Exercises to Eliminate Pathokinematics - Part IV

There are few exercises that contribute more to the overall health of the human body as well as facilitate activities of daily living better than the squat.  The ability to squat properly is critical for athletes and non-athletes alike.  Because squatting is a compound exercise which involves the entire kinetic chain, a person in motion during a squat is a window into the make-up of the human body at any given point in time.  Because of its importance as a diagnostic tool, and its wide application in daily living and sports, we have designed the movement assess with the squat as the number one exercise to film and analyze.  We know that if we see deficiencies in an individual’s ability to squat, we are seeing into the body’s core composition in many ways---and can pinpoint specific strengths, weaknesses and tightness that can be directly impacted through a targeted exercise program.

We also know from the research that the inability to squat is the number one cause of falls in the elderly, which often leads to broken hips and many other co-morbidities in aging adults.  We know that the squat speaks to the strength of the core, including the lumbar spine and hips.  Improving an athlete’s ability to squat has a direct impact on his or her ability to run, jump, land and lunge safely.  We also know that improving an athlete’s squatting mechanics has a direct impact on injury rates and performance output.  Studies show that we can increase vertical jump height and running speed measured by the 10 yard split and 40 yard dash by targeting and improving the mechanics and thereby, the efficiency of an athlete’s squat is critical. 

These are but some of the reasons the squat is the first exercise we typically address.  Because the squat is the “core” of so many of the exercises in a corrective exercise program, it is important to master before progressing to other more advanced isolation exercises.  Furthermore, if time is limited, as it so often is when training is intense or the season is live, the squat progression will give the athlete the most “bang for the buck” for time spent in the gym.  More details on the squat and how to get started follow in the paragraphs below.

The second most important exercise series in the corrective program is the Lumbar Hip Disassociation Exercise Series.  Again, the ability to disassociate hip flexion from spinal flexion is “key” to many sports activities as well as other activities of daily living.  Therefore, we believe the Lumbar Hip Disassociation Exercise Series is a foundational series upon which all other exercises in a program are built, and therefore is a starting point for the progression of the a corrective exercise program.  Ultimately, these exercises will drastically improve the athlete’s movement patterns, improve overall athletic performance and reduce the likelihood of certain types of lower extremity injuries, specifically those involving the lower back, hip, knee, and foot/ankle when prescribed and conducted properly.  These two in particular set the athlete up for safe and successful entrance into the rest of the Corrective Exercise Program. 

This section will provide you with instruction in these beginning stages of The Corrective Exercise Progression, beginning with a basic overview of how to get started and then going into detail on squats and the lumbar hip disassociation exercise series and more on why they are important: 

Squat Progression

                                               i.     Squat NMR

                                             ii.     Rapid Squats

                                           iii.     Controlled Squats with Weight 

Lumbar Hip Disassociation Exercise Series

                                               i.     Prep Exercise

                                             ii.     Single Leg Proprioceptive Neuromuscular Facilitation (PNF) with Hip Flexion

                                           iii.     Single Leg with Dynamic Lower Extremity Movement

                                            iv.     Modified Dead Lift

The Corrective Exercise Progression:  Each exercise in the CEP progresses from one level to the next.  However, it should be noted that throughout the progression, we will refer to the concept of “progression within a progression.”  This is simply a way to progress an exercise from one level of difficulty to the next without moving to the next prescribed level.  This is a concept that can be utilized when an athlete is not quite ready to progress to the next level but does require something more difficult than what the current level requires. This can be as simple as adding resistance, increasing the number of repetitions, decreasing rest time between sets, decreasing stability of the surface or using super sets. 

So, now you are undoubtedly wondering where to start and the answer to this question is the key to this entire program.  Starting off with a solid foundation will either make or break success in correcting pathokinematics.  The movement assessment is designed to assess individual weaknesses and tightness and everyone will not be the same.  However, a large majority of the athletes that we have tested over the years benefit from a foundation starting with several simple exercises up front.  So, remember when working through these beginning exercises the phrase:

Poor technique = poor motor planning = poor performance

With this in mind, we want to attempt to correct any poorly executed core movements from training day one.  Training day one is typically, in a rehabilitation setting, done on the same day as the initial evaluation.  In a performance setting, however, we are often more limited on time, so this may actually be on a separate day and consume the majority of the first training session.  No matter what setting, the sequence laid out here will aid in correcting core movements that show signs of weakness or tightness that could lead to pathokinematic movement patterns during the exercise progression, and during sport.

Squat Progression: 

Strength, endurance and co-contraction of the quadriceps and hamstrings are essential for maximal performance and injury prevention.  The one exercise that has been “proven” in the research to improve vertical jump and aid in creating co-contraction is the squat.  Performing full squats, would be considered more advanced exercises and therefore maintaining “healthy” knee/hip alignment is essential.  Therefore during the squat progression, it is imperative to follow the repetition to substitution concept very closely.  These exercises may also be performed as supersets.

It is absolutely vital that technique be a focus with these exercises from the beginning of the progression.  You are training for performance, muscle memory and motor planning.  Bad training technique adds to decreased performance.  With squats, common tightness in most athletes leads to the heels coming off the floor and the knees moving forward over the toes.  It is essential to keep the heels in contact with the floor throughout the exercise and the knees behind the toes at the end range of motion.  Common weaknesses in the female athlete (and males in many cases as well) also result in squatting technique which results in the athlete shifting more to one side than the other. 

Another vital concept related to the proper performance of the squatting exercise is to ensure proper kinematics and lumbopelivc control throughout the course of the exercise.  Making sure the knees do not progress over the toes will reduce any adverse shearing stresses imparted to the patellofemoral joint and hence reduce the potential for knee pain (squatter’s knee) from occurring with this exercise.   It is also essential for proper core stabilization to occur (keeping abdominals tight) throughout the course of the exercise in order to prevent excessive spinal extension or flexion.  Doing these things will reduce the extent of abnormal forces that can be imparted to the lumbar spine and thereby reduce potential for back pain sometimes associated with this more aggressive exercise.

Our research indicates that in fact 80% of athletes fail the full squat test.  This is despite the fact that many of them may be performing squats as a part of their regular exercise routine.  Failing this test is defined as ≥1” lateral shift.  A lateral shift typically results when an athlete who began squatting with poor mechanics was never corrected.  Through years of training, they have reinforced poor motor plans and abnormal proprioception into the system.  To the athlete, this feels normal, however these deficits result in significant asymmetries in load bearing of the tissues and asymmetrical strength gains as well as force production.  Therefore, if an athlete fails the Full Squat Test, they must perfect the Squat Neuromuscular Retraining (SNMR) prior to proceeding to any of the squatting motion exercises that follow here.  If an athlete does not perfect this test, then we will simply be training or reinforcing bad movement patterns or poor motor planning.  The SNMR is explained in depth below.  Again, remember: 

Poor technique = poor motor planning = poor performance

Squat NMR (Neuromuscular Retraining):

Teaching proper squatting motion is essential first step prior to progressing into the squatting routine as we said above.  It is essential to development of maximal force production while preventing injury and thus the reason the SNMR exercise is so essential.  The SNMR is an exercise used for retraining squat for the lateral shift prior to performing any squat training routine or progression.  It will be the base upon which most of our exercises will be developed. 

When correcting a lateral shift, one of the common things an athlete will state is that the "correct position" feels weird.  This sensation comes from proprioceptors throughout the lower kinetic chain giving the sensation of this changed position.  Since that is the position that was trained, then it will feel different or "weird".  This technique takes into account the fatigue literature to add in overriding this system and "re-setting the system" to the correct position.

1. Have the subject perform 20 squats through their full range of motion.
2. At the conclusion of the 20th squat, have them get into a squat sit position (end rom of motion of their squat) and hold that position with their hands out in front of them and palms pressed together.
3. Prior to beginning the perturbations, move their hips into a neutral position if they are in a lateral shift.  When in the neutral position, perform light perturbations through their hips, knees, arms in rotation, and shoulders.  Do this at a rapid pace but not hard enough that they are not able to maintain proper position.  Perform this for 10 seconds. 
4. Perform 20 more squats through their full range of motion.
5. Repeat the perturbation protocol as above.

This exercise series is TYPICALLY performed 2-3 times before the subject is able to squat without lateral shift, without cueing.  This should be a part of any home exercise program as well, having the athlete perform 3-4 sets of 20 reps with 5-10 second holds in the squat sit position.

If they are unable to squat to increasingly lower levels without the shift, progress the time at the higher level squat without the shift with attempts made at each session to progress toward a 90 degree or greater squat without any shift off of the midline.  The SNMR will typically consume approximately 10-15 minutes of a session.

 Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part III

Last week we talked about warm-up in some detail and this week we are going to focus on Dynamic stretches.  For the purposes of this blog, we will be covering mostly how this can be used in the clinic or in the gym.  The ACL Play It Safe Program uses some of these same concepts but applies them with sport to ensure maximal carry over in the later stages of rehabilitation or for performance enhancement or as a part of your injury prevention protocol.  We will cover this later in this blog series but stick to the clinical application at the moment.  Most importantly is that the concepts that are taught here should be implemented no matter whether you are doing this on the field or in the clinic. 

Dynamic Stretches:  The purpose of these exercises is to work on the flexibility of the athlete’s hips and lower legs in order to allow him or her the flexibility that is needed to participate in sport and to prevent injury.  Dynamic stretches are also designed to incorporate balance, strength and muscular endurance which will carry over to sport.  It is also critical that technique is strictly enforced.  Allowing athletes to perform the dynamic stretches with poor movement patterns simply reinforces bad movement patterns.  Poor movement patterns that will be carried over to remaining exercises and during athletic performance.

Dynamic Lunge:

Start by lunging out with the right foot, keeping both feet straight ahead.  Do not allow the right knee to go over the toes.  Bring the right elbow to the arch of the right foot, and hold this position for 3 seconds.  Extend the right knee to the straight position while bringing the left heel to the floor (make sure to keep feet and your hips pointing straight ahead).  Keeping the hands on the floor (the goal is to keep the palms flat on floor), hold this position for 3 seconds.  Lunge forward with the left leg while making sure to prevent moving into valgus and repeat the sequence on the left side.  Perform 10-15 yards or 8 repetitions on each side.

NOTE:   Several key positions to be aware of.  When lunging out, the contact with floor is controlled and not slapping the foot and controlling the knee.  With bring the elbow toward the arch of the foot, the thigh is kept in close to the elbow to push hip flexion and the hips are aligned straight and not allowing to roll out.  On side, hip position is maintained straight ahead.  Stride through is critical to control the knee and not allowing to go into a dynamic valgus.

Sumo Squat: 

Starting in a full squat position, grab your toes and pull up with each hand.  While continuing to hold onto your toes, fully extend both knees as far as your flexibility will allow.  Hold this position for 3 seconds.  From your hands on your toes position, walk your hands out to a full push-up position.  From this position, walk on your toes to bring your feet up to your hands.  Hold this position for 3 seconds, return to the starting squat position.  Perform 10-15 yards or 8 repetitions.

NOTE:   As instructed in the video, it is critical to maintain good hip and trunk position and stability during the push-up.  During the toe walk, the knees are kept straight during the entire walk up.      

High Knee Toe Ups: 

Standing with feet shoulder width apart, bring the right knee up toward your chest while grabbing with both hands and pulling to the chest as far as your flexibility will allow.  Simultaneously rise up into a calf raise on your left foot.  Pause and hold briefly.  Return to the starting position.  Repeat with the opposite side.  Perform 10-15 yards or 8 repetitions.

NOTE:  Some key points on technique is to ensure that the trunk remains upright during the hip flexed position.  This results in bringing the knee to the chest and not the chest to the knee.  Also important to make sure you are bringing the knee into straight knee flexion and not in a circumducted position (circular fashion).

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part II

Last week we started introducing the philosophy behind the exercises to reduce pathokinematics.  This week we will continue on this path with layout on the specifics of what will come in the coming weeks. 

The following series will provide you with instruction in:

1. Warm Up.  In order to prevent injury, the athlete needs to first warm up the body, raising the core temperature.  Then he or she is able to do some dynamic (movement based) stretching to further loosen the muscles and prepare him or herself for more demanding work on each muscle group.  In some cases, it is also appropriate for the athlete to work on more intensive sprinting and plyometric activities to address speed and endurance. These also serve to further increase body temperature.  The Warm Up consists of:

·       Cardiovascular Warm Up.  Due to the endurance demands of sports, cardiovascular training is an essential component and should be built in to the training plan as a part of the overall performance program.  Our cardiovascular warm up routine will provide you with the most efficient warm up to allow the athlete to achieve optimal gains in the shortest period of time.

·       Dynamic Stretches.  Dynamic stretches provide athletes with a unique stretching routine that focuses on flexibility, balance, strength and endurance.  Dynamic stretches are NOT ballistic stretches.  These use contract- relax techniques which facilitate optimal gains in the shortest period of time.  These stretches include:

§ Dynamic Lunge

§ Sumo Squat

§ High Knee Toe Up

·       Sprint Training.  For those athletes needing to incorporate anaerobic speed or sprint training into their routine, this section will provide a detailed program to allow the athlete optimal gains in speed and anaerobic power, using the 40 yard dash.

·       Proprioceptive Neuromuscular Facilitation and Plyometrics:  Once we have ensured that the athlete’s core body temperature is raised and the muscles are loose, we can incorporate more intensive and targeted pre-stretch, proprioceptive neuromuscular facilitation and plyometric exercises in preparation for the Corrective Exercise Progression.  These exercises are:

• Bilateral Hops
• Single Leg Hops
• Box Jumps
• Lateral Box Jumps
• Single Leg Lunge Hops
• Jump Squats               

2. The Corrective Exercise Progression (CEP). The exercises in this program will be categorized by the muscle and/or system being trained.  These exercises have been carefully chosen after a through literature review to ensure maximal outcomes.  Each exercise will have 3-7 levels of increasing difficulty within each progression in order to ensure they properly facilitate maximal gains in strength and performance.  Because of the size and scope of the CEP, will consume multiple blogs and devoted a section to each which follows:

The King and Queen of Exercise—The Squat and Lumbar Hip Disassociation

 

Squat Neuromuscular Retraining (SNMR)

Lumbar Hip Disassociation Exercise Series

Digging Deeper—Targeted Isolation Exercises

Gluteus Maximus Progression

                                               i.     Glut Max Press

                                             ii.     Leg Press

                                           iii.     Step Ups

Gluteus Medius Progression

                                               i.     Side Lying Gluteus Medius

                                             ii.     Side Step with Resistance Band

                                           iii.     Retro Monster Walk

                                            iv.     Standing Gluteus Medius

                                             v.     PNF Step Ups

Adductor Group Progression

i.      Standing Hip Adduction

ii.    Supine Adductors from Pike Position

iii.   Side Lying Adductors

Quad Progression

i.      Leg Extension

ii.    Standing Lunge—Alternating

iii.   Standing Lunge--Back

iv.   Walking Lunge

v.     Prone Place Running

Hip Flexor Group Progression

                                               i.     Single Leg Raises

                                             ii.     Head to Knee Pull-Throughs

Hamstrings Progression

                                               i.     Hamstring Pulls

                                             ii.     Modified Dead Lift

                                           iii.     Single Leg Dead Lift

Lower Leg Progression

                                               i.     Standing Calf Raises

                                             ii.     Seated Calf Raises

                                           iii.     Dorsi Flex Toe Ups

                                            iv.     Rebound Hops

Foot/Ankle Progression

                                               i.     Inversion/Eversion

                                             ii.     Standing Medicine Ball

                                           iii.     Bosu Ball Balance

Addressing “The Core” 

Abdominal Progression (Core Series)

                                               i.     Upper Abs on stability ball

                                             ii.     Obliques on stability ball

                                           iii.     Pike Position Lower Abs

                                            iv.     Side Bridge

                                             v.     Prone Bridge on Elbows

Lower Back Progression

                                               i.     6 Pack on stability ball

                                             ii.     Prone stability ball Leg Raises

                                           iii.     Good Mornings

Warm Up

Warm up exercises are an integral part of any exercise program.  With our program, we use cardiovascular exercise as an appropriate initial warm up step for athletes.  Warm up will consist of both aerobic exercises and anaerobic exercises.  The aerobic exercises will be used for general conditioning and the anaerobic for more sport specific conditioning.  The amount of aerobic and anaerobic conditioning for each individual is going to be determined by the demands of the sport.  For example, for soccer players and long distance runners, the aerobic component should be increased dramatically, while sprinters need more anaerobic conditioning.  At the end of the warm up period, we include a plyometric exercise component which further serves to warm up the muscles, joints and ligaments, as well as providing additional interval and power base training, which is proven highly beneficial in sport.

Cardiovascular Warm Up:  Cardiovascular training should include light aerobic exercise, which can consist of work on a treadmill, elliptical machine or stationary bike and should be at least 10-30 minutes in duration, depending on the aerobic demands of the sport for which the athlete is training.  This should not be a scheduled part of the program, but rather done on the athlete’s own time directly before the program begins.  This is accomplished by having them come in 10-30 minutes early to perform the cardiovascular warm up.  The exercise intensity should be gauged by the athlete’s heart rate (HR), which is determined using the Karvonen formula.

Training HR = [(HR _max – HR _rest) * .6 to .8] + HR _rest

This formula gives you the targeted training HR in beats per minute, at 60-80 degree of the maximum target heart rate.  The final number can then be divided by 6.  This will give you the HR the athlete will measure during a 10 second count. 

Example:  If an athlete wishes to perform with a training HR of 120 to 138 beats/minute, dividing by 6 gives you 20 to 23 beats per 10 seconds.  So when exercising, the athlete takes their HR for 10 seconds to determine if they are within this range.  If the measured heart rate is too low, increase intensity (e.g., speed/pace, difficulty), or conversely, if it is too high, decrease the intensity of the exercise.

HR _max  =  220 – age

HR _rest  =  resting HR for 1 minute

.6 to .8 determines the relative intensity of the exercise and the number chosen should be based on the general conditioning level of the athlete.

Using this formula will create a much higher intensity than that at which many younger athletes are accustomed.  Therefore it is important that they are taught how to use this formula and how to take their own resting and exercising heart rates so that they can learn to monitor their own heart rate throughout the warm up.

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part I

Throughout the last several months this blog we have discussed pathokinematics and the impact they have on both performance and the potential for injury in athletes.  In one of the previous series, we provided you with several tools to assess movement and interpret the results of those assessments.  We also discussed how technologies could be leveraged to address.

 A movement assessment should be designed to assess movement patterns (pathokinematics) that are commonly associated with increased risk for athletic injury and reduced athletic performance.   The goal of the assessment should be to identify strengths, weaknesses, and tightness in the musculature and other structures of the body that cause or contribute to pathokinematic movement patterns.  Once these are identified, it is possible to “prescribe” corrective exercises that directly influence and improve those weaknesses and tight areas of the athlete’s body, making them stronger, more flexible, and more capable of transmitting power throughout the kinetic chain and lower extremity during sports activities.  It should be mentioned here that in addition to corrective exercise, there are many other techniques and manual interventions that clinicians use to correct deficits we see and identify using a movement assessment.  These are beyond the scope of this blog and will not be covered here but should be considered in a comprehensive treatment plan.

 In the series “How to Eliminate Pathokinematics” we reviewed some General Facts and Terminology associated with exercise and training in preparation for the information contained in this blog series.  Here we introduce the Corrective Exercise Program, or CEP.  The Corrective Exercise Program (CEP) is designed to directly and specifically address the components that contribute to pathokinematic movement patterns.  This is a movement specific program and not a sport specific program.  It is the concepts and methodology from all this body of work from which we developed the ACL Play It Safe Program.  However, each of the exercises included here will be the more clinical exercises and not the group/team interventions that are a part of the ACL Play It Safe Program.  Each of the exercises described here have levels of progression that increase the difficulty and/or endurance requirement of the exercise.  If prescribed and conducted correctly over time, these exercises will not only drastically improve the athlete’s movement patterns but will also improve overall athletic performance and reduce the likelihood of certain types of lower extremity injuries, specifically those involving the lower back, hip, knee, and foot/ankle.

In 2009 unpublished study 40 college athletes were placed on an exercise program to directly address weaknesses observed in a movement assessment.  The results of this targeted exercise program were phenomenal.  It was shown that when the athletes participated in the exercise program for 8-12 weeks, they were able to increase their vertical jump by and average of 4 inches and improved 40 yard dash time by 1.4 seconds.  In our current body of work, we are not only seeing dramatic decreases in overall lower limb injury rates but also huge health care savings for the university.  We are demonstrating an average savings of $30k to $50K per team per season in DI athletics.  In 2016, we continued this work with DI Football.  The results of this work is currently being written up for publication but preliminary analysis shows the lowest recordable injuries in 8 years and the team was nationally ranked for the first time in the colleges history.   

Using what we learned from this and many other similar studies, as well as years of experience working with athletes, we have developed a set of exercises that assist in reducing the potential injuries in the lower extremity and improve performance.  The program details follow, but it is important to remember that before beginning any exercise program, it is a good idea to have a complete physical performed on the athlete. 

This program is designed so that it can be used in many different ways and for many different sports.  For example, the CEP can be used for rehabilitation of an injured athlete when targeted exercises are chosen to address the injury or injuries.  The Physical Therapist or Athletic Trainer can “pick and choose” those exercises most appropriate to address the rehabilitation needs of the individual.  The CEP can also be effectively used to address pain issues associated with overuse, repetitive motion or pathokinematic movement patterns in athletes.  We have found that when the CEP is used to strengthen the athlete, either when used in a targeted fashion or as an overall exercise regime, pain with lower extremity activities is reduced.

applications.

Of interest to many in today’s fitness world is the use of this type of exercise program in athletic performance enhancement.  Our results show that athletes who use the Corrective Exercise Program in fact increase athletic performance, specifically in peak vertical jump height and sprinting speed as noted above.  This has also been validated in work by Myers, et al who have showed similar results.  The CEP can be used to improve technical ability specific to a given sport, strength, speed, endurance and power output.  Portions of the CEP can be used to target specific weaknesses or areas of tightness and inflexibility the athlete demonstrates in the movement assessment, or can be used in its entirety as a full and complete exercise program.

Because of the difficulty and intensity of the CEP, when adding it (or parts of it) to an already full training plan, it is easy to over-train the athlete.  Care must be utilized therefore in prescribing exercises in the CEP that involve the same body parts as those already being taxed in the regular training routine or sports activity.  They should instead be used to replace or substitute for those exercises, or enough rest should be allowed between them.

As discussed above, after a thorough assessment of the athlete, we now have an idea of where their individual weaknesses and tightness exist.  As with any exercise program, you and the athlete should be sure that they are physically capable of safely beginning or proceeding with a rigorous exercise program.  The exercises in this progression begin at a fairly difficult exercise level, requiring participants to have a basic level of fitness and flexibility.   Again, please be sure to have your patients/clients check with their physician before beginning this or any exercise program. 

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.