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Foot and Ankle

Fitness training for those of us past 40 years of age is more complicated.  Physical performance and recovery capacity is dramatically different.  If you need proof, look around for the forty year olds in the NBA or NFL.  The good news is that with proper planning, consistent performance, and the wisdom that comes with age, we can stay fit and active for a lifetime.  I have compiled a collection of tips for the forty plus fitness client. 

Manage Eccentric Muscle Loading

sledDuring the concentric portion of a lift, the muscles shorten as the load is moved.  In the eccentric phase, the muscles gradually lengthen as the load is lowered in a controlled manner.  Eccentric muscle activity (lengthening under tension) produces more muscle micro trauma and, therefore, requires more recuperation time.  It is the eccentric aspect of a resistance exercise that creates delayed onset muscle soreness.

Older fitness clients do not possess the same recovery capacity as younger individuals.  Utilizing exercise activities that reduce eccentric stress is a valuable training tactic.  Concentric biased training allows older trainees to perform a greater volume of work and be ready a day or two later for the next training session.
Sled work is my favorite “concentric only” fitness activity.  The muscles shorten to propel the sled and never have to lengthen against resistance.  You can push, pull, row, and press a sled at fairly high levels of exertion and still sufficiently recover between training sessions.

Loaded step ups are a predominantly concentric contraction, lower extremity strengthening exercise.  It teaches balance, core control, and improves single leg strength. The eccentric aspect of a loaded step up is minimal and this makes it an essential exercise for older fitness clients.

My favorite upper extremity eccentric only training device is the Surge 360.  The Surge provides resistance through a series of multi-directional pistons.  All exercise activities on the Surge are concentric only.

Resistance tubing is another tool that can help manage eccentric muscle activity.  The force curve (increased load as the tubing is lengthened and decreased as it gets shorter) helps reduce muscle activity during the eccentric aspect of many exercises.
-Michael S. O’Hara, P.T., OCS, CSCS

In an effort to get back into shape, Monica added some stadium step running to her fitness program.  She went to the high school stadium and made twenty trips up and down the bleachers.  The initial sessions went well but after the first few weeks her knees started aching and the pain began to interfere with activities of daily living.  Monica tried some anti- inflammatory medications and ice but neither produced any relief.  She recently arrived at our physical therapy clinic for some help with her knee pain.

Running stadium steps is a demanding exercise activity that will produce a strong metabolic response.  Unfortunately, stadium steps are too stressful for most people.

Risk/Reward Ratio of the Stadium Steps
shutterstock_385922764For deconditioned individuals, stadium steps fall on the risk side of the risk reward ratio.  Most overweight and “out of shape” fitness clients have tight and weak hips.  They are inefficient in the skill of decelerating their body down the stairs and that skill deteriorates as they fatigue.  They need to use training methods that reduce orthopedic stress and limit biomechanical overload.

Stadium steps are a high level fitness activity.  It is the calculus of mathematical learning.   Deconditioned and overweight individuals need to start with basic algebra before venturing into quantum physics.  The better approach is to get fit first and then add stadium steps to your workout after you have improved strength, body composition, and mobility.

Run hills instead.  I have switched many stadium stepping physical therapy patients to running up and walking down hills.  It is a more forgiving form of fitness training than stadium steps and the benefits are superior.

Your Inner Gladiator
If you insist on stadium step training, I have some suggestions.  Spend six weeks strengthening your hips.  Most deconditioned folks, sit all day and have poor strength/strength endurance in the hips.  Weakness in the hips permits the knees to collapse inward on your downward bound through the steps.  I like bridges, hip lifts, mini band squats, and walking lunges.  See my recent article and video on my favorite gluteal strengthening exercises.

Foam roll the outside, inside, back, and front of your hips, thighs, and hip rotators.  Most stadium stepping pain patients are a big basket of myofacial restrictions.  They writhe around on a soft roller and look at me like I am crazy.  Restoring the mobility of the fascia that encapsulates the deceleration muscles of the hip will help improve performance.

Run up and walk down, softly.  It is the step descent that causes the biomechanical stress on the muscles and joints.  As you travel down the steps, think about actively engaging the gluteal muscles and decelerating with the hips and not the knee.  The louder the impact on the descent the more likely you are an inefficient decelerator.  Have someone watch you as you travel down the steps.  If your knee collapses inward, you need to get off the steps.
Build up slowly.  Do not start with twenty flights.  Start with three trips and gradually build up your work capacity–once a week is more than enough for most folks.  Find other training modalities that are less stressful.  Being too aggressive with a training program is one of the big reasons people fail with fitness, and it keeps me busy in the clinic.

Monica was, by her own account, twenty pounds overweight.  Her hip mobility was less than ideal and she had prior history of hip pain problems.  She had diminished hip range of motion and limited strength in her hamstrings and glutes.  During assessment of her deceleration skills, Monica tended to land in a collapsed inward knee position.  We had Monica perform a program of mobility and strengthening exercises for both hips and rest from all “cardio” activities.  Her knee pain resolved and she was able to return to a program of fitness training.
-Michael O’Hara, P.T., OCS, CSCS

A physician friend sent me this recently released research article on the benefits of maintaining strength and muscle mass as we age.  I think everyone should take the time to read this article.  We are keeping people alive for longer periods of time, but how well are they living?  The discussion of the extension of life span compared to enhancement of health span is worthy of consideration.  Improving muscle mass and strength dramatically improves quality of life, a factor often not given enough consideration.

10522_2015_9631_Fig1_HTMLAge-related sarcopenia is the loss of muscle mass as we age.  Sarcopenia and functional disability travel hand in hand.  Combating sarcopenia has become a hot research topic as greater numbers of the American population pass through old age and the cost of their care becomes an issue.  The good news is that age-related sarcopenia is a very treatable condition.  The bad news is that it takes some education and effort.   When discussing the need for strength training, these are the top questions/concerns I get from physical therapy patients and fitness clients:

OK, how much, how difficult, and how often?
After the eye rolling, this is the question I get from most of my sarcopenic patients.  The research training programs that successfully reversed age-related sarcopenia involved four to seven progressive resistance exercises performed for a total of twelve to twenty sets.  The participants trained two or three times a week and the level of perceived exertion fell into the mild to moderate regions.  You are looking at 90 – 150 minutes a week of mild to moderate exercise.  The important, and often completely missed, aspect of progressive resistance training is that you increase the resistance or load lifted as you become stronger.

Can’t I just do yoga, golf, tennis, hot yoga, swim, walk, chair yoga, tiddly-wink, Pilates, underwater yoga?
I am sorry but the research studies have not found that these training modalities produce the necessary stimulus to combat age-related sarcopenia.  You can still perform all of these activities– just include a consistent program of progressive resistance strength training.

I don’t know what to do…
Poor exercise selection and beginner’s enthusiasm are the biggest reasons people fail with progressive resistance strength training.  Exercise is like medicine, administer the correct prescription at the proper dose and the results will be good.  Just like a visit to your physician, it all starts with an evaluation.  You need to start at a level that makes you better and not broken.  Get instruction from a qualified coach and follow his/her plan.  A big warning- the world of fitness is filled with many “certified experts” -–it took them a full weekend to complete their training.  These experts keep us busy in the physical therapy clinic.

You can view the research article here: http://link.springer.com/article/10.1007%2Fs10522-015-9631-7
-Michael O’Hara, P.T., OCS, CSCS

Fitness training for those of us past 40 years of age is more complicated.  Physical performance and recovery capacity is dramatically different.  If you need proof, look around for the forty year olds in the NBA or NFL.  The good news is that with proper planning, consistent performance, and the wisdom that comes with age, we can stay fit and active for a lifetime.  I have compiled a collection of tips for the forty plus fitness client.

Improve the Function of Your Legs
115“You are as old as your legs” is the common quote in boxing.  Strong legs make you more durable (fewer injuries) and healthier.  Think of your legs as the engine that enables you to train the heart and lungs.  Most of the metabolically active muscle mass that stores glycogen and keeps our insulin sensitivity fine-tuned is located in the legs.  Despite this, many older gym goers spend little time training their lower extremities.

Older legs (40+) have special needs.  Most clients will get the best results with daily performance of mobility drills and two strength training sessions a week.  Choose exercises that reduce compressive forces on the spine and minimize eccentric muscle tension.  Eccentric muscle loading and compressive spinal loads make recovery more difficult for older clients.  A good lower extremity training program improves balance, core stability, strength, mobility, and has a very positive effect on body composition.  I am a big believer in single leg training as it covers all of these areas and minimizes the chances of exercise induced injury.

Give your body time to recover between strength training sessions.  Look at your weekly training routine and use a Monday and Thursday or Saturday and Wednesday split.  I would not perform any long duration cardio activities the day after a strength training session.  Perform some easy mobility work every day of the week.  It will take less than five minutes.
-Michael S. O’Hara, P.T., OCS, CSCS

Heel Drops Keep You in the Game and Out of the Therapy Clinic

heel_dropsIrritation of the Achilles tendon is one of the more common and debilitating injuries in the recreational runner population.  It is theorized that cellular changes in the Achilles tendon happen because the level of tendon loading exceeds the body’s capacity to create appropriate cellular repairs.  Achilles tendinopathy is such a common and difficult problem that I recommend all recreational runners perform heel drops, twice a week, as part of an injury prevention program.
A Swedish study from 1998 kicked physical therapy into a frenzy of heel drops.  This exercise is used to enhance the Achilles tendon’s tolerance of loading.  The initial studies recommended three sets of thirty repetitions, performed three times a day.  Experience in the clinic and gym has demonstrated that most people do better with less volume.
To perform a heel drop simply stand with the ball of your foot on a step and the heel off the step.  Use both feet to rise up on the toes with heels elevated as far as possible.  Remove one foot and then lower the body down slowly for a count of five.  The heel should end up well below the top of the step.  Use both feet to rise back up on the toes and repeat.  Start with five repetitions with the knee straight and the same number with the knee slightly bent, for a total of ten heel drops.  If you are unable to lower slowly, you must perform this drill with the foot flat on the floor and progress to the full heel drop as you become stronger.  Reduce the repetitions if your Achilles tendon becomes more symptomatic.  If all goes well, add a repetition every session until you reach twenty repetitions, ten with the knee straight and ten with a bent knee.
Perform heel drops twice a week as part of your strength training/injury prevention program.  If you are a recreational runner and you do not perform a strength training/injury prevention program, my number at Fenton Physical Therapy is 810-750-1996.

You can view video demonstration of heel drops by clicking here.
-Michael O’Hara, P.T., O.C.S., C.S.C.S.

I recently had the opportunity to hear a presentation on the latest and greatest in running research. The presenters used sophisticated computer software to measure the forces runners created with every foot contact. The variance between runners was dramatic. Some glided along with minimal evidence of foot to ground interaction and others shook the earth. The numbers did not coincide with greater bodyweights or sex. Some of the heaviest individuals ran with minimal impact and some of the more svelte runners were thunderfoots. Men did not necessarily land harder than women. What researchers did find is that high impact runners are far more likely to suffer an overuse injury.

Not everyone has access to force plates to measure ground force reactions, so how do you know if you are a high impact runner? The advice the researchers gave was to listen. The individuals with the hshutterstock_109581608ighest force plate impact numbers were the ones who produced the most noise when they ran on a treadmill. After analyzing over 200 runners, the students and researchers were able to easily predict force plate results based on the noise they heard during the treadmill warm up.

Distance running is a very high-level fitness activity, and you must have all performance parameters functioning at optimal levels to avoid injury. If you fail the treadmill listen test, then work on developing a smoother and less stressful gait pattern. Landing lightly has a big impact on staying healthy and pain-free while running. Take the time to read the February 10, 2016, New York Times article by Gretchen Reynolds, “Why We Get Running Injuries (and How to Prevent Them).”

Click on the link below to read the article:

http://well.blogs.nytimes.com/2016/02/10/why-we-get-running-injuries-and-how-to-prevent-them/?_r=0

-Michael S. O’Hara, P.T., OCS, CSCS

Suspension_LandingMost physical therapy patients are injured in a failed attempt to control deceleration. Most sports injuries do not involve contact from an opponent or any force greater than bodyweight. The athlete just plants a foot and attempts to move in a new direction. When an athlete is unable to properly control deceleration, he or she becomes much more prone to ankle, knee, hip, and even upper extremity injuries. Teaching physical therapy patients and athletes how to properly manage deceleration forces is an essential component of training.

For many people, it has been years since they have performed any jumping or hopping. They do not possess the core stability, balance, and proprioception necessary to control full bodyweight activities. A suspension trainer permits a gradual introduction on landing mechanics. You can slowly and steadily add load as you become more proficient.
Suspension Landing Performance

Use a TRX or similar suspension trainer attached at least nine feet up the wall. Grab the handles and face the attachment point. Place the feet at least hip distance apart. Bend at the ankles, knees, and hips. You will perform an easy jump and use the assist of the suspension trainer to support your landing. Attempt to land softly and hold a flexed ankle, knee, and hip position. We call this “sticking the landing.” Keep the knees in line with the feet and the torso upright.

Focus on landing in a smooth and efficient manner. The height of the jump is not important. Perform this exercise at the beginning of your workout, when you are rested and fresh. Five landings or less is a good start for most people.

This is the practice progression that I have found works well:

1) Basic bilateral landing
2) Rotation landing
3) Split landing
4) Single leg landing

Deceleration training is important for keeping older individuals free from falls and living independently for a lifetime. I recommend you take the time to get some instruction on proper deceleration mechanics.

For video demonstration of suspension landing performance, click here: Video_Practicing_Landing

-Michael O’Hara, P.T., OCS, CSCS

Training to develop lower extremity power is important for staying safe on the playing field and functional in everyday life. More important is the ability to efficiently and properly absorb force during a landing. Box jumps are a basic power exercise that will improve these skills. If you are a snow skier, volleyball player, or runner then box jumps should be in your fitness program.

Competition vs. Athletic Enhancement

Box jumps have become popular in fitness competitions. The goal during these games is to get a number of jumps finished in a prescribed period of time. During these events the box jump is the field of play and not a training tool. Athletes who wish to improve performance and reduce the chance of an injury perform box jumps to retrain the neural system and enhance mechanics. Training for a box jump competition and training to improve performance are very different.

Box Jump Prerequisites

You should score a 2 or better on the straight leg raise, squat, and in-line lunge portion of the functional movement screen before you perform box jumps. See one of our trainers if you have not had a movement screen assessment. You should be able to perform a solid stable landing on a “step and catch” off a twelve inch box.

Box Jumps

Box jumps are performed on a plyometric box. At FFAC, we use the Plyosafe boxes made by UCS. These twelve, eighteen, and twenty four inch boxes are made of layered foam padding to absorb much of the force when landing a box jump.

  1. Start in front of a twelve inch box. Your toes should be about six inches from the side of the box with the feet shoulder width.Box_Jumps
  2. Hip hinge–bending a little at the ankle and knees and more at the hips. Do not permit the knees to crash inward. Use the arms to aggressively drive the jump. Throw the arms up as you drive off the floor with the hips.
  3. Do not look down. Keep the eyes up and think about jumping up and extending the legs out long. Do not pull the knees up and turn the jump into a hip flexion exercise. You want to displace the hips vertically and not flex the hips forward in an effort to reach the top of the box. You should never land on the top of the box in the “cannonball dive” position.
  4. Your take off position should be the same as your landing position.   “Stick the landing” by staying stationary for two counts.
  5. Land soft with minimal noise created when you impact on the top. Good plyometrics are seen and not heard.
  6. Use a mirror to assess your landing position. The knees should line up with the feet and never buckle inward. Keep your torso tall and eyes up. Make an effort to get rid of any wobble in your landing.
  7. Step down (do not jump down), reload your stance, and repeat. We want to avoid the eccentric stress and impact of jumping down and remove any influence of the stretch-shortening cycle.

Perform three to five box jumps and then take a short rest to let your neural system recharge. Three sets of three to five repetitions is a good start. Box jumps stress your nervous system so stay with a low volume of high quality box jumps. As you become more proficient, work on using a higher box (most of us will never need a 30 inch box). Avoid the high box jumps you see on the internet that are mostly a measure of hip mobility and sponsored by the local spinal surgery center. Holding a kettlebell, weight plate, or wearing a weight vest and performing a box jump offers little reward and carries lots of unnecessary risk.

We all have limited time to train so choosing the proper training activities is important. The combination of box jumps and some properly performed kettlebell swings will go a long way to prevent injuries, improve strength, and enhance vertical leap.

For video demonstration of the box jump, click on the link below:

-Michael O’Hara, P.T., OCS, CSCS

A recent article in the New York Times by Gretchen Reynolds* covers the latest research on lower extremity function and aging.

As any physical therapist can attest, the older you are, the more likely you are to suffer a tendon injury or an overuse pain problem in the foot or ankle. Movement analysis of older runners reveals that they use the lower aspect of the leg less than younger runners. Forward propulsion and deceleration become more hip dominated activities. Based on the movement analysis data, the researchers in the article suggest older runners preferentially strengthen the muscles that control the ankle and foot.

The research validates the need to train your legs with the foot in contact with the ground.   In rehab and fitness, it is called closed chain training and it produces the carryover to real life performance and durability (no injuries) you need to age gracefully and stay independent.   Many older gym goers have balance deficits and mobility restrictions that draw them to strength training in a non-weight-bearing seated position. They miss activating the muscles that are crucial for walking and moving well. Step ups, lunges, and squats all involve the muscles of the foot and ankle and should be a big part of every training program. Knee extension, leg curl, and that hip in and out machine –- not much help…

To read the article, click on the link below:

http://well.blogs.nytimes.com/2015/09/09/why-runners-get-slower-with-age-and-how-strength-training-may-help/

-Michael O’Hara, P.T., OCS, CSCS

*“Why Runners Get Slower With Age (and How Strength Training May Help)”, Gretchen Reynolds, September 9, 2015, New York Times.

Physical therapy patients and fitness clients often ask me what type of running shoe they should purchase. My answer is to choose the shoe that feels the best. The more important question is whether they should use distance running as a training modality. A recent article in The New York Times* covers some recent research on running shoes.

Running shoe hype does not correlate well with real life results. If you are a runner, the best advice is to select a shoe that feels good and be skeptical of advertisements and marketing. Trust your senses and not the salesman. Run in the shoes, and if they feel bad then hand them back. Keep a record of the shoes that make your joints happy and stay with that shoe.

Get Fit First

Distance running is an extremely demanding activity that requires good mobility, superior strength levels, and an appropriate body mass. If you are sedentary, maybe a little heavier, and have difficulty performing basic squat and lunge patterns, you should begin your quest for fitness with an activity other than running. Many other exercise modalities can move you toward your fitness goals with a much lower risk of injury. The best place to start is with a proper Functional Movement Screen evaluation provided by a qualified trainer. Get stronger, improve your mobility, lose the excess body fat, and only then, consider a gradual introduction into distance running.

*New York Times, August 5, 2015, “Choosing the Right Running Shoes,” Gretchen Reynolds

To read the article, click on the link below:

http://well.blogs.nytimes.com/2015/08/05/choosing-the-right-running-shoes/?_r=0

-Michael O’Hara, P.T., OCS, CSCS

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