Thursday, 31 January 2013

Shin Splints, all you need to know.

Shin Splints

Shin Splints

Shin splints is the name given to a number of different clinical conditions that cause pain in the shin. There are many different types of shin splints: periostitis, stress fractures, tendonitis, and compartment syndrome to name a few common ones.
Periostitis is the inflammation of the periostium, which is the sheath surrounding a bone. Generally found in weight bearing joints following excessive activity, it is common in the tibia (shin bone) and foot.
A stress fracture is a common overuse injury often seen in athletes. A fracture (broken bone) is usually caused by direct impact to a bone, as you would see following a fall or car crash. A stress fracture however occurs with much lower forces that happen repetitively over a long period of time – they are also known as "fatigue fractures." Stress fractures can occur in any bone, but are usually seen in the foot and tibia (shin bone) as they are the ones supporting your body weight and so usually have the most load.
A tendon is the structure that connects your muscles to your bones and so they endure high loads when you perform ballistic activities like running. Tendonitis is when the tendon becomes inflamed and using its associated muscle (often at high speeds as with running) generates sufficient force that it becomes painful.
Compartment syndrome is usually from extensive muscle use, where pressure from an inflamed muscle builds up within the muscle sheath and causes pain. It is actually quite hard to diagnose, but it can be extremely painful and prevent even the most resilient runner from training.

There are many different causes of shin splints (in its many different forms).  We can separate them into extrinsic and intrinsic causes.

Extrinsic are the forces from outside the body which overload the tibia and surrounding muscles and tendons and are commonly from:
• Type of surface; running on surfaces that are too hard or too soft or even running on a camber.
• Running in inappropriate or worn-out footwear
• Running downhill
• Running technique
• Incorrectly progressed training to allow the body adapt to the increasing loads. This is especially true with beginners but can be seen in seasoned athletes who progress their training too quickly.
Intrinsic causes are from forces within the body.
• Excessive or too rapid over-pronation of the foot, which exerts unaccustomed force through the bone and/or associated muscles.
• Insufficient pronation (supination) which does not therefore adequately absorb shock, which also exerts excessive forces through the bone and/or associated muscles.
• Any intrinsic factor that affects the amount of pronation, like abnormal pelvic biomechanics, leg length discrepancies, tight calves, even spinal problems can affect the amount of pronation.
Usually it is a combination of both the intrinsic and extrinsic causes that produce symptoms; you can often ‘get away’ with just one. So for example an inexperienced runner who increases their mileage too quickly, but also has over pronating feet, will be especially susceptible. Just as an experienced runner who progresses their hill training too quickly, and unknowingly has a pelvic rotation which is causing a leg length discrepancy which influences the amount of pronation occurring in the foot/ankle, would likely have some form of reaction too.

The variety of different types of shin splints is matched by the variety of different symptoms, but they are commonly.

• Tenderness on the front/inside of the shin (tibia)
• The shin is hot and inflamed
• Sometimes there is swelling
• Pain settles after exercise, but recurs on resuming training
• But pain can also persist when at rest

Tests and diagnosis
Differential diagnoses are difficult with shin splints as there is such a high variety. Your medical history is the main factor that your doctor or therapist will be able to diagnose your injury from. However X-rays, MRI scans and pressure tests can all help provide the necessary information to help your specialist decide which is your type of shin splints and therefore how best to manage it.

Self help is critical when managing any injury, and shin splints is no exception and the R.I.C.E (Rest, Ice, Compression and elevation) principles apply here:
Rest. Obviously avoid the activities that cause your pain until it has subsided. Usually though you can continue some form of training to prevent you going ‘stir crazy’, like cycling, rowing, swimming and running in water.
Ice. Ice will help reduce swelling and inflammation. There are different ideas on how long to apply the ice and how, but generally speaking its accepted that you should be icing for 10 – 20 mins and this can be applied 3 – 5 times per day. The re-useable ice packs are very convenient and easy to apply.
Compression. If the shin is swollen then a compressive support can be helpful in combination with the ice pack. If you have compartment syndrome, a compression support will probably not help you.
Elevation. When swollen, elevating the shin can help.
Also look at what you consider could be the causes of your shin pain. Think about the extrinsic factors that could have contributed to your shin pain and take logical steps to avoid them in the future. Factors like wearing the correct shoes for your foot type - get them checked by a suitably qualified and experienced person. Think about getting your foot and pelvic biomechanics checked too. When prescribed correctly, orthotics to correct your foot biomechanics and exercises to help any pelvic or spinal problems that may be causing your shin splints can be very helpful. If you are a supinator (if you do not pronate enough to absorb shock) then shock absorbing insoles can be very helpful too.
Anti-inflammatory drugs and pain killers can sometimes help you over the worst of the pain, so it may be worth discussing this with your GP.
Lower leg stretches can be helpful:
• Kneeling on the floor, point your toes out behind you and slowly sit back on your heels, pressing the top of your feet towards the floor. This will help stretch the anterior tibial muscle on the front of your shins.
• Stand arm length from a wall, put your hands on the wall, place one foot a stride length in front of the other, keep your back leg straight and your heel on the floor, then lean forward to stretch your calf. You can get a better stretch by having your heel turned out slightly from the mid line. This stretches the long calf muscle called gastrocnemius.
• Stand in the same position, with feet flat, one leg in front of the other but instead of leaning forwards to stretch the calf of the back leg, bend your knee to feel the stretch lower down towards the Achilles tendon. This stretches your soleus muscle.
As well as calf stretches, exercises to strengthen the muscles in your shins can also be helpful once the acute pain has subsided. Here are some exercises that you may find helpful (see separate word doc):
As always prevention is better than cure, so do check the causes outlined above and try to avoid them wherever possible.

QA section
I have a 17 year old son who is a sprinter with persistent hamstring problems. He has had them on and off for a long time now and nobody seems to be able to get to the bottom of it. Can you help?
Thankfully as the medical profession understands more about hamstring problems and their causes, these recurrent problems are getting less frequent. Typically, as with most injuries, the causes are split into 2 categories: extrinsic and intrinsic. The extrinsic causes are those which are from external factors. In this case they can be inadequate warm ups, incorrectly progressed intensity of training and poor technique. Intrinsic causes are those that can be found within the body itself. Factors such as tight sciatic nerve (the nerve that runs down the back of your leg) can cause the hamstring to go into spasm to protect the nerve when it is stretched at high speeds when he sprints. Other factors such as lower (and upper) back problems, pelvic biomechanical issues and muscle imbalances are also common causes. It is important to see a specialist sports injury therapist who understands biomechanics and how these factors can affect your hamstrings to see which one is in fact the cause of your son’s problems.
I am a 55 year old runner and have been running all my life. I have recently been getting knee pain on the inside of my knee for no obvious. It aches after a run and is especially sore and stiff after I have been sitting watching TV for a while. Is there anything that I can do to help?
The most likely causes of pain on the inside of the knee are a strain to the medial (inside) ligament of your knee, damage to the cartilage (meniscus) on the inside of your knee and arthritis of the bones on the inside of your knee. If you have recently had any trauma to your knee then it may be either the ligament or the cartilage. If you haven’t, then the most likely cause is arthritis, especially if you have damaged the knee in the past. It sounds like it could be the early stages of arthritis and so sensible measures to slow down the degeneration would probably help. Make sure you are running in the right shoes for your particular foot type, check this out at a local running shop which has a treadmill and so can measure your foot movement and can more accurately predict the right type of shoe for you. Also you can try getting the knee stronger by doing some exercises to strengthen it. (See separate word doc). Trying to vary your training would also help. You don’t say how often or how far you run or indeed at what level, but try to mix up your training as much as possible by having some running sessions, but also ‘cross train’ and try some non weight bearing exercises such as rowing, swimming and cycling. You will most likely find that the more you can mix up your training the longer your knee will last.

Sunday, 27 January 2013

Metatarsalgia (Ball of Foot Pain)

Metatarsalgia (Ball of Foot Pain) Metatarsalgia is a general term used to describe a painful condition in the metatarsal region of the foot (often referred to as the ‘ball of the foot’. Pain associated with metatarsalgia is often experienced under the 2nd, 3rd or 4th metatarsal heads. Differential diagnosis of metatarsalgia is Mortons Neuroma which exhibits more localised pain as the interdigital nerve is entraped between the metatarsal heads. Mortons Neuroma can also be extremely painful. Metatarsalgia is a common condition that can be treated simply and effectively. If left untreated it can be debilitating to sufferers. Biomechanical Aetiology An underlying cause of Metatarsalgia and Mortons Neuroma is excessive pronation. Excessive pronation can over time cause weakening of the soft tissue structures resulting in ligamentous laxity and sometimes muscle wastage. As the foot pronates the metatarsals plantarflex and rotate resulting in shearing forces on the forefoot structures and loss of the transverse arch, causing pressure and pain to be experienced. If left untreated, metatarsalgia can lead to the development of Mortons Neuroma. As the foot continues to pronate, the metatarsals plantarflex and rotate, causing the interdigital nerve to become entrapped between the metatarsal heads - which can cause intense localised pain at the site of the nerve impingement. Symptoms Metatarsalgia is most commonly characterized by a burning pain in the ball of the foot. Some patient's describe the pain as being like a stone bruise. This condition often restricts patient's mobility, or length of time they can be standing or walking, due to the intense pain and discomfort that can be experienced. Mortons Neuroma generally exhibits more localized pain, at the site of the nerve impingement. It is generally the result of prolonged compression of the interdigital nerve (most commonly between the third and fourth toes), causing irritation and possibly enlargement of the nerve. Sufferers often experience numbness and pain in the affected area. Treatment As most patient's exhibiting symptoms of Metatarsalgia generally pronate excessively, orthotics with a metatarsal dome added to the dorsal surface should be prescribed to realign the subtalar joint to the neutral position, which reduces the plantarflexion and rotation of the metatarsals. The metatarsal dome added to the orthotic assists with lifting the dropped metatarsals, and restoring the transverse arch, thus relieving the pain and discomfort. Orthotic with metatarsal dome addition Patients suffering from a Mortons Neuroma will also benefit from wearing orthotics, as much of the pressure being placed on the interdigital nerve will be relieved by correcting pronation and restoring the foot to the subtalar neutral position, in combination with the metatarsal dome that assists by lifting and spreading the metatarsal heads, causing less compression of the nerve. Additional Treatment Sometimes additional treatment methods can be used in conjunction with ICB Orthotic therapy to ensure long term treatment success. Such treatments include: Foot joint mobilizations: to ensure the bones and joints are correctly aligned. Acupuncture: particularly useful in providing quick short-term pain relief of Mortons Neuroma. Wearing shoes with increased width in the toe box - tight fitting footwear should be avoided.

Achilles Pain

Achilles Pain Achilles tendonitis (also known as Tenosinovitis or Tendonopathy) is inflammation, irritation and swelling of the Achilles tendon at the attachment to the calcaneus. There are two types of Achilles tendonitis: 1. Non-insertional: caused predominately by excess pronation 2. Insertional: caused mainly by supination or a high forefoot valgus deformity Biomechanical Aetiology As shearing and tractional forces are placed on the Achilles tendon, inflammation can occur at the attachment to the calcaneus.  A major underlying cause of Achilles tendonitis is the result of aggravation caused by pronation or supination - or a combination of both. As the calcaneus inverts at heel lift, the gastrocnemius assists and as the foot accelerates into an excessively pronated (or supinated) position, the calcaneus is everted (or inverted) causing medial/lateral tendo-achilles traction. This results in transverse shearing of the tendon and sheath, leading to inflammation and pain being experienced. Lateral Achilles pain is associated with a Pes Cavus (high arch) foot structure or a forefoot valgus >10° Unilateral Achilles pain can also be associated with a structural or functional leg length discrepancy. The Achilles tendon fans out at its insertion to the calcaneus and is sandwiched between the superficial achilles bursa and the retro-calcaneal bursa. Sometimes an abnormal prominence of the postero-superior process of the calcaneus, known as Haglund's deformity, may be present, causing irritation of the bursa or tendon. Often many patients with this condition are supinators which causes lateral lower limb pressure whilst making the foot less efficient in energy absorption, transferring this stress to the achilles tendon region. Superficial bursitis may cause tenderness posterior to the tendon. Retrocalcaneal bursitis usually exhibits tenderness while squeezing the area deep to the tendon. Symptoms  The patient often experiences inflammation, pain and swelling of the Achilles tendon at the attachment to the calcaneus. Pain can be experienced either on the medial or lateral aspects of the Achilles. In extreme cases the Achilles tendon can rupture and detach from the calcaneus, or a compensatory bone spur may develop as the body's natural compensation to prevent the tendon from rupturing. Bilateral medial Achilles pain is often associated with pronation. Bilateral lateral Achilles pain is often associated with pronation and a high forefoot valgus. Whilst unilateral Achilles pain can be associated with a structural or functional leg length discrepancy. Treatment ICB Orthotics should be prescribed and fitted to assist in controlling pronation (or supination). To help alleviate the tension and inflammation (and resultant pain), a heel lift can be added to both the left and right orthotics. The heel lift should be removed from the orthotics within 2 weeks (or less if the pain and inflammation have subsided). If the heel lifts are worn for a longer period the Achilles tendon may start to shorten.  Orthotic with a forefoot valgus addition. Additional Treatment R.I.C.E. (15 minutes, 3 times a day) Rest from running Achilles stretches - after inflammation is reduced, stand with legs straight on balls of your feet on a curb, step or rung of a ladder. Drop heels down and hold position for 20-25 seconds per leg in extended and flexed positions. Stretching of the calf muscles.

Pre season tips for Rugby.

Top 10 Pre-season Rugby Tips on Training

1. Develop an overall fitness base before training. Before trying to emulate what top players and top teams do in their training, ensure that you have got an adequate fitness base. The ability to run with a normal gait, and the ability to perform basic strength training exercises through a full range of movement are key before trying to put the body under load and stress. Fartlek running is a good way to build up your endurance. Performa sets of walking, jogging and running for 15 seconds each, repeating for more sets until you can do this for 30 minutes total, which will help prepare you for more specific training.

2. General strength before specific strength. Circuit training is an ideal way to start your strength training base, using body weight exercises to start. Try to perform as many different types of exercise as you can, using your upper and lower body as well as trunk and whole body exercises such as the burpee. Then move on to using medicine balls, dumbbells and other implements such as sandbags or tyres. After that, use barbells to develop maximal strength and then use all of the above methods to help develop power and speed by using faster movements with lighter weights.

3. Separate endurance training and strength training. It is difficult to improve strength and power at the same time, unless you are a complete beginner. Rugby needs a good endurance level to allow the work rate to remain high during multiple phases of play. It also requires speed and power and the ability to change direction at pace. Strength training is essential to help prevent injury and provide the stimulus to improve speed and power. Try working one month at a time with an emphasis on each component; in the endurance month you may have 8-12 sessions devoted to endurance type training and 2-4 sessions devoted to strength maintenance. In the following month try the reverse, with 8-12 strength sessions and 2-4 endurance sessions.

4. Strength training is not bodybuilding or weightlifting. Your training should replicate the demands of the game. Single joint lifts can be used early on to ensure joint strength and left/right balance within the body, but more complicated lifts should be used later on. Similarly just doing weightlifting exercises such as the clean or snatch will mean that you work only in one plane of movement. Look to vary between strength, power and muscular endurance because all 3 are needed.

5. Small-sided games and activities are better than straight line running. Time is limited when training, especially for amateur players, so the opportunity to combine skill work with fitness work should be taken as long as neither purpose is compromised. Several studies have shown that small-sided games in sports are as or more effective than repeated straight line running. The risk of injury is less when playing games such as 2v2 or 3 v3 than when doing repeated intervals. The exact cause is not known, but could be due to the variety of the movement patterns. Monotony of training can lead to overtraining and risk of injury. Having smaller games allows all the players to participate and be active within the game. Changing the pitch size and overloading attack or defence also allows different players to work at different rates.

6. Train on the floor. A lot of time in rugby, especially rugby league, is spent getting up and down from the floor. Working on the floor and moving around on the floor should be incorporated into your warm up and also your training sessions. Commando crawling, crawling, tiger crawling, forward rolls, sideways rolls, wrestling on your back and in kneeling are all examples of work that can be done. Running and putting your chest on the floor every 5-10metres is very fatiguing. Adding different movements at the 30second and 1 minute marks can add further variety.

7. Flexibility should change depending on the time of day. Flexibility improves with stretching, but the type of stretching performed should vary. Ballistic stretching that starts off in a controlled fashion and gradually gets more rigorous should be done first thing in the morning. Dynamic stretching that takes the body through greater ranges of motion that mimics the demands of playing should be done was part of your warm up. Isometric stretching takes place after strength training and involves a contraction of the muscle before the stretch takes place. Static stretching should be done in the evening post-exercise and allows muscles to be taken gradually to a point of mild stretch and held for up 60 seconds at a time.

8. Hydration should take place before and after training as well as matches. If you are dehydrated before you start training or playing, you will not be able to make up for it during the match. It is better to remain hydrated throughout the day and arrive at the match or training fit to play. Half time and injury breaks should be used to sip fluid and rehydrate. Post-match fluid intake is key to help recover before the next session. A rough guide is to take on 1.5 litres of fluid for every kilogram lost during the match.

9. Time of fuel is important. There are two key points to take on fuel post-match. Some food should be taken within 15 minutes of finishing that has a protein and carbohydrate base. A meal should be consumed within 2 hours of finishing. Food taken at these times helps restore muscle glycogen rapidly into the muscles. After two hours or so, the recovery process is a lot slower and your body may not have restored its energy supply before the next session.

10. Limit your alcohol intake. All the good work in the gym and on the pitch will not be as effective if you consume too much alcohol, which can affect your training for up to three days after you have drunk it. In particular, high intakes may limit your body’s ability to synthesise protein, restricting muscle and tissue repair and growth.
Last updated: 16-01-2013
I Move FreelyBiomechanics Coach

Saturday, 26 January 2013

Self Myo fascial foam rolling.

Myofascial Mobility Through Strategic Movement
by Anthony Carey Date Released : 19 Jun 2012

Performing self-myofascial release using a variety of tools is now a common strategy among fitness professionals, with the term “myofascial” denoting the inseparable connection between muscle and fascia. As our scientific knowledge base grows, our understanding of what occurs during the myofascial release process has also grown and matured. Building on that knowledge, this article will present a strategy of improving myofascial mobility through strategic movement.
The Science Behind Myofascia and Movement
Once ignored as irrelevant tissue, fascia has been a hot topic in orthopedically-related research and conferences in recent years. While other PTontheNet authors have covered much of the current research surrounding fascial anatomy and biomechanical properties, it’s still worthwhile to review some of the current research – ranging from embryological influences to biochemistry – that are most relevant to this article. The specific relevance of much of this information varies depending on one’s professional background and objectives. The fitness professional will be most interested in how we can positively influence the myofascial system using tools that clients can manipulate themselves in conjunction with movement.
Structurally, Van der Wal (2009) describes fascia into two mechanical/functional types:
  1. Fascia that separate and permit sliding and gliding of muscles (and tendons) against each other and against other structures. This is muscular fascia adjacent to spaces that are filled with loose areolar connective tissue (“sliding tissue”) and, sometimes, adipose tissue.
  2. Fascia that connects and transfers force. This is intermuscular and epimysial fascia that serve as areas of insertion for neighboring muscle fibers, which can mechanically couple bone and soft tissue.
It could be argued that in the areas of fitness and biomechanics, the interest in fascia has been more on the very important role of force transmission, stability and mechanical economy of the fascial network. Conversely, it could also be argued that the fields of orthopedic medicine and body work have centered more on the influence and intervention of a less than optimally functioning fascial system and its relationship to pain and dysfunction. Because all of the characteristics of fascia are interdependent during movement, training principles should reflect as much.
Klinger and Schleip (2004) showed in vitro that the stiffness of fascia is in part due to its water content. And when fascia is stretched or compressed, water is extruded from the tissue like wringing out a sponge. As the water content is lessened, the tissue becomes softer and more pliable. During this period there is also a relaxation of the arrangement of the collagen fibers. Within hours, the water returns to the tissue at a higher concentration than before with increased stiffness of the fascia. These results were confirmed in a more recent study in which they described a “super compensation” of increased water/stiffness hours after the stretch (Schleip et al., 2012). This means that the period following the extrusion of the water and prior to its refilling is a window of opportunity for better access to the elastic component of the muscle tissue, which can influence the alignment of the collagen fibers and mobilize joint motion. From the training perspective, this is the time when solid gains in mobility/flexibility can be achieved.
Tool-Assisted Self-Myofascial Release
The term “self-myofascial release” is applied to techniques done independently of a practitioner. Tools used for this process typically include foam rollers, other rollers of varying shapes, sizes, and textures, and balls. A common objective related to this work is to release “tight” tissue and/or improve flexibility. The mechanisms behind this can be thought of as both compressing and elongating simultaneously. This concept is clear when we use Tom Myer’s 2001 analogy of the human body being a fascial “bag.” Imagine applying pressure with your finger to a water balloon. The pressure compresses the balloon inwards. As it does this, the balloon’s fibers elongate against the increased outward pressure of the water. It also becomes obvious that you cannot affect one part of the balloon without affecting the whole.
Many manual practitioners and fitness professionals still consider the process of myofascial release to be purely a mechanical tissue response – that is, the pressure or stroking makes the tissue longer and/or softer by affecting the ground substance, adhesions, and crosslinks of the collagen fibers. This may be just a small part of the tissue response because there is an abundance of mechanoreceptors in the fascia, which means that fascia plays a critical role in proprioception and nociception (Yahia, 1992). And receptors in the fascia – such as the epimysium and deep fascia – far outnumber those around the joint (Cantu and Grodin, 2001). Paramount to this is that within these mechanoreceptors the majority of input comes from the interstitial receptors that are intimately connected to the autonomic nervous system (Schleip, 2003).
According to Schleip, stimulation of the intrafascial mechanoreceptors “leads to an altered proprioceptive input to the central nervous system, which then results in a changed tonus regulation of motor units associated with this tissue.” The result is relaxed, freer moving, more pliable tissue.
The autonomic nervous system has also shown to be influenced by oscillating and vibratory movements via the tonic vibratory reflex-TVR (Comeaux, 2011). One of the premises behind the role of the oscillations in the body’s neurophysiology is related to the abundance of rhythmical cycles found both inside and outside of the body. Physiologically, there are rhythms associated with functions such as the heartbeat, breathing, sleep cycles and hormonal cycles in women. Even one’s relaxed, self-regulated gait is rhythmical in nature following the reciprocation of the opposite sides of the upper and lower body utilizing stored elastic energy.
Many disciplines and techniques have utilized the effects of oscillation on the autonomic nervous system. It is a part of osteopathic techniques, joint mobilization, cranial sacral work, facilitated positional release, Trager work (psychophysical integration therapy), and Muscle Energy Technique, to name a few. One trait that is common to all of these techniques is that the patient/client is a passive participant minimizing gravitational forces while lying or sitting.
How Oscillating Motion Can Help Your Clients Move Better
One strategy of improving myofascial mobility during training sessions is to incorporate strategic, oscillating movements grounded in evidence-based principles along with the personal trainer’s personal experience. The neurophysiological pathways elicited through manual therapies mirror those elicited via rhythmical, oscillating movements. These movements prepare the body for more global myofascial mobilization movements.
Fascia adapts its fiber arrangement, length and density according to local demands (Findley, 2009). This follows Davis’ Law of soft tissue modeling. Along with this, both macro and micro trauma will have local effects on arrangement, length, and density with global influences on the body. Habitual postures, repetitive movement patterns and a musculoskeletal health history give us insight into the myofascial restrictions that influence the client’s movement patterns.
Critical Execution Points
Myofascial restrictions will limit motion at the joints. Stretching or mobilizing techniques that approach a joint’s barrier and stress the joint capsule (intimately tied to the intervening fascia) will discharge joint receptors that up-regulate increased muscle tonus around the joint. In addition, the threshold for discharge is likely to be lower in joints that have previously been damaged and not thoroughly rehabilitated or that have experienced degenerative changes. For example, an unstable ankle joint from a previous ankle sprain may respond to rapid, end range or close to end range loading with increased co-contraction of the peroneals, anterior tibialis, toe extensors and gastroc/soleus complex. Therefore, the movements suggested here work in a range below any barriers presented by the joints or myofascia.
Two key variables associated with the oscillatory motion are rhythm and amplitude.
  1. Rhythm relates to the tempo and timing of the movement. The movement should be continuous with no pause or delay at either end of the movement. A gentle, controlled momentum utilizing the stored elastic energy of the myofascial line(s) being addressed is used as part of the motion to produce a sense of “rocking.”
  2. Amplitude refers to the size of the oscillation created by both the range of motion in the direction of the barrier (tissue tension) as well as the return range of motion in which the tissue tension is disengaged. These movements should not approach the associated joint barrier and maximal tissue tension. Instead, the motion should have small amplitude in both the direction of tissue tension and in the direction where tension is removed.
Advantages of Movement-Based Myofascial Release
A physiological advantage to a client actively performing these movements in a gravitational field is the addition of heat and fluid exchange within the tissue created by the muscles associated with the movement (Ingber, 2003). Mechanically, more overall connective tissue can be influenced via movement. Huijing (2007) has shown myofascial force transmission between and within muscles, demonstrating connections between both synergistic and antagonist muscles. Within a muscle fiber, up to half of the total force generated by the muscle is transmitted to surrounding connective tissues rather than directly to the origin and insertion of the muscle fibers.
The overall objective of the oscillatory movements is to reduce myofascial tone so that the range of motion can gradually be improved through the targeted myofascial lines by increasing the amplitude of the movements. As tonus is decreased, the oscillations create a pumping action of the tissue. As range of motion is increased, fascial lines in parallel as well as in series are positively affected.
As the local amplitude of the movement can be increased, the progression would be to include engage more of the myofascial line by involving related anatomical segments. For example, if you were beginning with the oscillating motion focused on the anterior hip joint in the sagittal plane you would begin with anterior to posterior motion of the pelvis on the relatively fixed femur. To progress this, you would gradually incorporate motion of the thorax moving in opposition to the pelvis. Further progression would be incorporate shoulder flexion as a continuation of the anterior thorax, lengthening the myofascial line from hip to hand.
Returning to the ankle joint as the example, limited dorsiflexion is a common movement challenge for many clients. This can be due to myofascial restrictions from the plantar fascia to the hamstrings and/or over activity of the surrounding musculature due to instability-as in the case of chronic ankle sprains.
Oscillating Myofascial Release in Action
A popular technique to address this is through a kneeling lunge (shown below). With this maneuver, the knee is driven over the toes as the heel is kept on the floor. The goal is to move the knee to its maximal range (tissue barrier), progressively lengthening the tissue over time.

Kneeling Lunge

An alternate approach is to use the same positioning, but instead of taking the knee to its maximal range over the toes, a shorter range of motion is reached.  Within this shorter range, we use oscillatory movement, moving into and out of dorsiflexion. As the mechanoreceptors in and around the joint down-regulate activity, the amplitude can be increased, which subsequently increases the range of motion.
A challenge with this strategy is that its success or failure is not immediately observable by you, the personal trainer. Instead, it relies upon the kinesthetic awareness of your client and their ability to sense the reduction in resistance from the tissue and systematically increase the amplitude of oscillations as the body becomes receptive to the movement. One common error is for the client to increase the amplitude prematurely and approach the joint barrier.
The video below provides additional examples of movement-based myofascial release techniques you can use with your clients:

Strategic movement can be an adjunct or complimentary strategy your client uses for self-myofascial release in combination with tool assisted devices on the fitness floor. Both forms of myofascial release will benefit the client as will manual treatments by a trained therapist.
If we can agree that the body is in fact a rhythmic structure, then with oscillating movements you are creating rhythm where rhythm is not present due to myofascial restriction. By following a philosophy of “ask – don’t tell the body,” you can work with the body versus against it to actively improve function of the myofascial system.
Cantu, R.I., & Grodin, A.J. (2001). Myofascial Manipulation: Theory and Clinical Application.Austin, TX: PRO-ED, Inc.
Comeaux, Z. (2011). Dynamic fascial release and the role of mechanical/vibrational assist devices in manual therapies. Journal of Bodywork & Movement Therapies 15, 35 e 41.
Findley, T. (2009). International Journal of Therapeutic Massage and Bodywork, 2(3): 4-9.
Huijing, P.A. (2007). Epimuscular myofascial force transmission between antagonistic and synergistic muscles can explain movement limitation in spastic paresis. Electromyography and Kinesiology, 17(6): 708–724.
Ingber, D.E. (2003). Tensegrity II. How structural networks influence cellular information processing networks. Journal of Cell Science, 116: 1397-1408.
Klinger, W., Schleip, R., & Zorn, A. (2004, Nov.). European Fascia Research Project Report. 5th World Congress Low Back and Pelvic Pain, Melbourne, Australia.
Myers, T.  (2001).  Anatomy Trains:  Myofascial Meridians for Manual and Movement Therapists.  New York, NY:  Churchill Livingston.
Schleip, R. (2003). Fascial plasticity – a new neurobiological explanation. Journal of Bodywork and Movement Therapies 7(1):11-19 and 7(2):104-116.
Schleip, R., Klingler, W., & Lehmann-Horn F. (2005). Active fascial contractility: fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics.Medical Hypotheses, 65: 273–277.
Schleip, R., Duerselen, L., Vleeming, A., Naylor, I., Lehmann-Horn, F., Zorn, A., Jaeger, H., & Klinger, W. (2012). Strain hardening of fascia: Static stretching of dense fibrous connective tissues can induce a temporary stiffness increase accompanied by enhanced matrix hydration.Journal of Bodywork & Movement Therapies, 19: 94-100.
Stecco, C., Gagey, O., Belloni, A., et al. (2007). Anatomy of the deep fascia of the upper limb. Second part: study of innervation. Morphologie, 91: 38–43.
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Sunday, 20 January 2013

Rethinking Proprioceptive Training & Ankle Instability

Rethinking Proprioceptive Training & Ankle Instability
Ankle sprains are one of the most common injuries in physically active individuals – and one of the most common foot and ankle related injuries treated in an emergency room setting. It is estimated that up to 70% of individuals who experience an ankle sprain have residual symptoms including instability or recurrent sprains (Hoch, 2012). This persistent instability is referred to as chronic ankle instability (CAI).

To date, most research has focused on the residual impairment within the proprioceptors of the musculotendinous junction, the connection between a muscle and its tendon, and joint capsule, the dense connective tissue forming a sleeve around the joint. In response to this research, most CAI treatment programs include your standard “proprioceptive," or balance exercises, and peroneal muscle strengthening.

With the prevalence of CAI and advances in exercise science, it is important to periodically review a client’s program design to determine if the most current treatment guidelines are implemented in the training program and if the exercise selection follows evidence-based practice.

This article will review the latest research in proprioceptive training and neuromuscular control of the ankle. This article will also challenge current rehabilitation programs and apply evidence-based practice toward a new way of looking at “proprioceptive training” as applied to CAI.

Learning Objectives:
  1. Review two types of chronic ankle instability, including mechanical and functional.
  2. Review the different types of neuromuscular control, including open-loop and closed-loop systems.
  3. Introduce training techniques that can better optimize the neuromuscular system to improve ankle stability and reduce the risk of recurrent ankle sprains.

Types of Ankle Instability

When approaching a client or athlete with chronic ankle instability, it is important to understand the two types of ankle instability – mechanical and functional. 

The first, mechanical ankle instability (MAI), is an actual structural reason for ankle laxity. The lateral ankle ligaments play a key role in the structural support of the ankle joint. Limiting plantarflexion and inversion, the anterior tibial fibular ligament (ATFL) is the most common injured ligament during an ankle sprain. This lateral ligament is typically injured while the ankle experiences an inversion ankle sprain, or an outward rolling of the ankle. Depending on the severity of the ankle sprain, a partial or complete tear of this ligament will greatly compromise the stability of the ankle. These patients often go on to have surgical correction. 

The second type of chronic ankle instability is when the individual experiences symptoms of ankle “weakness” or that the ankle is “giving way." Referred to as functional ankle instability (FAI), mechanical laxity has been ruled out in these individuals and therefore an impairment in neuromuscular control must be considered. 

As fitness professionals, the most common type of chronic ankle instability you will encounter is functional ankle instability (FAI), therefore this will be the focus of this article. 

Neuromuscular Control of the Ankle and FAI

Defined as the interaction between the nervous system and the muscular skeletal system to produce a desired effect, neuromuscular control is the cornerstone to all human movement (Ogard, 2011). There are two subdivisions within neuromuscular control, the open-loop system and the closed-loop system. Just like closed-chain and open-chain kinematics, we must consider both subdivisions when we train the neuromuscular system. 

Open-loop neuromuscular control is often referred to as the preparatory phase of human movement. More specifically, this is the pre-activation of the ankle stabilizers before the foot even touches the ground. This is a protective mechanism that allows the body to better react to ground reaction forces and unstable surfaces. Studies have shown that individuals with FAI have a lower pre-activation state of their ankle stabilizers, namely the peroneals, and therefore strike the ground with more instability and in a more inverted position (Ogard, 2011). 

Closed-loop neuromuscular control is a reactive or reflexive-type muscle contraction in response to afferent sensory input, input that is received by the muscles and transmitted to the brain. A great example of closed-loop neuromuscular control is when you accidentally step off of the side of a curb. Peroneal muscle spindles sense the inversion stretch (afferent signal) which creates a reflex-type concentric contraction of the peroneals to quickly pull your foot into eversion (efferent signal). This efferent signal is the brain, or central nervous system, responding to the afferent signal received and sending input to the muscles to react. 

With the peroneal muscles coined as the “primary lateral ankle stabilizers," strengthening the peroneal muscles is the foundation to closed-loop neuromuscular training and most ankle rehabilitation programs. 

“Proprioceptive Theory” for Ankle Instability 

When a patient is referred to physical therapy for an acute sprain or CAI, the foundation of the treatment program is most often “proprioceptive” exercises. Often times, the referring physician will write on the prescription “proprioceptive training." 

For the past two decades, ankle rehab programs have been following the “Proprioceptive Theory” for ankle instability. The “Proprioceptive Theory” for ankle instability states that joint and peroneal tendon proprioceptors are disrupted during rapid ankle inversion, and therefore must be strengthened to regain ankle stability. 

 But what exactly constitutes “proprioceptive training”? 

Current Concepts in Proprioceptive Training

A 2011 study by Ogard et al. argues that although ”proprioceptive training” is a key component to ankle rehabilitation programs, it does not clearly define proprioceptive training. 

“Proprioceptive training” is often synonymous with balance training. By definition, “balance” is our body’s ability to maintain center of mass within our base of support (Ogard, 2011). However, “proprioception” is the central nervous system processing limb and trunk movements while balancing. 

There are several balance exercises that are included in rehab or personal training programs with the intention of improving a client’s proprioceptive abilities. However, these exercises may not be as effective as expected. For example, a common exercise that is considered to be a “proprioceptive” exercise – standing on an Airex pad – may not yield the necessary proprioceptive training needed to restore ankle stability. While standing on this unstable surface, the proprioceptive feedback from our feet and ankles is dampened and shifted which means our somatosensory system increases the sensory input from both the visual and vestibular systems. In other words, this exercise may not be really training our “proprioceptors,” but rather re-allocating sensory input to maintain balance. 

So if these unstable surfaces, which are the hallmark to ankle rehab programs everywhere, are not stimulating our proprioceptors – are they even improving our stability? 

A 2007 study by Refshauge et al. evaluated the impact of ankle proprioception and stability after 4 weeks of wobble board training in subjects with FAI. What was observed is that wobble board training only improved movement detection velocity at the slowest speed. Studies have suggested that ankle inversion velocities are up to 3.5 degrees per second, however the wobble board program was associated with only a 1.1 degree per second. 

Although the current ankle rehab programs focus on improving balance and proprioception through unstable surfaces, the research does not support this with an associated reduction in ankle instability. If this is the case, how can we better create rehabilitation programs that better stimulate the proprioceptive system and therefore better reduce risk of injury or re-injury?

Rethinking Proprioceptive Training

With the popularity of minimalist footwear and barefoot running, some of the same concepts are taken into ankle rehabilitation programs. One of the greatest benefits to barefoot or minimalist running is the degree of proprioceptive input with each step they take. 

One of the most important sensory input systems in the human body is skin on the bottom of the foot. Thousands of mechanoreceptors that are sensitive to light touch, texture, vibration, pressure and skin stretch are stimulated with every shift of the body and each step we take. As these different mechanoreceptors are stimulated, specific muscle activation patterns are stimulated to stabilize the foot and ankle joints, as well as to dissipate ground reaction forces. 

Recommended Proprioceptive Training

It is better to stimulate the mechanoreceptors in the plantar foot which are faster than ligament and musculotendon proprioceptors. The following are training techniques that can better optimize the neuromuscular system in order to improve ankle stability and reduce the risk of recurrent ankle sprains. 

Training Techniques:

1. Textures:

Based off of feedback from Merkel’s Disks, texture offers a great way to stimulate the most sensitive of the plantar cutaneous receptors. Studies have shown that when comparing stabilization when standing on textured surfaces versus smooth surfaces, there was a greater than 9% decrease in postural sway with the textured surfaces (Hatton 2011). A great way to begin introducing different textures in your client’s programming is by standing on the underside of a DynaDisc. 

The ridges on the underside of a DynaDisc are designed to stimulate the many proprioceptors on the bottom of the foot. Depending on the level of your client, begin with minimal or no air within the DynaDisc, then add air as they become stronger. 

With your client barefoot, have them begin by standing with both feet on the DynaDisc. Eventually, integrate 20 – 30 second periods with the eyes closed to further recruit feedback from the plantar foot. As the client becomes stronger, the client can progress to a single leg stance with eyes open and single leg stance with eyes closed. 

2. Vibration: 

Another great technique for stimulating the plantar cutaneous receptors is specific to vibration response. Again, this proprioceptive feedback is most acute when the client is barefoot. Some fitness professionals have access to whole body vibration surfaces such as a PowerPlate. Whole body vibration platforms offer a great surface for performing all balance or single leg exercises. Depending on the type of vibration surface, both static and dynamic balance exercises can be integrated. 

3. Ankle taping: 

One of my preferred techniques for enhancing proprioceptive feedback is through the stimulation of skin stretch. Studies have demonstrated increased reaction time and joint position sense in athletes who have their ankle taped. It was found that this faster response time was directly related to the stimulation of Ruffini organs which are sensitive to skin stretch.

You can easily integrate skin stretch proprioceptive feedback into your client’s programming by placing tape from the lateral to medial ankle and from distal to proximal on the plantar aspect of the foot. 

One of the most common forms of ankle instability witnessed by fitness professionals in their clients is functional ankle instability (FAI), described as ankle weakness or "giving way." As a result of this instability, the client may be directed to engage in physical therapy and/or personal training involving "proprioceptive training," commonly interpreted as balance training. Although the traditional balance exercises utilized in many ankle rehabilitation programs have the intention of improving a client's stability, these exercises may not be as effective as expected. Simply, balance exercises may not be enough to stimulate the proprioceptors needed to optimize the neuromuscular system in order to improve ankle stability. By stimulating the mechanoreceptors in the plantar foot with training techniques involving equipment with textures, vibration, or skin stretch, there may be a greater improvement in ankle stability and reduced risk of recurrent ankle sprain


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