercise list, just perhaps the way we deliver them. We previously spoke about motor control and motor learning (here) and how our instructions can progress just as our exercises do, but the following relates to children and adolescents in particular.

Consider the stimuli.

Children aged between 14-16 have well-developed visual perception of static objects however their perception of moving objects and visual cues for postural control continue to mature through adolescence. When very young children learn new skills such as standing and walking, they become heavily reliant on visual cues. Quatman-Yates et al suggest that puberty and growth spurts (think gardener with new shears) brings new postural challenges that causes adolescents to regress proprioceptive feedback and increase reliance on visual cues again. From a rehab perspective, we need to consider this as part of our balance and proprioception program. How many of us default to a single leg stand and throwing a tennis ball back & forth from therapist to athlete? For our Motor Moron, this may not be an optimal form of treatment in early stages, where it is commonly used, however it may incredibly beneficial to that athlete in the later stages or as part of ongoing rehab as we try to develop that dynamic perception.

Consider the amount of stimuli involved in an exercise versus what your goal of that exercise is

We should also consider the amount of stimuli we add to an exercise. Postural stability in children is believed to be affected by multiple sensory cues. If we consider that children are more dependent on visual cues than adults are, perhaps our delivery of external stimuli should be tailored also. With a multi directional running drill for example, there is sometimes an element where the athlete is given a decision making task (a red cone in one direction and a yellow cone in another) and they have to react quickly to instructions from the therapist or coach. Rather than shouting instructions like “red cone”, “yellow cone” etc, hold up the coloured cone for the corresponding drill. This way we are utilising this developed visual perception, minimising the number of stimuli and also encouraging the athlete to get their head up and look around rather than looking at their feet.

When to include unilateral exercises:

Within adult populations, it is often considered gold standard to make exercises unilateral as soon as tolerable. If they can deep squat pain free and fully weight bear through the affected side, progress them to pistol squats ASAP, or single leg knee drives. However, young children (pre-pubescent) may struggle with this for a couple of reasons.

Difficult enough even for an adult to perform, but uncoupling the actions of the each leg & fine muscle movements to maintain balance are extra challenging for children

Firstly, we need to consider postural adjustments. Where as adults and young adults can adjust their balance with smooth control and multiple, small oscillations, children rely on larger ballistic adjustments. There is also reduced anterior-posterior control in younger athletes which suggests reduced intrinsic ankle control. Put this alongside immature structures and (if working a physio, most probably) an injury then single leg exercise become a progression that may be further down the line than an adult counterpart with the same injury. Instead, consider semi-stable exercises. Support the contralateral leg with a football or a bosu ball – something that is difficult to fixate through but provides enough stability to support the standing leg.

Secondly, we understand that coupled movements are mastered earlier in adolescence, around 12-15 years old but uncoupled movement patterns take longer to develop, 15-18 years old (Largo et al). A good example is watching a young child reach for a full cup of water at the dinner table. It is much easier and more natural for them to reach with both hands than it is with one, as coupled movements are unintended. Rarely do you see a child taking a drink with one hand filling their fork with the other – yet this is something commonly seen with adults as they are able to uncouple and segmentalise. Another example is watching a child dynamically turn, watch how the head, trunk and limbs all turn as a “block”, it is not until further down the line where dynamic movements become more fluid. The argument here is that surely running is an uncoupled movement? Or kicking a football, swinging a tennis racket, pirouetting in ballet – they are all uncoupled, segmental movement patterns that we expect kids to do, and in all they cope with. Correct, but it is usually in rehab programs for kids that we begin to introduce unfamiliar tasks and exercises that they may not have encountered before. Also, we should respect the impact of the injury on proprioception and control. So these are all considerations for starting points in exercise & if a regression is ever required.

For this reason, it is important that exercises are monitored and reviewed regularly. There is no need to hold an athlete back because of their age and making assumptions on motor function because of their age. If they can cope, then progress them. But be mindful of “over-control” where speed and variability of movement are sacrificed in place of accuracy and control (Quatman-Yates et al 2015).

Become a Motor Moron hunter

It is worth spending some time watching training, watching warm ups, watching gym sessions and talking with coaches and S&C’s trying to identify a Motor Moron as soon as possible. It’s important to minimise the chances of an immature sensorimotor mechanism ever meeting a growth spurt. It is when these two things combine that we see kids doing immaculate Mr Bean impressions and therefore increase their risk of injury.

Regularly re-assess your exercise programs. If things arent quite progressing as quickly as they should, it may not be failed healing of an injury, but it may be that we are providing the sensorimotor mechanism with too much information!

 

Yours in sport,

Sam

 

“The Young Athlete” conference 9-10th Oct, Brighton. Here

Motor learning theories – why should progression stop at physical?

As a younger physiotherapist, I don’t think I ever consciously paid attention to the psychological aspect or power of my job. By that I mean, I didn’t read any research around it – it all seemed a bit wishy-washy and non-tangible. But quickly you realise that a verbal cue that just clicks with one patient turns into a complex dance choreography with another.. “No, I just wanted you to bend you knee.. why are you doing the worm?”

I’ve talked before about the clinical reasoning behind exercise progression and regression and in doing so, I skimmed the surface of the addition of intrinsic & extrinsic stimuli.  So now I want to build on the concepts of motor learning to underpin that exercise progression.

My inspiration for this blog came from a couple of podcasts by the PT Inquest gang, Erik Meira (@erikmeira) & JW Matheson (@EIPConsult). Well actually, first I bought a chinchilla, then I wrote this blog. If that doesn’t make sense, don’t worry. It doesn’t. But listen here (PTInquest).

The gents speak in detail on two particular podcasts about non-linear pedagogy and how this teaching concept & theory of motor learning ties in with implicit learning. I will break down the idea and definitions shortly, but the reason I wanted to blog about this rather than just direct listeners to the podcast, is I feel the motor learning concepts need to be progressed just as much as the physical demands of an exercise are considered.

What are we talking about?

Ok so breaking down some of the terms. Because from first hand experience, these terms can be confusing. Cap in hand moment but, I Published a model to explain exercise progression (here). You will see I have described implicit & explicit learning – where in fact I mean intrinsic and extrinsic. Very different things, here’s why:

Intrinsic exercises – relies on internal feedback mechanisms, such as capsuloligamentous structures – Pancian & Ruffini receptors within joint capsules providing proprioceptive feedback that the athlete is acutely tuned into. A good example is a single leg stand where the athlete is consciously thinking about balance, aware of every movement in the foot & knee, the upper body and arm position etc – those exercises where nothing else in the room matters apart from the mark on the floor you are concentrating on to keep your balance.

The opposite to this are Extrinsic exercises – these revolve around the athlete and their environment. A snowboarder reacting to a sheet of ice after carving through powder, or a downhill biker absorbing the changes in terrain – their thought process is very external. Its about the factors they can’t control. At no point (or at least for an extremely limited time) are they consciously aware of their scapular position or degree of knee valgus, for example.

Explicit teaching – This is probably something that is easy for us to relate to. It’s a teaching technique that most of us are comfortable with because we can achieve quicker short term goals. “I want you to put your feet shoulder width apart” or “keep your knees in line with your second toe during the squat” – very clear instructions that require the athlete internalise their thoughts, suddenly their actions become intrinsic. But we get quick results in line with our (not necessarily their) goals.

Implicit teaching – this is a bit more tricky. It is giving the athlete non-directive instructions with the aim of externalising their thoughts. “When you jump onto that box, I want you to land as quietly as you can” or as the PT Inquest lads say “Land like batman” (in the batman voice). If you are encouraging effective change of direction, Conor always says “Push the ground away with your foot.” We are still giving instructions, but the athlete is thinking about external environment; noise, surface contact etc.

And this is where non-linear pedagogy comes in. Creating learning environments for athletes to explore movement variability. After all, that perfect text-book single leg squat we spent weeks mastering isn’t going to look so perfect on a skier trying to regain their balance. Chang Yi Lee et al (2014) use the example or learning a tennis stroke – comparing linear pedagogy of prescriptive, repetitive drills versus non-linear pedagogy of more open instructions like “make the ball arc like a rainbow.”

Think shoe lace tying – easier to learn with the rabbit going round the tree etc

 

How does this fit into progression?

The ideal scenario is for the athlete to have as little reliance on us as therapists or coaches as possible. We wont be following them around the track, or on the pitch reminding them of their pelvic tilt.

I think the concepts of non-linear pedagogy are brilliant to explore with coaching. Working with young athletes for example that are still developing their motor control and have some fantastic imaginations to tap into.

However with a rehabilitative role, I think we need to be more inclusive of all concepts. Learning of a new task is initially rapid but without the addition of further stimuli it can quickly plateau (Gentile 1998). A rehab program should always be low risk, high demand (Mendiguchia & Brughelli 2011).Consider the pathophysiology and the structures injured. No injuries happen in isolation, if muscle is injured we will have some neural limitations also. The presence of swelling and inflammation decreases cell metabolism along with a decrease in the presence of oxygen; so we can assume that proprioception is reduced and risk of secondary injury is high.

Therefore, following injury, it is always a good concept to assume that skill level has regressed to novice, regardless of the level of athlete pre-injury.

“So whats the knee brace for?”                                             “Well you only had your surgery 2 weeks ago – just being safe”

What if we were to encourage intrinsic, explicit, linear pedagogy exercises in the early stages? We don’t need to be adding external stimuli at this stage. It’s important to internalise in order to rehabilitate proprioception. You can’t safely expect someone to externalise while proprioceptively deficient – as soon as someone can weight bear, we don’t start throwing them a tennis ball whilst stood on a Bosu (I hope!)

As the injury improves and skill levels progress, it is then important to move our instructions towards non-linear pedagogy methods, encouraging extrinsic thinking via implicit instructions. By end stage rehab, our instructions should be “start – stop” and hopefully not much more.

Just as we would progress the demand of physical activity following injury, we should really progress the cognitive demand also – but we need to start from a safe, effective position in acute stages.

Yours in sport,

Sam

Walking the “Plank” with core stability prescription

My colleagues are currently taking great pleasure in including “clams” in their exercise programs just to wind me up, so thought it was about time I gave them some new material. (See my thoughts on clams here).

Like “Clams” I have similar opinions on the rational behind including “planks” as part of an exercise prescription for athletes. I will start, and re-iterate later on, that there are times when they are appropriate, providing they have been clinically reasoned. But this is my point, do we throw them into rehab plans / injury prevention plans out of habit or have we individualised the exercise for an athlete?

 

 

What are the benefits?

Performed properly, the Plank is an isometric exercise that crudely speaking, activates the “core”. In doing so, it should encourage a sustained hold of a posterior pelvic tilt and neutral spine for a set duration of time, also working the shoulders and lower limbs to support the torso. Stability provided by the trunk muscles allows for whole body dynamic balance (Anderson & Behm 2005) and as such, these muscles require both strength and endurance.  The deep stabilisers of the lumbar spine display a small cross-sectional area, as such their ability to generate any torque is limited, so their function is to provide local stability and require this endurance component we talked about – perfectly targeted by a well performed plank. In patients with chronic low back pain, isometric exercises had positive effects on increasing the cross-sectional area of the multifidis muscles (Danneels et al 2001).

If we apply the principle of Optimal Loading, then there may be examples of injury where a static exercise is the only way of applying load to an individual. It may be that they are limited with any rotational components of exercise and are pain free in a neutral position. We also understand that isometric contractions can have an analgesic effect on patients (Bernent et al; Huber et al), hence the popularity of adductor squeezes for adductor tendinopathies.

 

..So what is wrong with Planks?

There are undoubtably examples and case studies where the use of a Plank is appropriate for an exercise program. However, un-supervised, there are many compensation patterns that patients can adopt when performing this exercise.

If prescribed as a home exercise, you should have great confidence in the athletes proprioception and ability to self correct. Otherwise you will likely re-enforce the exact reasons why you are treating the athlete in the first place. My biggest gripe with Planks, or Side Planks, or any isometric core exercise is that most people will fixate instead of stabilise. Locking the back into extension (plank) or into side flexion (side plank), or tilting the pelvis anteriorly, or flexing through the thoracic spine are examples of relying on passive structures like ligaments and joint capsules rather than stimulating active structures that should stabilise these joints.

“Don’t replace STABILITY with FIXATION”

Core stability is “the product of motor control and muscular capacity of the lumbo-pelvic-hip complex” (Click here for an excellent core stability review by Paul Gamble). The clue in this quote are the the words “stability” and “motor control”. There are very few examples in sport or even in daily living where we need to hold a whole-body isometric contraction for 1 minute or more. Essentially movements in sports occur in multiple directions. Even in events like Skeleton or Luge, the athletes are reacting to perturbations from the track or adjusting their course via small shoulder or lower limb movements, so I’m struggling to think of the cross-over benefits of a plank into sport. The benefits of a strong lumbopelvic region help transfer ground reaction forces to produce movement and integrate the function of the kinetic chain. Weakness or dysfunction of any link in the chain can increase risk of damage to another structure and as such, any one muscle should not be views a more important to another in terms of lumbopelvic stability (Brown 2006).

 

Note the increased Lumbar lordosis. Also, the stripy athlete underneath is rotated slightly.

 

 

“Don’t give me problems, give me solutions”

As I said, in principle there are he benefits to core stability, especially in terms of proprioception and limbo-pelvic dissociation. But for me, the trick is to stimulate the core during movement.

Some simple modifications of the Plank can greatly enhance its suitability for athletes.

 

1) Plank with Wall Taps:

Assume the traditional Plank position, you can regress this with bent knees, similar to a press up regression. Position the athlete about 2ft from a wall, facing the wall. Ask them to reach forwards and tap the wall with alternating arms but maintain stability of the pelvis and trunk.

Although a sagital plane movement, the athlete will be working against a transverse plane to stop the pelvis and lower trunk from rotating to the side of the moving arm.

 

2) Plank with Stacking

Again, in a traditional Plank position, but this time set up a stack of 3 x 2.5kg weight discs on one side of the athlete. Ask them to reach over with their opposite hand, pick up a weight and start stacking on the opposite side. Repeat until all weights have transferred sides, then begin with the other arm. In doing so, instruct the athlete to stay as still and controlled in the hips and lumbar spine as possible, the movement should come from the shoulders only.

By reaching across with one hand, you are de-stabilising the torso. Moving the weight from one side to the other adds a transverse element to the exercises, as well as the challenge of moving with and without a weight.

 

 

 

3) The Side Plank with arm tucks:

Add an element of upper body rotation whilst stabilising the pelvis. Instruct the athlete to keep their hips up (relative hip abduction of the lower leg), tuck their extended top arm underneath themselves (like putting on a seatbelt) but in doing so, don’t let the pelvic twist. Encouraging dissociation of the pelvis and spine to stop them moving as one column.

 

 

There are so many variations that I haven’t included; you can add cables or theraband and ask the athlete to pull  in different directions maintaining the plank position, you can add movements of the lower limb or think of various ways to de-stabilise the more advanced athletes. For those athletes that just “get it”, there are brilliant variations of the Bear Crawl which may be appropriate – for me, a perfect example of “core stability” (averagely demonstrated below)

– Bear crawl core stability exercise

 

Conclusion

Activities during sport require both static and dynamic strength – however in rehabilitation, these should be dynamic exercise with a pause rather than prolonged holds. At times, we may have to regress back to its most simple form in order to educate the athlete on correct positioning or increase proprioception but there should always be a plan to progress into dynamic core stability, rather than progressing the time holding a plank.

When designing rehab programs, we should always consider the individual – what do they need to cope with for their sport / daily life? What physical capabilities do they have at this moment of their program? Am I challenging them appropriately?

I hope this provokes some thought and discussion, please let us know your experiences and opinions

 

Yours in sport,

 

Sam

 

Exercise Progression & Rehab Programs

A year or so ago, I put on a CPD evening for our part time staff at the football club discussing exercises and the clinical reasoning behind developing a program (needless to say I got talking about the use of clams for a quite a while – clam blog). In this presentation, I started drawing my reasoning process onto powerpoint using some coloured blocks to help visualise the theory that I was trying to describe.

The theoretical model was recently published in Physical Therapy in Sport and I thought I would use this blog to try and discuss it in a less formal way than the writing style allowed in publication.

 

The model (here) is designed to be fluid and adapted to any individual by any level of clinician. Let me quickly introduce the components:

A theoretical model to describe progressions and regressions for exercise rehabilitation (Blanchard & Glasgow 2014)

 

• The triangular blocks (1) represent the fundamental exercise, the core ingredient that will remain throughout the progression. The arrows running up the side of the triangles represent an ongoing progression throughout the rehab process such as speed, duration, repetition etc. So basically, something that can’t be affected by the stimuli that are added or removed. If you add an unstable surface to an exercise, you can still progress by increasing the duration.
• The coloured blocks represent a stimulus that will help the exercise progress. This can be one of two things;

1. Internal – something that the patient has to focus on intrinsically. A decreased base of support for example, where the patient must focus on the balance element of an exercise.
2. External – the addition of something to the exercise that takes the patients focus away from the movement or action they are performing – adding a ball to a running drill, or a verbal command that initiates a change in direction.

The blocks are interchangeable and can be added / removed at the clinicians discretion.

• Adding a new block, which will progress the exercise, is accompanied by a regression of the “gradient” on the blue triangle. Creating a step-like progression across the model. As you progress with an internal or external stimulus, its important to bring the difficulty levels back down, so reducing repetitions or speed or duration. This allows the pateints to adjust to the new stimuli without fear of re-injury or task failure. When teaching a child to ride a bike with stabilisers, you don’t take them off and ask them to cycle at the same speed you did with them on. For that reason, you wouldn’t get someone going from 30 reps of a hamstring bridge straight into 30 reps on a single leg bridge as a progression. You would decrease base support and reduce reps to allow adaptation.
• Adding a “block” doesn’t mean you have to add something to the exercise. The block represents a step up in their progression. So progressing from two legs to single legs is technically “taking away base of support” but is an addition to the ongoing progression.

 

Lets use an example, recently I started designing a program for a teenage footballer with a proximal adductor strain. New to professional football with no history of conditioning.

In the sub-acute stage, once intial pain had settled, we began looking at his movement patterns and stability and noticed a huge imbalance with his left sided control through sagittal and transverse planes compared to his right. He is left footed, so his plant leg (right) is used to supporting his body weight.

His body awareness and “physical literacy” was so poor we had to regress him right back to basics. The following represents a small proportion of a larger exercise program. I’m not usually an advocate of planks in a multidirectional sport like football, but in this case, his single plane control was so poor that I swallowed my pride and began with basic planks.

When I say basic, we reverted to short lever planks with the knees on the floor – this was the only was we could get him to control the relationship between his trunk and pelvis. Looking at the model, this short lever plank would be the singular blue triangle at the start (1). We built up the duration of the hold from 30 seconds to 90 seconds over time. This would be the arrow running up the gradient of the triangle.

 

The addition of the first block (2) was to increase the length of the lever so that he now has to hold a traditional plank. In doing so, we dropped from 90s hold back down to 30 seconds and over time, built up to 90s. (These are just arbitrary times, based on no real evidence).

 

The next block we added was a rotational element (3), but to ensure the progression wasn’t too sharp, I removed the long lever and returned to a short lever position. I then asked the player to move a light 1.25kg weight from his left side, with his right hand and place it on his right side. Then with his left hand etc etc. The purpose of this was to introduce a transverse task to a sagittal plane activity – as the arm moves from the ground and across the body, the player has to control the rotation through his trunk and avoid rotation at the pelvis. Instead of duration, we built up repetitions over time.

 

Now that we were confident he could hold a plank, and control rotation in a short lever plank, we could combine the two blocks as the next progression. Now in a long lever plank with a rotational element.

 

The next progression was to add an unstable surface (4). To do this, the player performed a plank with his thighs on a gym ball. This in itself was quite easy so we instantly added a rotational component with an unstable surface, gym ball pelvic rotations (see video here). So now on the model, we have the basic “plank” triangle at the top, a block underneath to symbolise the long lever, another block to symbolise rotational control and a third block to symbolise an unstable surface.

 

“The length of time required by an individual to master a task has

been described as a linear function that begins quite rapidly with

the introduction of a new task and then plateaus or slows over time

as practice continues (Gentile, 1998).”

 

 

This is a very simplistic example of how the model works, but hopefully it demonstrates the fluidity that is intended with it and how the blocks are interchangeable and can work independently or as part of a more complex progression. Every program you write will be individual and the progressions will be different, therefor every model will look different. Some will continue longer than others, some may be shorter than the one I’ve described here. Some will end up with taller columns due to the number of progressions. The width of one column compared to its neighbour may be different size due to the length of time it takes for the patient to master. And so on and so on. If I continued, hopefully I could have ended up with the player doing this:

But whats the use of that defending a counter attack?

 

Like many conversations I begin or poor jokes I tell, this may be one of those things that only makes sense in my head, but I would love to hear if it makes sense to others – if you think it works and examples of doing so.

 

Yours in Sport

 

Sam

 

 

Case study: “Bulls Eye Lesion”

Every now and then in clinic you come across an injury that doesn’t quite fit “the norm” in terms of its recovery and management. I know every injury should be considered unique and every individual managed differently, but I thought I would share the management of this particular injury as it did prove tricky, we did fail a couple of times but eventually we got it just right.

 

Background:

This case study revolves around an 18 year old central midfielder, skeletally mature (no increase in height throughout the year / evident secondary sexual features) with a regular playing and training history prior to this injury. The presentation started in the autumn, after a complete pre-season and a good few weeks of competitive season underway. The player was in & out of training with a niggling groin / quad but with nothing substantial showing in assessment (the benefit of hindsight would be a very good money earner for any clinician that could harness it and set up a course!)

Towards the end of an under 21 game, the player was visibly struggling with pain at the top of his thigh, unable to sprint or strike a ball but 3 subs had been made, so he was inevitably staying on the pitch. At the end of the game, there was pain on palpation of the proximal rectus femoris and sartorious region. At this stage, there was nothing more to assess – there was no point, we would only aggravate something without actually learning too much more.  He presented the next morning with visible swelling in a small pocket of proximal thigh, palpable crepitus and pain with straight leg raise at 20 degrees.

 

Review of anatomy

The rectus femoris is a long fusiform muscle with TWO proximal attachments. The Direct Head attaches to the AIIS and Indirect Head attaches to the superior ace tabular ridge and the joint capsule. It has a long musculotendinous junction, as such can execute high velocity shortening as well as coping with significant length changes – remember it is a two joint muscle crossing both the hip and knee, with an action like kicking it must cope with hip extension coupled with knee extension during the pull-back of the kick, so both ends of the muscle are undergoing an eccentric load (Figure 1). The muscle structure itself is made up of mostly type II fibres so this high eccentric load makes the muscle quite prone to injury (Mendiguchia et al 2013 source).

Figure 1: Demonstrating the demands on rectus femoris during a kick

 

“Bulls eye lesion”

The term “Bulls eye lesion” was coined by Hughes (1995 source) following the presentation of injury on MRI (Figure 2). The high signal signs around the tear of proximal injuries. Occasionally this causes a pseudocyst, thought to be the serous fluid in the haematoma.

Figure 2: MRI scans highlighting a “Bulls-eye lesion” presentation

Predisposing factors to a proximal tear include fatigue, insufficient warm up and previous injury. From this case, we know that the pain started at the end of the game with the player in a fatigued state, and there was a history of niggling pain on and off for a couple of weeks.

 

Management:

The initial management of this injury was relatively routine, revolving around the POLICE guidelines (see Cryotherapy Blog). By day 2/3 we were addressing pelvic control exercises & posterior chain assessments. By day 5 we could achieve pain free stretching of the hip flexors and were using “Compex” to achieve isometric contractions of the quad while the player did upper body exercises.  After day 7 we were able to begin loading through a pain free range, working on co-contractions and concentric contractions of the quad.

To Speed up, you must be able to slow down – Bill Knowles

In the early-mid stages of rehab, we began working on movement patterns but at a painfully slow speed. Using the Bill Knowles mantra above, we progressed though different ranges of box step ups at slow pace to elicit a co-contraction of quads, hamstring and glutes (Figure 3). We slowly lowered the player through a Bulgarian split squat (Figure 4) to work on stability through range and we did some bridging variations (anti-rotational core) to encourage isometric control of the pelvis (Figure 5 – excuse the size 11 shoes taking up most of the picture!!).

Figure 3: a) Low box step up with knee drive

 

 

Figure 3: b) medium box step up

Figure 3: c) High box step up

 

 

 

 

 

 

 

 

 

 

 

Figure4: Bulgarian split squat (a & b) with progressive knee drive added later (c)

 

 

 

Figure 5: Single leg bridge (a) with ipsilateral arm fall out (b) and contralateral arm fall out (c)

 

By adding speed to the high box step up, we were able to switch the demand of the quadriceps to an eccentric action as the hip extends from a flexed position and the pelvis rapidly comes forward. We felt confident adding this eccentric component after we had cleared the player at a decent weight using the cable machine and a jacket to work though some deceleration work on the hip and knee (Figure 6).

 

Figure 6: Cable decelerations. a) start position b) end position with 3 sec hold. c to e) Dead slow step backs with weighted cable pulling posteriorly

 

The Bulgarian split squat was advanced by adding a knee drive at the top the squat, taking the back leg from a position of full hip extension through into hip flexion, a rapid concentric action. Following the model of exercise progression and regression (source) we added weight, removed the concentric component and decreased the speed again before building back up in a now weighted position.

The later stage of rehabilitation saw the player undertake more field based conditioning, working under fatigue whilst completing technical drills and building up his range of passing and shooting, all the while maintaining his gym program to supplement his rehab. This late stage rehab combined the expertise of the physiotherapy department, working alongside the strength and conditioning coach to discuss reps and sets of all drills and help periodise the weeks for the player and design the field based conditioning sessions; the sports science department was able to use GPS for all outdoor drills to help monitor load and provide up to date feedback on key information, in this case monitoring the accelerations and decelerations for the player in a fatigued state.

It was important that the stress elicited in this late stage was in line with the rest of the squad mid-competition. Rob Swire and Stijn Vandenbroucke (source) explain the importance of rehab being harder than the team training. This is because we have control over rehab, but no control of training so we must be confident that player won’t break down again in training!

The player returned just under 8 weeks later. He continued his gym program for another 4 weeks after his return to training and (touch wood) has had no recurrence of this injury since.

 

Conclusion

Knowing what I know now, I would be more cautious of this nondescript pain around the proximal thigh. The indirect head runs quite deep and typically presents as a gradual onset. The niggle the player was displaying a few weeks before was probably a worsening of this small tear, that when fatigued and put under a double eccentric load such as kicking or sprinting, was bound to “give” at some point.

I’m sure that reading this back, it seems pretty obvious that there was something wrong with the player initially. Again, another lesson learnt from this relates to the players age. He had not had a soft tissue injury prior to this, so his subjective history was vague and typically teenager-ish. Its important to remember that young players and professionals don’t necessarily understand their own body. If they play things down, its important that we as clinicians double check everything before we clear them and not just rely on their feedback alone.

 

I hope you find my reflections useful

 

Yours in sport

 

Sam

Don’t clam up over lower limb exercises

 

I regularly find myself debating this exercise with students, new staff, and part-time staff all from different clinical backgrounds and I always find myself asking them – “Why is that patient doing clams?”

For those unsure of the terminology, the “Clam” exercise is designed to activate the external rotators of the hip, performed in side lying with limited pelvic / lumbar rotation.

Firstly I’d like to make it clear that this exercise does have a place in some rehab plans and I am not adverse to including it as part of a program where necessary – but I strongly disagree with it being a mainstay in rehabilitation plans. Purely going from anecdotal evidence, people seem to use clams as a way of increasing endurance of the glutes, particularly glute med. Often prescribing high sets and reps to target the endurance component of the muscles. Previous literature has suggested that Maximum Voluntary Contraction (MVC) of greater the 50% is required to produce any strength gains in an individual muscle (Atha 1981). Figure 1 below demonstrates the EMG activation of glute med during 2 clam exercises, at 30 and 60 degrees hip flexion. Its clear from this study that the activation of glute med is below the required level to achieve any strength gains.

Glute med (if it ever did work in isolation, which I don’t think it does) would concentrically abduct the hip, isometrically stabilise the pelvis and lower limb, and eccentrically control adduction and internal rotation. The best types of activity to stimulate these actions are going to be weight bearing exercises (Figure 1); (Krause et al 2009).

There is evidence to suggest that the posterior portion of glute med is deactivated with any degree of hip flexion, with the bias for primary movement coming from gluteus maximus (Delp et al 1999). This said, Di Stefano et al’s (2009) study produced similar glute med activation at 30 and 60 degrees hip flexion. Either way, my argument is the same – clams probably aren’t working the structures you intend to target.

Reference: DiStefano 2009 here

Clinical Reasoning

My question to clinicians who regularly use clams is always “why?”. What is the purpose of this exercise? At the moment, I work with an elite athletic population. How often in their training and/or competition do they have to externally rotate a flexed hip in an open chain from a side lying position? Never. Even in standing, I can only think of them opening up their hip to control a ball in mid-air but then they are mainly using hip flexors to activate that movement – something we strictly instruct them not to do with a clam. So now that we can’t think of a transferable example for this exercise, I would ask “why are we doing high reps and sets of an exercise we don’t need to do?”

Problem solving

We have already said that the best exercises for glute med activation are weight bearing exercises and the reason for that is exactly the reason why we shouldn’t try and isolate glute med… in weight bearing, it will work as one part of a complex and brilliant kinetic chain. This was highlighted in a very interesting study recently by Kendall et al (2013) who used a nerve block on the superior gluteal nerve and then performed the Trendelmberg test. Even with a neural block to the gluteal muscles, patients maintained pelvic alignment through the step test, highlighting that in isolation, the glutes alone do not support the pelvis.

One of my preferred, early stage exercises to improve hip control / stability is a single leg isometric movement (figure 2).

Figure 2: Single leg isometric flutes (brilliantly demonstrated by @riarottner)

The patient is instructed to rest the contralateral leg against the wall for balance only. All of the body weight should be through the standing leg. Explain to the patient that their foot is superglued to the floor, but you want them to rotate their thigh out (encourage external rotation). There should be no movement from the upper body, bum should be “tucked in” with text book posture and they should hold this contraction for 10s, repeat 10 times. I promise, it will burn your glutes towards the end. Try this yourself and pay particular attention to what else happens further down the chain. You’ll see activation of the VMO and the medial arch will raise as tibialis posterior activates too. A brilliant example of the kinetic chain in action.

“Providing the patient is able to single leg balance, any exercise targeting hip control should be done unilaterally”

Now, there are examples in the patient populations where this is not an appropriate exercise. For example, early stage ACL injuries due to the torsion this creates through the femur and tibia. Instead I would adapt the exercise to something that we were all taught very early on in our physiotherapy degree – a simple small box step, placing one foot from the floor onto a step and back onto the floor – where the standing leg is the working leg. If you are strict enough with posture and lumbo-pelvic control, this is great early stage exercise for the glutes and easily progressed into a full step up, step downs, lateral steps, greater step heights etc. (For exercise progression, please see my shameless plug for my recent Model of Exercise Progression). Kendalls (2013) paper that we mentioned earlier, supports this simple trendelmberg exercise for patients with marked hip abductor weakness. Krause et al (2009) found an increased activation of glute med with single leg exercises compared to double leg stance, so providing the patient is able to single leg balance, any exercise targeting hip control should be done unilaterally.

For the non-weight bearing patients there is reasoning to perform these open chain exercises. While we have said we may not be increasing strength, we know that there is some activation occurring within the glutes so we limit an atrophy and maintain neuromuscular activation while the patient is NWB. Refer back to figure 1- the top exercise for glute med EMG is straight leg hip abduction so even with these NWB patients there are more appropriate alternatives to the clam.

Conclusion

Two of the core elements of physiotherapy is the ability to clinically reason and to provide effective exercise prescription. I would encourage people who regularly use any exercise, not just clams, as part of their mainstay exercise protocol to consider exactly why they are using them. I personally don’t think there are many examples where the clam is an appropriate exercise for sports medicine populations. The exception being NWB patients who are unable to control long lever exercises like single leg hip abduction. Therefore, there is an argument that the clam may quickly become an extinct creature.

 

Yours in sport

Sam