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

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:

Conclusion

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.

References

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.

van der Wal, J. (2009). Connective Tissue Architecture and Proprioception. International Journal of Therapeutic Massage and Bodywork, 2(4).

Yahia, L. et al. (1992). Sensory innervation of human thoracolumbar fascia. Acta Orthopaedica Scandinavica 63(2): 195-197.

Rethinking Proprioceptive Training & Ankle Instability

Rethinking Proprioceptive Training & Ankle Instability

by Emily Splichal

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. 

Conclusion

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

References

Guitierrez, G. et al. Neuromuscular control and ankle instability. Am Acad Phys Med Rehab, 2009. 1(4): 359-365.

Hatton, AL et al. Standing on textured surfaces effects standing balance in healthy older adults. Age Ageing, 2011. 40(3): 363 – 368.

Hoch, M. et al. Plantar vibrotactile detection deficits in adults with chronic ankle instability. Med & Science in Sports & Exercise, 2012. 44(4): 666-672.

Liu, W. et al. Noise enhanced vibrotactile sensitivity in older adults, patients with stroke and patients with diabetic neuropathy. Arch Phys Med Rehab, 2002. 83 (2): 171-6. 

Ogard, W. Proprioception in sports medicine and athletic conditioning. Strength Cond J, 2011. 33(3): 111-118.

Robbins, S. Factors associated with ankle injuries. Sports Med, 1998. 25(1): 63-72.

Yeung, MS. An epidemiological survey on ankle sprains. Br J Sports Med, 1994. 112-116.

iPad And Tablet-Related Injuries On Rise.

iPad And Tablet-Related Injuries On Rise

The Chartered Society of Physiotherapy says it has seen an increase in the number of people with upper body pain, which could be related to the use of hand-held devices and tablets.

Businessman Jeremy Asher used to spend around six hours a day switching between his laptop, smartphone and tablet computer, until his body began to protest.

"I woke up one morning with an intensely sharp pain right around the shoulder blade. I thought … perhaps it would go away after a night or two. But it didn't. In fact it seemed to be even worse, and it was starting to even stop me sleeping."

He was treated for a nerve problem and is now pain-free, but cases like his are becoming more common.

Chartered physiotherapist Amanda Stockton says she has seen more patients with symptoms including neck, shoulder and wrist pain, as well as headaches.

"When you're using a tablet, your neck is pointing sharply down, so your joints are getting stiff and your nerves are possibly overworking."

The unofficial term "iPad shoulder" emerged earlier this year after researchers at Harvard University looked into the risks of using tablets.

The study's leader Dr Jack Dennerlein suggests prevention is key.

"A lot of this can lead to chronic neck pain," he said. "And who knows - over the long term, these chronic issues can lead to other chronic health issues such as arthritis."

Apart from sitting upright in a chair, experts recommend keeping the tablet near eye level and taking regular breaks.

Dr Dennerlein added: "Find support in how to hold it up so that you can look at it properly. Don't use your arms if you don't have to. Go hands free. Find a good case."

Pelvic bio mechanics. A few answers.

To wedge or not to wedge??Is this the answer??

there are times when they are not. Take the example of the wedging of the feet in the pedal in an attempt to correct an overly flat foot in the shoe or cleat. Bearing in mind that 60% of the biomechanical problems that exist in feet are compensations for faulty biomechanics in the pelvis or hips, then you can see that it’s critical to ensure that the hips and pelvis are fully functional before the feet are addressed.

A ‘rotated’ pelvis, (which is where the pelvic bone gets stuck in an abnormal position) can go unnoticed for many years until the compensations start to cause problems. Typically a rotated pelvis is caused by unaccustomed lifting or carrying, performing a repetitive movement abnormally or perhaps compensating for another biomechanical issue elsewhere in the body. When the pelvis rotates, the piriformis muscle on the outside of your hip goes into a protective spasm. This spasm effectively prevents the joint from functioning correctly and so other areas have to compensate. If the problem is caught early enough, treatment will help. If however the problem is left for more than 6 weeks, the muscle will change its composition and become fibrotic and be unable to function normally. In theses cases treatment will help in the short term, but whenever you start training again, the problem recurs.

The body can compensate in a variety of ways for the rotated pelvis causing a leg length discrepancy, causing a variety of potential problem areas.

Common examples are that the foot can flatten to shorten the length of the longer leg or the opposite foot can increase the height of its arch to lengthen the shorter leg. Alternatively the knee of the longer leg can bend more to shorten it, or the knee of the shorter leg can bend less to lengthen it. In addition, the spine can side bend more to allow the shorter leg greater reach. These are only some of the many ways the body tries to compensate for a leg length discrepancy. Also bear in mind that the problems are worse in cycling than many other sports as you are fixed in a position determined by an external factor, unlike with running where you are relatively free to compensate how you like. All of these compensations though will increase the load on the structures that are doing more work. Typically they will result in knee pain, back pain, thigh or hamstring pain and hip pain. Moreover they make it very difficult to set your bike up correctly, as how do you know whether to set the seat/pedal relationship right for the longer leg or the shorter leg?

To manage these issues, we first have to return the abnormal muscle tone in the pelvis (the piriformis muscle) to normal. In other words you have to do ‘anti-spasm’ exercises for the muscle. Stretching or flexibility work just won’t cut it. You need to return the muscle to normal function, not just stretch it. Once the spasm is eradicated as much as possible, then you have to perform exercises to stabilise the pelvis. In other words exercises that allow your muscles to control your pelvis and trunk without them needing to go into spasm. Part of this process is achieved by so-called ‘core stability exercises’, but also you need to speak to your health care provider about plyometric exercises for pelvic muscles that you can do in the gym.

Once your pelvis is in good shape, and if you continue to get problems with your troublesome body part, then you can safely get a qualified practitioner or specialist to consider prescribing the wedges.

So if anyone says to you that wedges in your shoes can help with your knee, back or hip pain, you must make sure that they check your pelvic biomechanics first.

For a full bio mechanical assessment, book an appointment with Andy or Jason, our fully qualified Bio mechanical coaches.

Writen by ITS.

Electrolytes and their importance to the athlete.

Electrolytes and their importance to the athlete.

During intensive exercise the body needs to convert oxygen into energy (oxidative metabolism) yet only one quarter of the energy produced enables you to move, the rest is released from the body as heat. This is where sweat comes in; when working in a warm environment the heat produced must be eliminated from the muscles being used, to the blood. Without this effectively occurring in the body there is risk of a noticeable decrease in capacity to perform, possible hyperthermia and further health risks. Rehydration, particularly in the hot weather is crucial for replacing lost fluids and maximising performance.

In April of last year Olympic medallist and extreme sportsman, James Cracknell endured the 156 mile, gruelling Marathon des Sabres in the scorching Moroccan heat. During this marathon he had his urine tested twice a day in order to detect any signs of dehydration, trauma or malfunction. The tests where essential in enabling him to not only perform at his best but survive the experience under those conditions.

If there is no one at hand to test urine and check for dehydration there is a simple test that can be done.

The nail blanch test/capillary nail refill test; Hold your hand above you heart line and press down on the nail bed until it turns white but not so that it hurts, then let go. If the nail bed returns to the normal pink colour within 2 seconds, your circulation is good. If it takes longer than 2 seconds the result may be a sign of dehydration. 

It isn’t just water you need for adequate hydration over long periods of exercise. The body can only absorb a safe and proportionate amount of fluid (plain water) this is approximately one litre of water per hour. A 2% decrease in hydration results in a 20-35% drop in performance whether that be mental or physical or both. In order for the produced heat to be transferred from the muscles being used to the blood where it can then reach the extremities of the body and/or be released as sweat, other components need to be added to water.     

Electrolytes are minerals such as sodium, chloride, potassium, bicarbonate, calcium, phosphate and magnesium. These electrolytes are found in the fluid within the body and are obtained by the food and drinks we consume in our diets. They are fundamental in regulating nerve and muscle function, blood pressure and pH, hydration and the repair of damaged tissue. When there is an imbalance of fluid within the body, mineral levels change and can be lost. This loss can alter blood chemistry; affect muscle action and other mechanisms of the body. Not only inadequate intake of fluids can cause an imbalance of electrolytes but also some medication, vomiting, diarrhoea and sweating.

Blood contains more minerals than sweat and therefore at times when there is inadequate water taken in to counteract the water lost during exercise, the concentration of these minerals (electrolytes) in the blood increases. When the amount of water lost through sweating is equal to the amount consumed, the major electrolytes (sodium and chloride) decrease. This however is more apparent in ultra-endurance athletes where exercise lasts longer than 3 to 4 hours. For training of up to several hours at a time, it is important that fluid along with glucose, are taken in to prevent dehydration, exhaustion and heat stroke. The combination of sodium and carbohydrates can help stimulate the absorption of water in the body and this is especially important during periods of recovery where rehydration of both fluid and electrolytes are essential. It is thought that the most effective post training rehydration drink should have around 1100mg of sodium per litre¹.  Vita-coco is natural coconut water that contains naturally occurring minerals, though relatively expensive it is one of the best hydration drinks available.

 

Stroud Sports Clinic Ltd.