How to Eliminate Pathokinematics - Part IX

Last week we discussed the role of the core, strength training and the importance of rest.  This week, we will build on those discussions to talk about periodization training and psychology of sport. 

Periodization

Periodization refers to the habit of planning the annual or seasonal workout schedule to allow the body to rest and recover and then be in a period of continual overcompensation followed by more rest and recovery.  This concept was developed and popularized by a Romanian sports scientist by the name of Tudor Bompa in the 1960s and was first published in his work Theory and Methodology of Training.  The concept basically refers to a progression from more general fitness related training to more specific training needed for the sport, so it is related to the concepts of specificity, hypertrophy and adaptation discussed earlier.  Periodization concepts are also used to target the special needs of the individual athlete as determined by previous injuries or other kinds of sports performance limiters, e.g., pathokinematic movement patterns, certain kinds of muscle weaknesses, etc.  Periodization training typically involves the use of macro-cycles, meso-cycles and micro-cycles, the details of which are beyond the scope of this book.  However, if we look at training on an annual or seasonal basis, we can break the training plan into several distinct periods:

 

1.  Preparation:  This is the period of training that comes first in which skills, mechanics and techniques are refined, the athlete begins a regular training schedule after having taken time off, and he/she prepares for a more intense period of training.  During this phase, strength/resistance training should be developed, cardiovascular training built, and movement economy practiced.  This period can last anywhere from four to twelve weeks.
2. Base:  This is the period of training in which endurance, force and speed are built.  This is when the athlete prepares for the next session which is the building session by establishing an overall base of fitness that will carry him/her through the season.
3. Build:  This period is where the athlete gradually increases intensity, duration and frequency of workouts to more closely approximate the requirements of the sport he or she is competing in later in the season.  The build period includes a lot of endurance and muscular endurance work, plus increased force training.  It is during this period that many athletes push too hard, and are more susceptible to injury.  Because the concept of periodization means a progressively increasing and strategically focused training schedule, it is important to remember to allow more recovery time as the quantity and intensity of training increases.
4. Peak:  The peak period is the time during which the athlete’s intensity is highest, and therefore recovery needs are also highest.  This is where the athlete attempts to most closely simulate the specific needs of his/her sport prior to the first race or competition, including all the strategies required for racing or other competition.
5. Race:  Race period, or as it might be known in some sports, “Competition” period, is the time when the athlete should be fully prepared and be at the highest fitness level possible for his or her sport.  If the preparation, base, build, and peak phases were all maximized and used properly to strategically progress the fitness and endurance level of the athlete, then he or she should be ready to compete at the highest levels possible.
6. Transition:  This period is the “off-season” and usually lasts from 4-8 weeks.  This is a time when rest (both physical and psychological) is substituted for focused sport specific training.  Active rest and cross training are effective ways to maintain overall fitness during the transition time. 

 

Transition time can also be used during an active season for longer term rest and recovery.  Transition time is applied often after “breakthrough workouts.”   Breakthrough workouts are those that require more than 36 hours to recover[i]  and are used to push the body to overcompensate in order to learn to combat fatigue and increase mental stamina.  They are often focused primarily on increasing muscular endurance.  The number and frequency of breakthrough workouts varies greatly by athlete and sport, and should be planned with full periods of rest and recovery afterward to avoid injury and allow the body to build.  

 

Remember:  Strength and performance gains actually occur during periods of REST.  Performance gains do not occur during training, as is commonly believed.  It is only during the periods of rest between periods of break-down of the body that it is regenerated and becomes stronger via a process of overcompensation or, as it is also known, adaptation (Appendix I).  Again, to reiterate an earlier statement, the idea in athletic performance improvement is to do as little training as possible to generate an adaptation response that results in the body becoming stronger and more efficient at the given activity.  Anything more results in overtraining and anything less results in sub-maximal performance gains.

 

Periodization should also be considered during and inside a regular training schedule.  One method that we like involves three or four weeks of increasing training volume and intensity followed by one week of rest and recovery, with a drop in both volume and intensity of training.  This week allows the body to rest and recover, and ultimately become stronger.  Each week during the harder first three or four weeks of the cycle, training volume or intensity are not increased by more than 10 % at a time.  This is what many coaches, trainers and experts in the field refer to as the “golden rule” of training.  Any more can lead directly to injury.

 

All of that considered, it is vital during all training phases that proper movement is carried through all phases.  So, no matter what phase the athlete is in or what lift is being performed, if poor movement is allowed to continue, this will limit overall performance.  Whether that is measured as maximal poundage lifted or timed sprint speed, strength training that allows for movement compensation is strength training that is reinforcing poor movement. 

 

Take the following case in point.  This valgus occurring at the right knee was limiting her PR.  Once this was corrected, kinetic energy transfer across the system was much better which allowed for an increase in her PR.

 

 

 

Psychology of Exercise and Sport Psychology      

 

In order to help athletes and others change their movement patterns during exercise or sport, we have to understand two things:  a.) what motivates them to exercise or train in the first place and b.) what will motivate them to work hard to change their behaviors in order to exercise or train in a different way.  There have been hundreds of studies on the psychology of exercise and more specifically sports psychology in recent years.  Researchers have studied the psychology of exercise in the general population and also taken the interdisciplinary approach to understanding sports psychology for athletes by looking specifically at the fields of kinesiology (the study of human movement) in combination with psychology.  The question remains, what are the drivers of exercise, training and participation in sports? 

 

It is beyond the scope of this book to delve too deeply into the underlying motivators in sports performance and exercise across all populations.  However, it is critical that we, as professionals who help athletes (and others) learn to move better in order to avoid injury, maand sensitive to, the psychological and motivational drivers of performance.  Without this sensitivity, we will be ultimately unable to affect any real and lasting change that will result in improvement. 

nage pain, rehabilitate when injury has already occurred, and improve athletic performance, be cognizant of,

 

That said let’s consider a few of the more commonly accepted “exercise” motivators across the general population such as:

 

• Competition
• Current cultural trends towards health and wellness
• Love of a chosen sport/fun
• Release of brain chemicals that reduce stress, anxiety, etc.
• Mental escape
• Sense of control
• General sense of accomplishment
• Pay,  prizes, awards, scholarships
• Social aspects
• Body image
• Reduce effects of aging
• Ability to eat more
• Exercise addiction
• Relaxation
• Weight loss or management
• Rehabilitation from injury or illness
• Educational requirement
• Mood elevation, increase feeling of happiness
• Force of habit

Researchers have found that the number one motive for exercise across all populations is to improve health.  For younger athletes however, ages 16-25, the number one motivator is competition.  Support of family and friends was paramount to success with exercise programs, and it was found that those persons who participate in shorter workouts at higher intensities feel more confident that they can continue exercising in the future.  It has also been found that people who exercise at a moderate intensity, more often, are more successful sticking with their exercise program than those who exercise at higher intensities, less often.[iv]

Ultimately, before undertaking what amounts to a behavioral and physiological change program in a given athlete, the professional should work with the athlete to understand his or her personal motivations to change.  Is it for injury prevention?  It is for injury rehabilitation or pain management?  Or is the change required or desired primarily for performance improvement?  Ultimately, without this knowledge, it is unlikely that the professional will be able to design and prescribe a program that will strengthen where there are weaknesses, loosen where there is tightness, re-program long-established neuromuscular patterns, influence habits and ultimately improve movement.

In addition to the above, we also must understand how to motivate an athlete to "train differently".  If they are use to using massive weights and performing multiple reps with pathokinematics, how do we change their mind set.  Two things we have found to be very beneficial and which is supported by the current research.  In 2015, Agresta et al published a paper in the JOSPT that showed the importance and impact that visual feedback has on helping runners change their gait patterns.  When an athlete sees how they move and understands how that correlated to impact on performance and injury rates, they are much more likely to focus on corrective techniques.   In 2013, Ardern et al in the AJSM showed that one of the major factors determining an athletes ability to return to sport post ACLR is what is called Sport Locus Control.  Simply stated, this is the athletes perception that they are in control of their destiny versus something external.  This is important in assisting athletes in changing their movement patterns so they feel like they have some control over that.

Sport Locus Control can easily be provided to the athlete by:

1. Filming them during movement assessment and review the video with them
2. Educate them on why the movements are occurring and the impact has on performance and injury rates
3. Educate them on the exercises that will assist in reducing these pathokinematics
4. Education them on things to watch out for with their traditional strength and conditioning exercises
5. Empower them to know they can make a difference

Taking these simple steps will go a long way in helping the athlete overcome and correct pathokinematics not just for a season but for their entire athletic future.


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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[i] Friel, Joe and Byrn Gordon, Going Long:  Training for Ironman Distance Triathlons, , The Ultrafit Training Series, Velo Press, 2003, page 32. 

[ii] Friel, Joe, The Triathlete’s Training Bible, Second Edition, Velo Press, Boulder Colorado, 2004., pp 222-223.

[iii] Friel Joe and Byrn, Gordon, Going Long:  Training for Ironman Distance Triathlons, The Ultrafit Training Series, Velo Press, Boulder, CO  2003, pages 193.

[iv] Waehner, Paige.  The Psychology of Exercise Quiz:  What really motivates us to exercise?  About.com, Exercise, 2011.

 

How to Eliminate Pathokinematics - Part IIX

Last week, we talked about the importance of stretching and flexibility and use of dynamic stretches.  This week we will continue our discussion by looking at the impact of the core.

Core

Another key concept to define here is the “core” or midsection.  This has been defined by many different authors to include various muscles, groups of muscles and body parts.  For our purposes we define the core as anything from the pectoral muscles (chest) to the knee. 

It is critical to examine the role of the core in pathokinematic movement patterns.  In order to do this, let’s further define the core.  It includes the latissimus dorsi, multifidus and other back muscles, the muscles of the abdomen, including, but not limited to the obliques, rectus abdominus and transverse abdominus, the muscles of the hips such as the adductor, abductor and rotator groups, (including the piriformis and gemelli brothers), and the gluteal group.  Also, for our purposes, we will include the pectoralis major and other chest muscles, as well as those in the front of the hip, such as the hip flexor group.  Last, we include the muscles of the upper leg, including the quadriceps and hamstrings groups.  All of these are connected in some form or fashion either by origin/insertion or through fascial connections.

Strengthening the core adds to increased force attenuation which results in reduced potential for injury, as well as increased transfer of energy across the system, i.e., greater power distributed throughout the kinetic chain.  Without sufficient core strength/endurance, there is inefficient transfer of energy across the region.  This adds to altered length tension relationships of the lumbopelvic region as well as muscles attached to this region, including the quadriceps, hamstrings, and gluteals.  It stands to reason, then, that improvement in core strength, endurance and power improves athletic performance, and reduces potential for low back pain and lower extremity injuries. 

The correlation of core strength to performance as well as injury prevention has been well vetted in the research.  In 2011, Chaudhari et al JSCR showed that improvements in core strength added to improved athletic performance in MLB pitchers with less walks and hits per inning in players with good core stability .  Chaudhari et al further showed in 2014 AJSM that improvement in core stability in MLB pitchers also resulted in 44% less time on the DL when compared to MLB players without.  This is just a few of the multiple studies showing the impact on athletic performance.  Other benefits of strengthening the core will be discussed in the next section on the Role of Strength Training. 

When training the core, proper technique is critical.  All too often, success is determined by ones ability to do a more difficult form of the exercise than in performing the easier form of the exercise correctly.  This is often seen in core training and it is important to keep in mind that the movement patterns and compensations that you train in your training sessions will be the ones that the athletes will resort to in a fatigued state.

One example of this is the plank.  All too often, we test teams and players who have been doing planks as a part of their training however fail when we test them.  Unfortunately, they end up training improper form so when testing them in the proper position they are not able to maintain that position.  What is the proper position.  This video produced by Theraband helps to explain proper form.

Role of Strength Training

Why is strength training important in the discussion of pathokinematics?  We know from our research that the core is directly responsible for power output to the lower extremity.  We also know that the upper body sends signals to the lower body through the core on which way to move and when.  An example of this is in running.  When the runner’s arm moves forward, the location of the elbow tells the knee where it needs to be in space relative to the rest of the body in order to maintain balance, and the location of the hand and wrist tell the ankle where to be in position, relative to the rest of the body.  All of these signals are sent through the core via the kinetic or power chain.

We also know that if we have certain core weaknesses, these lead directly to imbalances in the lower extremity.  For example, as discussed previously, we know that weak gluteus medius and maximus muscles are directly related to valgus at the knee (or a turning in of the knee) during movement.  This can lead directly to changes in the striking pattern of the foot and ankle, and eventually the entire system from the gluteus medius muscle (part of the core) down is compromised.  Certainly we can see how power output is reduced as well as efficiency.

Through strength training, we can effectively increase the effectiveness of the core in managing balance/proprioception and in sending power through to the lower extremity.  In the following chapters on the Corrective Exercise Program, you will see exercises designed to directly impact the core.  Additionally, we know that strength training builds bone density, increases endurance and facilitates a higher resting metabolic rate, all of which are directly related to health, fitness and injury prevention.

One factor to consider when training to impact pathokinematics in sports is fatigue.  More precisely is training in a fatigued state.  Training the core, gluts, single limb performance and proprioception in a fatigued state is critical to carry over to sport.  Doing so, aids in assisting to maintain better posturing and movement during the later phases of competition.  For an exercise to do post practice, try this exercise.

Role of Cardiovascular Training

Cardiovascular training has application in the discussion of pathokinematics as well.  It is critical that athletes employ some sort of cardiovascular training, combined with stretching, prior to beginning an exercise session in order to warm the body and loosen muscles, ligaments and tendons so they will be prepared to work.  When the body is cold, it is more difficult to reach full extension during exercises or movements that require it, because the muscles and connective tissue are simply not elastic enough to allow a full range of motion.  As a result, the athlete must compensate for the inability of the body to get into certain positions early in the exercise routine, which can lead to injury and decreased performance---and over the long term, poor motor programming.  Body tissues that are cold and consequently less elastic are also significantly more prone to injury.  Of course cardiovascular training in combination with other kinds of training is part of an overall program of fitness for athletes and non-athletes alike.  It facilitates heart and lung health, blood flow to the brain and extremities and an increased metabolic rate, even at rest.  Weight-bearing cardiovascular training also contributes to bone health, which becomes increasingly important as we age.

 Rest and Recovery

Many injuries occur because of illness, burnout, or overtraining.  In fact, two of the biggest enemies to sport are break-down and staleness, which is sometimes called burn out.  Consistency, moderation and time to recover are all essential to avoid injury and maximize athletic performance.  Because consistency in training is the single biggest predictor of fitness in athletes, care must be taken to avoid long breaks in training that can be caused by illness or injury, and which can lead to de-compensation or de-conditioning.  Consistency leads to continuous improvement, but for many athletes, the perception is that working harder, faster or more often is the key to higher performance.  Consequently, for these athletes, it is hard to listen to the body and take time off when needed.  The result can be long periods of missed training due to breakdown of the body over time and chronic fatigue. 

Rest is essential to recovery and to getting stronger.  In other words, without rest the body’s systems do not have time to regenerate and then during the next workouts, form and endurance suffer.  Sleep is the most important recovery strategy since during sleep the body secretes growth hormone that repairs damaged muscles and repairs other physiological systems that are taxed during training.  The key to effective training is to tax the body JUST enough so that it is able to recover and regenerate, and get stronger, before the next work out.  If we don’t allow enough rest, then breakdown leads to more breakdown, until finally the body becomes injured or ill. 

The idea in any training or rehabilitation program is to increase the quantity of quality training and eliminate training that is of poor quality altogether.  Most amateur athletes, in particular, train too often and often too much.  They are notorious for not training hard enough on hard days or training easy enough on easy days.  In other words, many athletes train at a moderate level all the time.  This leads to chronic fatigue and eventually overtraining and injury.  At the very least, it prevents real performance gains in endurance, speed, strength, power, or efficiency.  So, in other words, we want our athletes to train as little as possible to achieve the desired adaptation response.

Be sure to include at least one day of complete rest in the athlete’s routine each week while training, and include regular active recovery days as well.  Active recovery can include days of shorter training duration, lower intensity or cross training in another sport or activity that uses different muscle groups.  Also, as noted before, during intense periods of training, it is important for the athlete to get enough sleep and many trainers recommend including an extra hour every night, in addition to regularly scheduled naps during the day if possible.  On days where there is even the slightest hint that the athlete is tired, or unmotivated to complete his or her training, there could be an underlying reason that should be paid attention to:  The bottom line is, even with extra rest built in to the athlete’s schedule, when approaching a work out:  “when in doubt, leave it out.”[ii]

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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[i]McGee, Bobby, Running Mechanics, Art and Science of Triathlon Lecture Series, Endurance Films, USA Triathlon Training Series, 2009.

[ii] Friel Joe and Byrn, Gordon, Going Long:  Training for Ironman Distance Triathlons, The Ultrafit Training Series, Velo Press, Boulder, CO 2003, page 10.

How to Eliminate Pathokinematics - Part VII

Last week we spent a lot of time discussing squats because we feel this is such an essential movement.  This week, we will spend an equal amount of time on stretching and flexibility because we feel this is just as important.

Stretching and Flexibility

Stretching and flexibility are often areas neglected by many athletes, especially working ones, since often training time is limited already.  However, for every hour invested, stretching activities may in fact pay the biggest dividends of all training activities.  It is important for your athletes to spend time every day stretching and working on flexibility.  For many sports, commitment to increasing flexibility can result in “free speed” by improving posture, position and aerodynamics in sports such as cycling and almost all others.  Also, by increasing flexibility through a regular stretching routine, many injuries can be avoided. 

During exercise, and most activities of daily living, muscles and connective tissue are shortened and tightened over time.  Rarely do we require our muscles to go through the full range of motion they are capable of during sports activities, or even during other kinds of activities.  Instead, during sports we simply contract the muscles over and over, in the same ways, and so eventually they tighten and lose the ability to lengthen to full capacity.  This can not only limit performance through limited power output and poor positioning, but also can increase the likelihood of injury, because tight muscles that are asked to perform rapid or extensive motion without adequate flexibility can be subject to tearing and trauma that would otherwise not occur.

Let’s look at swimming as an example.  In order to get a full, long arm stroke and maximum reach during each rotation of the shoulder, the muscles of the shoulder and upper back must be flexible.  This allows the arm to fully extend, the body to roll to the side and balance in the streamlined position momentarily, while the forearm rotates in and down vertically during the catch phase of the stroke.  The shoulder then brings the forearm in toward the body allowing the pulling motion to extend the hand and arm past the hip during a rolling motion of the core at the finish.  Also, during swimming, it is critical that the ankles be loose and flexible enough to allow complete plantar flexion, creating a straight line extending down from the shin over the top of the foot during the kick, which decreases drag through the water.  The importance of this cannot be overemphasized, as drag is the number one limiter in swimming efficiency and speed.

Another example where we see great benefit in having elastic muscles is in cycling.  Tight hamstrings on the bike limit the extension of the leg down stroke during pedaling, prevent full range of motion on the second half of the pedal stroke, and minimize power output.  Hamstrings that are tight effectively prevent the leg from straightening, which ends up reducing power output generated in the core, and transmitted via the extension of the hip and knee at the bottom of the pedal stroke.  Often cyclists will lower their seat to counteract tight hamstrings, but since this further prevents adequate straightening of the leg as the hip flexor and knee propel the leg forward and the quadriceps pushes the foot downward, power is further reduced.  In turn, tight hamstrings put more pressure on the lower back, requiring the rider to contract the lower back in response with every pedal stroke, particularly when riding in the aerodynamic position in pursuit or aero bars. 

An effect of tight hamstrings can also be seen in running mechanics when the hamstrings effectively produce a “stopping” motion during the roll and propulsion of the body forward after the toe off.  To look at running in more depth, it is easy to see that flexible quadriceps and hip flexors allow the leg to swing more freely on its axis and allows greater extension of the forward foot and leg, as well as greater recovery of the leg behind the center of gravity as the runner moves forward.  In addition to limiting the range of motion of the lower body during running, tightness in the hamstrings, hip flexors, gastrocnemius, and quadriceps limits the capacity of the runner to use gravity to catapult the body forward.  Tight lower extremity muscles can contribute to a kind of “braking” effect during forward propulsion.  The athlete is not then able to use eccentric loading and the resulting “elasticity” of his or her body weight against ground forces to his or her advantage.  This means the athlete has to expend more energy to travel the same distance at the same rate of speed. 

Although the benefits of stretching are not agreed upon in the athletic or scientific communities, it does appear that stretching can decrease the likelihood of injury and speed recovery in some cases.  If we assume there are some benefits to stretching and after looking at several sport specific examples that further reinforce the need for regular stretching, let’s explore a few stretching styles.  There are many, but for the purpose of this blog, we will address:  ballistic, static, contract - relax, active isolated stretching (AIS), dynamic stretching and yoga.

Ballistic stretching involves bouncing repeatedly to try to loosen the muscle.  It has been found that this actually tightens the muscles due to repeated contractions, which can actually lead to injury, and so is not a recommended method for stretching.  Stretching in this fashion initiates a response by the muscle spindle to contract which has the net result of a contraction of the muscle which further resist stretching. 

Static stretching involves stretching the muscle to the point of slight discomfort (not pain) and then holding the position for a minimum of 20-30 seconds in order to allow the muscle to “release” and consequently loosen and relax.  This is probably the most popular form of stretching today.  It is important to avoid static stretching before a warm up or workout, when the muscles are cold.  Static stretching is best done at the end of workouts, or at least after a thorough and adequate warm up of the muscle groups involved.  When static stretching is applied with the literature, we can find even more dramatic results.  In a study by LaStayo et al published in 1994 in the Journal of Hand Therapy, the authors found that static stretches held for a sustained period of time (15 min or greater) resulted in greater plastic changes in collegian tissue.  This equated to longer lasting length changes than traditional stretching.  The concept TERT (total end range time) has been applied since then in sports medicine centers around the US.  When the concept of TERT is applied with moist heat (moist hot pack) or deep thermal heat (US), then the impact is even greater.  

Proprioceptive neuromuscular facilitation (PNF) was discussed in more detail earlier in this chapter as it pertains to enhancing the benefits of exercise.  However, studies indicate that PNF (contract - relax) is an even more effective method of stretching than static stretching, although it is not as widely used.  This may be perhaps because little is known about it, it takes more time and requires the skill of a skilled clinician, athletic trainer or strength coach.  The details of PNF are many and are beyond the scope of this blog, but the concept is to perform a static stretch for a few seconds, immediately followed by a contraction of the same muscle for an equal amount of time.  Upon relaxation of the muscle, then the stretch is taken to the new range of motion and the process is repeated for several repetitions. 

Active isolated stretching (AIS) uses the principle of “reciprocal inhibition” which means that in order for the muscle on one side of a joint to contract, the muscle on the opposing side must completely relax.  This type of stretching is similar to PNF, but is different in two primary ways:  1., the stretch is deepened by contracting the opposing muscle or muscle group at the same time, and 2., the stretch is sometimes deepened by using a prop or tool such as a block, strap or cord.   These two techniques are very common in yoga, which is discussed in more detail below.  Different from static stretching, PNF and active isolated stretching are done in shorter time segments, which results in an increase in range of motion with each repetition. 

Before a workout or training session is the appropriate time to undertake dynamic stretching.  Dynamic stretching should occur just after a period of overall cardiovascular warm up of approximately 5-10 minutes.  Dynamic stretching will be covered in detail in the next section, but ultimately involves an increasing warming of the muscles through incremental increases in muscle fiber length gained by rhythmic and repetitive movement through stretching postures. 

Another excellent way to increase flexibility and stretch muscles in preparation for exercise or after exercise for recovery is yoga.  Many elite athletes today build some sort of yoga into their training routine.  There a  Yoga, in whatever form you choose, focuses on body awareness, proprioception/balance, core strength and mental focus on both body position and movement patterns, in addition to facilitating muscle, tendon and other connective tissue lengthening and strengthening.  With yoga, as is true of many other exercise and stretching methodologies, the style is less important than the frequency and consistency of stretching activities that protect and strengthen the entire body system.
re several types and styles of yoga, varying from meditative styles such as Vinyasa and Iyengar to power styles, such as Flow Yoga and Ashtanga.

Dynamic Stretches

 

Dynamic stretches are not like traditional static stretches.  They are stretches combined with movement.  They are unique in the fact that they work on flexibility, proprioception, strength and endurance simultaneously.  They are not ballistic and one should not bounce at the end range of motion.  This type of stretching is very effective in increasing flexibility via a contract – relax methodology, which is used in both PNF and AIS stretching as well. 

When doing dynamic stretches, it is important to keep the following guidelines in mind:

1. Dynamic stretches should not cause pain.  Athletes will feel a stretch throughout the lower kinetic chain but should not experience pain during or after the stretch.
2. If the athlete is too tight to obtain the optimal position, have him or her move into a range that is comfortable and progressively keep attempting to move into the ideal position.  The goal is to have the subject obtain the full range of the motion.
3. Participants should perform some warm up prior to attempting dynamic stretches.  We recommended 10-30 minutes of cardiovascular warm up first.
4. Although these are used as a warm up exercise, they are difficult and will result in some muscle soreness.  Therefore, a vigilant eye to technique is important to prevent training or retraining of poor motor patterns.  If the subject has a difficult time performing the full range of the motion (like step through in dynamic lunge) you can break the movement up into easier components (step through to the opposite foot instead of to the full forward lunge).

Dynamic stretches are an extremely effective tool to increase flexibility as well as lay the foundation for appropriate motor planning when performed correctly.  These are also an essential part of the maintenance program that should continue to be a part of any continued conditioning 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. 

How to Eliminate Pathokinematics - Part VI

Last week we covered several different types of training methodologies that can be employed including the use of manual resistance/perturbations and plyometrics.  This week, we are going to cover a vital concept that we all know a lot about.....Squats.  No matter what your thought is on squats, good, bad or ugly, they are a foundational movement of life.  From our first ability as an infant to squat prior to walking to our ability to maintain our ability to reduce our risk for falling as a senior citizen.  Squats are essential.  Although we all know a lot about them, the intention of this blog is to put us all on the same page about them so that when we are training for movement, we are all looking at the same thing when it comes to the ability to squat.

Squats and the Basics

Strength, endurance and co-contraction of the quadriceps and hamstrings are absolutely essential for maximal performance and injury prevention in movement for sports as well as the activities of daily living.  The one exercise that has been “proven” in the research to not only aid in creating co-contraction between the quadriceps and hamstrings, but also to improve vertical jump is the squat. 

Squats have been a highly controversial weightlifting method for a number of years.  Health care professionals have often considered squats more harmful to the low back and knees than beneficial.  Therefore squats have often been discouraged if not avoided completely despite the fact that they are so commonly used in most well developed exercise and sports performance exercise routines.  Some of this controversy arose from the assumption that squats place large shear stresses at the knees as well as excessive loads on the lumbar spine. 

This original misconception was created in the early 60s from a paper published by KK Kline in which he showed that squatters had inherently greater laxity in their medial and lateral collateral ligaments than non-squatters.  This was measured by a non-validated device and resulted in KK Kline making the assumption that repetitive squatting with resistance led to greater laxity of the medial and lateral ligaments.   Despite the fact that this original research has been debunked by decades of research since then, many orthopedist and those in musculoskeletal care still make the assumption (assumption since not based on the science) that squats are bad for your knees.

So, if that assumption is true, why are squats good for us?  For one thing, there is a great deal of research in the last 10-20 years that clearly shows that the shear stresses at the knee and the excessive loads on the lumbar spine are actually lower than previously thought and mimic those forces people experience with daily activities.  Weight training exercises can be divided into two broad categories: open kinetic chain and closed kinetic chain exercises, as discussed previously.  Open kinetic chain exercises are used for isolation, in which the body part is not in contract with a surface.  An example of this we used earlier is seated leg extension.  Here the feet are not in contact with the floor and this exercise is used for isolation of the quadriceps.  This is considered a less functional form of exercise because it is training the body to work in a fashion in which it does not normally work during daily activities or sports.  During sports, the leg rarely has to extend itself against a weight in an open chain situation and therefore this type of exercise does not have a high carry over to sports. 

The other type of exercise is considered closed kinetic chain when the body part is in contact with a stationary surface.   The squat, as mentioned before, is an example of this type of exercise.  Here we are training the body in the same ways it functions in the course of daily activity and in sports.  During this exercise, the muscles of your legs, back, stomach and upper body are co-contracting to provide stability to all segments.  These types of activities have a high carry over to daily activities like sitting in a chair, getting out of the car, ascending and descending stairs, jumping for a rebound or driving an opponent back in football.

Any exercise, if performed incorrectly, can result in injury.  With squats, it is very important to keep the following key techniques in mind throughout the course of the exercise:

1. Never use more weight than the athlete can handle.
2. Always maintain a neutral pelvic position throughout the exercise and keep the abdominals tight – this is often the limiting factor in how much weight an athlete can use.
3. Never allow for a lateral shift to one side or the other during the squat – this results in asymmetrical loading of the back, hips, knees and ankles.  This type of loading pattern (seen in the example cited earlier in the section on Repetitions to Substitution) increases stress to one side while reducing the strength needed on the other.  It is imperative to watch for this compensatory strategy.
4. Avoid letting the knees pass over the toes in the descent to the squat position – this adds shear stress to the patellafemoral joint.  Although there might be slight anterior positioning of the knees to the toes this should be minimized with a proper hip hinge.
5. Keep the feet shoulder width apart with your feet slightly toed out – do not toe out too far due to the fact that this increases shear stress in the sacroiliac joint.
6. Never place plates under the feet – this shifts the weight line forward adding increased stress to the spine and adding to tightness of the gastrocnemius.
7. Never allow the knees go in toward the mid-line during ascent or decent.  This is a classic compensatory strategy for individuals with identifiable weakness of the gluteus medius.  Allowing the athlete to continue doing this when squatting simply reinforces this weakness.
8. Stop if at any time the athlete experiences back pain and re-evaluate the squatting form.  If the pain is not eliminated, have the athlete evaluated by a qualified health care professional before continuing with squats.
9. Never progress to the next level until the most basic form of squat has been mastered.

Squats do not have to be done with super heavy weight in order to facilitate strength gains.  Technique should be emphasized over weight although all too often the exact opposite is the case.  Remember that every rep that is done with poor technique (lateral shift, adduction toward midline, etc) is 3 reps that must be done to train the proper motor pattern.

Squat Neuromuscular Retraining (SNMR)

Our research indicates that 80% of athletes fail the Full Squat Test (FST) used in a movement assessment.  This is despite the fact that many of them may be performing squats as a part of their regular exercise routine.  Because of this alarming statistic, teaching the proper squatting motion is the essential first step before beginning or continuing a squatting routine.  It is essential to development of maximal force production as well as preventing injury. 

We define failing this test as a  ≥1” lateral shift to either side of the mid line (as depicted in this Olympic athlete here).  This lateral shift typically happens when an athlete is unaware of the proper mechanics involved in squatting, or when an athlete began squatting with poor mechanics that were never corrected.  In the latter case, through years of training the athlete has reinforced poor (incorrect) motor plans and abnormal proprioception into the system.  To this athlete, “off-center” movements feel normal.  However these deficits result in significant asymmetries in the way the tissues bear the load, which results in asymmetrical strength gains and force production and an increased potential for injury.  Although we describe this as a lateral shift, recent papers have described this motion as lateral displacement of the pelvis during the squatting motion.  What these papers describe is for all intents and purposes a lateral shift.

Squat Neuromuscular Retraining (SNMR) is the starting point for most athletes to improve squat mechanics.  This exercise is performed with a mirror and the subject is initially given lots of verbal and tactile cueing to prevent lateral shift, spinal rotation, or any other pathokinematic movements.  Have the subject perform the squat just prior to the point of lateral shift or other breakdown in form.  Once he or she starts to shift, or the form disintegrates in some other way, correct the athlete with verbal and tactile cueing back to the midline and proper body position.  Have the subject hold this position for 5 seconds. Return to the starting position and immediately have the subject return to the same position as in the previous repetition, attempting without cueing.  If the subject is unable to obtain the proper position during ascent or descent, cue and have them hold again for 5 seconds.  Have the athlete perform 20 repetitions with a 5 second pause.  After a short rest, have the athlete repeat the squat in front of the mirror, this time attempting to descend to a lower level without a shift or other change in form.  This exercise is typically performed over 2-3 sessions before the subject is able to perform a proper squat without cueing.  SNMR should also be a part of the home exercise program as well, where the athlete performs 3-4 sets of 20 reps with 5-10 second holds.  We will revisit this exercise in the Corrective Exercise Progression.

Another more aggressive technique that can be employed with this exercise is the SNMR with
perturbations.  In this scenario, the athlete performs 20 full squats.  during the 20 squats, we are not too concerned about the lateral shift that occurs during these 20 as we will address this in a moment.  At the conclusion of the 20 reps, the athlete gets into a end range of motion squat with their hands out in front of them.  The position of the arms is in full extension and the palms are palms are pressed together firmly to the point that they feel their pecs engaged.  While remaining in the squatting position, you quickly position them into a neutral squatting position.  Then you do perturbations throughout their entire kinetic chain including at the hips, knees, arms (in rotation and diagonal) all while avoiding anterior and posterior.  The key with these perturbations is not to "break them" but rather to challenge them to the point just before failure.  This is immediately followed by another 20 more reps and repeating of the perturbations.  This can be done for 2 to 3 sets.

This is a very aggressive form of training but also a very effective form.  One thing athletes will always tell you is that neutral position feels weird.  This sense of weirdness comes from proprioceptors and a system that has been trained that an abnormal position is normal.  Anything outside of that will feel odd.  So, this training methodology takes several neural concepts into consideration.  First is that proprioceptors fatigue.  Second is that once in this fatigued state they can be re-trained by over stimulating the entire system with proprioceptive input (perturbations).  If employed correctly AND if the athlete is doing this as a part of their home exercise program, this will be corrected in 2-3 visits.  If not, then you should re-evaluate the "root cause" of the problem to determine if there is a better fit intervention.

Full Squats and Jump Squats

Performing full squats (to 90 degrees of flexion and higher) and jump squats are both considered  more advanced routines and therefore maintaining “healthy” knee/hip alignment is essential during these activities.  It is imperative to follow the repetitions to substitution concept described above when embarking on a routine that involves full squats and/or jump squats. 

It is also absolutely vital that technique be a focus with these exercises.  You are training for performance, muscle memory and motor planning.  Bad training technique adds to decreased performance as well as weaknesses that can lead to injury.  With squats, common tightness in many athletes can lead to the heels coming off of the floor and the knees protruding over the toes, particularly as the squat deepens.  Training with this form can lead to tightness of the gastrocnemius and excessive shear stresses in the knee (patellofemoral joint).  Therefore, it is essential to help the athlete 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 athletes can also result in a squatting technique where the athlete shifts more to one side than the other in a lateral shift (see the sections above on Repetitions to Substitution and SNMR) and/or where the knees come in toward the mid-line during ascent or descent.  Shifting can aid to increased fatigue of the leg, which takes the majority of the load in this instance and therefore can increase the potential for injury.  Knees coming in toward the mid-line add to increased stress to the ligamentous structures of the knee, increased stress to the illiotibial (IT) band and lumbar spine.  Finally, some squatters are tempted to excessively toe out their feet.  This position, especially in females, places a tremendous stress through the sacroilliac joint and can be a major source of low back pain.  To determine your natural foot position, march in place for 10 seconds and stop while noting the position of your feet (this should be your natural toe out position).    

With the jump squat, weakness in the lumbopelvic region and ankles can again add to the knees to coming together at the mid-line.  These weaknesses and improper form also add to a “hard” landing rather than a “soft” landing when jumping.  Hard landing adds to decreased force attenuation (shock absorption) and increased stress to ligamentous structures.  By bending the knees slightly at impact there is more shock attenuation, less force and therefore less fatigue with a corresponding reduced potential for injury.  


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. 

How to Eliminate Pathokinematics - Part V

In our last blog, we discussed various topics from proprioceptive retraining to eccentric training to use of open kinetic chain versus closed kinetic chain training.  This week we will take it a step further by investigating use of super sets and plyometrics and their application to retraining movement.

Supersets, Mega-Sets and Monster-Sets

Another concept related to our exercise progression is the concepts of supersets.  Because many injuries and performance issues are the result of muscular fatigue, we have incorporated the use of super setting into this program.  A superset is simply moving directly from one exercise to the next without rest in between sets.  This increases the physical, including strength, endurance and cardiovascular, demands of the exercise routine which can result in improved endurance and power output, especially at the later stages of activity in sports, i.e., “later in the game.”  A progression of the superset concept is the mega-set and the monster-set.  These concepts will be incorporated throughout the Corrective Exercise Program, and we will use the following definitions:

1. Superset – move right from one exercise to the next.  Superset in our program includes only 2 exercises.  The first exercise is performed and then followed immediately by the next exercise without a rest.  Following completion of the second exercise, rest. 
2. Mega-set – refers to moving right from one exercise to another exercise to a third exercise without any rest in between.  Once the third exercise is complete, then the athlete should rest for a sufficient amount of time in order to return to 70% of resting heart rate. 
3. Monster-set -- the most difficult of the three.  This is the combination of more than 3 exercises.  Once the final exercise is complete, then the athlete should rest for sufficient amount of time in order to allow a return to 70% of resting heart rate.

Supersets, mega-sets and monster-sets are very aggressive forms of exercise and caution should be used with this training methodology.  The athlete needs to be watched closely to ensure that he or she maintains proper form in all stages of all exercises—for every single repetition.  It is also essential to ensure that the athlete is adequately prepared nutritionally for this amount and type of training stress.  This means he/she should eat at least 1-2 hours prior to the exercise.  If not, blood glucose levels could fall, compromising performance and even in some cases, causing sickness.  Supersets, and the more advanced mega and monster-sets, like plyometrics should be done near the beginning of an exercise session when the athlete is fresh.  This ensures maximal strength, endurance and form.

This type of training methodology can be used in many ways, but some common uses include:

1. To target a specific muscle.  When working on endurance of an isolated muscle it is good to combine exercises that focus on that muscle.  One common example of this is the use of side stepping and retro monster walks in a superset fashion.  These two exercises focus on gluteus medius strength and endurance, but require the muscle to work in different ways.
2. Pre-fatigue of accessory muscles.  If you are attempting to work on maintaining proper kinematics in the final stages of a hip abduction exercise, and are having a lot of gluteus maximus involvement toward the end of the routine, you could superset a gluteus maximus focused exercise to pre-fatigue the gluteus maximus, then follow with a gluteus medius targeted exercise.
3. For endurance of the entire kinetic chain.  Monster-sets are great for working the entire kinetic chain.  An example of this is a monster-set of jump squats, with SEBT (star excursion balance test), side-stepping and then abdominals on a stability ball. 

Don't be afraid to put your hands on the athlete.  The best training mode or apparatus is the hands of a skilled clinician. One technique we employ throughout training is the use of manual resistance or manual perturbations at the end of a sequence of exercises.  Use of manual resistance or resistance with perturbations by a skilled clinician is invaluable.  This allows you to maximize training benefit by pushing the athlete to the next step while maintaining proper form and technique.  Simply grading our resistance allows us to emphasize maintaining proper positioning while continually fatiguing the stabilizers.

Concept of Pre-Stretch (Proprioceptive Neuromuscular Facilitation)

From anatomy, exercise physiology and motor learning, we know that if we provide a rapid stretch to a muscle, a stretch to the muscle spindle results.  If the stretch to the muscle spindle is followed by an immediate forceful contraction, the muscle can produce more force than  By producing more force, you are able to work the muscle more because you are involving more of the muscle fibers than you would if you just contracted from a resting state.  This allows us to increase work the muscle does which results in improved power and performance over time. 
if just contracted from the rested state.

This is the same concept used in plyometric strength training (box jumps, jump training, etc.—see the next section) and it has been utilized in performance training protocols for decades.  We use this same concept throughout our training program in order to push the physical demands of the program and to force larger gains in strength and power. 

However, where most training programs fail with this concept is allowing too much time to elapse between the stretch and the contraction.  Like repetitions to substitution, as the athlete fatigues, he/she will begin to allow more and more time to pass between the stretch and the contraction.  When this happens, the kinetic energy that is stored with the rapid stretch is lost and therefore the athlete is not able to get maximal muscle contraction when force is exerted.  The key then is to have a forceful contraction immediately following the stretch.   It is important to keep an eye on the athlete as fatigue sets in, and, much like repetitions to substitution, stop or rest when the time between the stretch and the contraction increases.

Plyometrics

Plyometrics is a training medium we can use with athletes that raises the intensity of the exercise and one that has a high carry over to sport.  Plyometrics incorporates the concept of pre-stretch or proprioceptive neuromuscular facilitation described in the previous section.  However, caution must be used in employing plyometrics in a training program because these types of exercises, when applied incorrectly, can add to or even cause certain kinds of musculoskeletal injuries.  Some of the most common injuries seen with plyometics are:

1. Ankle sprains/strains
2. Shin splints
3. Patellar tendonitis
4. Meniscal injuries
5. ACL injuries
6. Low back/SI pain
7. Muscle pulls/strains

All of these injuries are avoidable with application of some common sense when using plyometrics as a training medium.  When using plyometrics, keep the following in mind:

1. Plyometrics should not be used more than 2 times in a training week – using more than 2 times a week can result in overuse injuries like shin splints.
2. Plyometrics should never follow a heavy training day – performing plyometrics after an unusually hard practice or training session the day before can lead to over training and muscle strains/sprains.
3. Plyometrics should always be employed at the beginning of the training session and not at the conclusion – using at the end of a training session results in poor performance and technique which can lead to ACL, meniscal and other types of injuries.
4. The concept of repetitions to substitution should be strictly adhered to when using plyometrics – this has a HIGH specificity to sports and therefore training with bad technique results in carryover of bad technique to sport.
5. A plyometric routine should follow a standardized progression without skipping one phase and jumping to the next – this can avoid 90% of the injuries resulting from this type of training.

It is important to keep in mind these simple suggestions when developing your program and in deciding how and in what sequence plyometrics will be employed.  With all corrective exercises, there is a fine line between pushing an athlete enough and pushing them too much.  Following the above concepts will aid you tremendously in making a more objective decision based on observed movement rather than self reported exhaustion.  Keeping all this in mind, it is imperative to push the athlete with every session as long as stability, healthy alignment and proper technique is maintained. 

Increased Intensity = Improved Performance

Keeping this concept in mind does not mean that raising the intensity always equates to improved performance.  Take the following case as an example.  This young athlete was prescribed plyometrics for 4 weeks under the supervision of her treating clinician and strength coach.  I suspect that any of us seeing this would argue that we would never let this happen to our athlete.  YET, it happens everyday.  When exercising in group settings with little supervision or when high level training methodology supervision is delegated to less skilled individuals.  This type of technique does not and will not lead to improved performance.  Rather, she has paid us to train her to poorer performance and increased risk for injury.

Once technique and stability are mastered, it is appropriate to move to the next level.  Never skip a level until this has been assessed. Many programs claim to improve athletic performance.  What we have attempted to do is combine the research from all of the related sciences (neurology, exercise physiology, and biomechanics) to bring you unique concepts not found with many of the current prevention programs.  Our goal is to allow you to progressively, systematically and safely progress your program to the next level.  In order to continually progress strength/endurance, to improve movement patterns and to improve athletic performance, you must constantly challenge the body.  By following the above concepts, you will be able to safely take the athlete to the next step while challenging their entire neurological, physiological and musculoskeletal system.

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.