Monday, February 27, 2017

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. 

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