Foot and Ankle
Stability, Mobility, And Better Posture
The squat has been described as the king of all exercises. The large amount of muscle recruited during squatting makes it a very metabolically demanding exercise. In athletics, the capacity to perform a full squat with proper torso, hip, and knee position has been correlated with greater durability–fewer injuries. The overhead squat test is one of the patterns assessed in the Functional Movement Screen and is used in physical therapy and athletic training. Squatting with the load placed on the front of the body is an excellent way to enhance mobility, stability, and strength. Compared to leg presses, seated leg curls, and knee extension, front squatting creates much more carry over to activities of daily living and athletics. The problem is most people do not know how to get started with front squats.
When you squat with the load across the front of the body instead of on the upper part of the back, the stress on the spine is reduced. You can “cheat” a back loaded squat by leaning forward, but you cannot lean forward with a front squat. Leaning forward on the front squat causes the load to fall from your shoulders or hands. Front squatting creates a greater core stability demand and reduces shear force on the lower back. Full depth front squatting will improve your posture and restore mobility in the hips, shoulders, and thoracic spine.
Front squatting is an exercise that is more equivalent to daily tasks and athletics. Lifts in real life rarely place the load across your shoulders. When you lift the grandchild, carry the groceries, or hoist the wheelbarrow, the load is in front of the body. During athletics, the opponent is in front of you, and you must stay upright and tall to dominate the activity.
Front Squat 101
Before loading the squat, practice bodyweight squats to a depth target. I like to use a 12 inch box or a Dynamax ball (12 inches in diameter). You should be able to perform a body weight squat to a thigh below parallel position with a stable spine before attempting a loaded front squat. When you perform a loaded front squat, initiate motion from the hips by sitting down and back. Push the knees out and descend so the thighs travel to below a parallel to the floor position. Keep the chest up and torso tall as you push back up. Finish at the top by contracting the gluteal muscles and keeping the front of the rib cage down.
Choose A Proper Implement
While the barbell offers the greatest loading capacity, many individuals do not possess the shoulder mobility to hold the bar on the shoulders. The Goblet Squat position with a kettlebell or dumbbell works just as well. A sandbag hugged close to the body in the high Zercher position or bear hug hold has a high degree of athletic carry over. Avoid the Smith machine variation. You end up leaning on the machine and this eliminates much of the core stability demands and exposes the spine to greater shear force.
Michael S. O’Hara, P.T., OCS, CSCS
The Downside Of Upside Down Exercise
Exercise activities that place the head below the heart have become more popular in fitness programs. In almost every gym you see decline bench pressing, incline sit ups, glute-hamstring developer exercises, and more recently, hand stand push ups as a regular part of many exercise programs. While these activities may have some value, you might want to reconsider training in an inverted position for some other reasons.
When you invert your torso, the contents of your stomach can more readily travel back up into your esophagus. Head below your belly with a hiatal hernia, a little extra mesenteric fat, and some strong contractions from the abdominal muscles, and you have the perfect environment for gastroesophageal reflux disease (GERD). Millions of Americans (14%-20% depending on the study) take medications to manage the symptoms of GERD—heartburn, chest pain, persistent cough, difficulty swallowing, hoarseness. Prilosec and Nexium are the biggest moneymakers the pharmaceutical industry ever created. Many Americans (10%-15%) have GERD, but are unaware of the problem because the tissue damage has not reached symptomatic levels. Erosive esophagitis or Barrett’s esophagus is a clinical finding of cellular change in the esophagus and a precursor for esophageal cancer. Esophageal cancer is one of the more deadly types of cancer.
Glaucoma or Retinal Disease
The head down position raises pressure inside the eyeball. As little as 30 degrees of decline has been shown to increase intraocular pressures. It is estimated that 2.2 million Americans have glaucoma, but only half of these know they have the problem. Individuals with glaucoma already have elevated intraocular pressures and should avoid these positions. The back of the eye (retina) is susceptible to changes in vascular pressures, so if you have any retina issues, avoid the head down position.
High Blood Pressure / Hypertension
Your heart, lungs, and arteries are conditioned to pump blood with your body in an upright position. Many vascular alterations occur when we flip into a heads down position. When you assume the head below your heart position, the arterial pressures inside the skull increase. Elevated cranial blood pressures can lead to headache and much more severe problems such a stroke. One in three Americans are walking around with high blood pressure. Add in an exercise induced elevated heart rate and some less than pliable carotid arteries and you have the ideal environment for a big bad brain event. If you have hypertension, I would not go about using any inverted positions in the gym.
Apart from going blind, having a stroke, and developing an incurable cancer, you should be fine.
Michael S. O’Hara, P.T., OCS, CSCS
A Step Up In The Right Direction
Anterior Step Ups
Most of the lower extremity training in the gym occurs with both legs working at the same time. Leg press, leg extensions, squats, and deadlifts all train both lower extremities simultaneously. In life, we almost always function in a single leg, or predominantly single leg manner. All athletic activity requires a high degree of single leg control to be proficient and remain free of injury. Your fitness training should include activities that improve balance, proprioception, core stability, and strength while on one leg. One of the best single leg exercises to add to your training program is step ups.
Connecting Your Lateral Subsytem
When you stand on one leg, the team of muscles that keep you upright and tall are collectively called the lateral subsystem. They consist of the groin muscles (muscle on the inside of the thigh), the gluteus medius (outside of the hip), and quadratus lumborum (side of the spine). These muscles must work in a coordinated fashion to keep you straight and stable. A step up exercise places a strong demand on the lateral subsytem. Seated machine based exercises have no effect on this essential neuromuscular interaction.
Keeping You Safe
When I start clients on step ups, the most glaring deficit is almost always single leg stance balance. Many of these people run, bike, and regularly attend group exercise classes, yet they have very limited control when they stand on one leg. I do not care how much weight you use on the knee extension machine or how flexible your hamstrings have become; if your balance is poor, you are at a far greater risk for a fall and/or injury. Anterior step ups will help improve single leg stance balance.
Deadlifts, squats, and leg press all create spinal compression. The anterior step up exercise creates much less in the way of compressive force on the lumbar spine. Fitness clients and athletes with a history of lower back pain can strengthen the legs with less spinal stress.
Real Life Carry Over
There is specificity to training. The exercises you perform in the gym must look and feel like the activities you must perform in real life. Your performance on a step up is far more likely to carry over to real life than your performance on a leg press or leg curl machine.
Anterior Step Ups
If you perform this at home, make sure you use a stable step up box—I would not use a padded lifting bench, milk crate, or old air conditioner. A mirror can be very useful in monitoring your performance. Most people can start with an eight inch household step.
Stand facing the box with one foot completely on the box–from heel to toes. When you perform a step up, use your gluteals and hamstrings to push through the foot and drive up into single leg stance. Do not jump up on to the step by leaning over and “popping up” with the rear leg. Bring the rear leg up to 90 degrees hip flexion, and hold a single leg stance for two counts. Try to abolish any wobble in your single leg stance position. Lower back down using the stance leg to control the descent. Perform all of the repetitions on one leg and then repeat on the other leg. If you find one leg is significantly weaker, then start with that limb first. Perform two or three sets of eight to ten repetitions.
Master your bodyweight on the eight inch step first and only then move to a higher box. A good goal is to move up a box height that places the top of the thigh just below parallel when the leg is placed on the box.
You can load the anterior step up many ways. I like using a medicine ball held at chest level as the first progression of loading and then progress to using an Iron Grip plate. For athletes the Barbell Step Up is a great functional exercise. It is best to perform this exercise in a power rack in case you lose control of the weight.
Michael S. O’Hara, P.T., O.C.S., C.S.C.S.
Pushing Through Fitness Barriers
How Sled Pushing Can Produce Big Results
Most of us have busy schedules and limited time to exercise at the gym. We want the most benefit possible for our time spent working out. Sled Pushing is a high value activity that can be utilized by almost all fitness clients.
True Core Stability
How our “muscles in the middle” truly work is in a standing position with our legs in contact with the ground. The legs are usually in an asymmetrical stance, transferring force from the ground through our body into the arms. Most “core stability” exercise performed in the gym put you in a supine position with no leg to arm connection. Sled pushing more closely emulates the demands place on our spinal stabilizers during daily activities.
In sports performance, the development of acceleration—the first four or five strides– is critical. Weight room training with box jumps, barbell squatting, and hang cleans has been shown to produce better vertical leap numbers, but not nearly the same gains in 40 yard dash times. Sled pushing places the body in the forward lean position you need to properly accelerate out of the blocks when sprinting. It trains the neural pathways that turn on your acceleration muscles.
The Road to Easy Recovery
Sled pushing is all concentric muscle activity and no eccentric. Eccentric muscle activity, the muscles lengthen against a resistance, creates much of the muscle soreness brought on by exercise. Your body needs more time to recover from eccentric muscle activity. You can perform a greater volume of work with a sled, and not be terribly sore the next day. For older trainees, whose bodies require more recovery time, sled work is a valuable training tool.
The Injured Athletes Rehab Training
If you have a knee, lower back, or hip injury you may not be able to perform squats, lunges, deadlifts, or kettlebell swings. Sled pushing is an alternative rehabilitation exercise for the lower body. I have had great success treating runners with knee pain using sled work as a recovery exercise. The core stability demands of sled pushing are helpful in restoring lumbar function in lower back pain patients.
Scalable to Any Fitness Level
Beginners can start with an empty sled and gradually add weight. I have been able to progress physical therapy patients from 25 pounds to 125 pounds in as little as four week’s time. Pushing is a very primal movement pattern, so most people catch on after two or three attempts.
Michael S. O’Hara, P.T., OCS, CSCS
TEST FOR SUCCESS
Easy Answers With The Y Balance Test
We are always looking for better ways to measure our physical therapy patients’ progress. You want to know if the treatment you prescribe is producing positive changes in the patients’ pain and functional mobility. You want to be able to identify weaknesses and focus efforts on the most significant problems. One of the best functional assessment tools is the Y Balance Test.
The Y Balance Test is a stance platform with three moveable reach boxes. Each box travels along a measuring stick. The patient stands on the platform and with the opposite foot, pushes the reach boxes down the measuring stick. A successful test involves reaching as far as possible and then successfully returning to a stable single leg stance position.
Measurements of the distances the patient was able to reach are recorded. Comparisons are made between the right and left legs. As the patient moves through therapy, he or she can be reevaluated on the Y Balance Test to measure the success of treatment intervention. A great effort is made to train away any asymmetry in reach distances between the right and left leg. Asymmetries in reach scores are correlated with greater incidences of future injury.
The Y Balance Test is a true measure of how we use our legs. Most activities of daily living and nearly all sports are all about single leg control. Unfortunately, most clinical tests look at only one joint segment, in non weight bearing positions. The Y Balance Test gives the clinician and patient a real world assessment of the interactive function of the foot, ankle, knee, hip, and torso in a standing position.
Patients like the test because it is easy to understand and gives them a clear training goal. The Y Balance Test takes minimal time to perform and patients do not have to be strapped into a machine or tethered to a computer. Patients often report that as their scores improve, they notice a decrease in pain.
Y BALANCE TEST
Research proven: Repeatable and reliable.
True measure of real world lower extremity function.
Easily understood scoring system.
Michael S. O’Hara, P.T., OCS, CSCS
GET IN YOUR CAGE
Stretch Station Mobility Restoration
Invented by Gary Gray, a physical therapist from Adrian Michigan, the Stretch Station has been a primary piece of equipment at all of our facilities. It enables the physical therapy patient or fitness client the ability to perform three dimensional mobilization of the major peripheral joints and spine. I have not found another piece of exercise equipment that is as beneficial for improving movement as the Stretch Station.
It Has To Happen In Standing
The Stretch Station allows you to mobilize joints and move in the anti-gravity, standing upright position that it functions in every day. Gravity eliminated, floor stretching programs often fail to produce better movement when gravity comes back into play. Any new movement you develop with mobility training is only beneficial if it can occur in a standing position.
A Little Lift Goes a Long Way
Traction force (pulling apart) of a joint is a key component of all manual medicine. It helps relieve pain and makes greater joint mobility easier to achieve. The overhead bars of the Stretch Station enable you to lift up and partially decompress the spine, hips, knees, and even ankles during mobility training. This low level traction force assists in the development of better mobility. Deconditioned and overweight patients can perform hip and knee mobility training and remain pain free with the assist of the Stretch Station.
One Good Turn…
Most floor mobility training does little to develop better rotation at the joints that are supposed to produce
rotation–thoracic spine, hips, and ankles. The Stretch Station has an angled floor and multiple handle sites that enable users of all sizes to work on improving rotation. Thoracic spine and hip mobility work is particularly beneficial for athletes that must swing a club or throw a ball.
Identification of Asymmetries
Using the Stretch Station, patients and fitness clients can immediately identify when one side of the spine, one hip, or one shoulder is more restricted than the other. Training away asymmetries at a single joint or movement pattern is important for injury prevention and optimal performance.
A Bridge to Better Performance
I have fitness clients perform thirty seconds of mobility training on the Stretch Station followed by a complimentary strengthening exercise. The idea is to neurologically reinforce the new motion achieved with the Stretch Station using an appropriate strengthening activity. This pairing of the Stretch Station work with a strengthening drill has been very effective in restoring movement and decreasing pain.
Michael S. O’Hara, P.T., OCS, CSCS
GETTING THE ARROW OUT OF YOUR HEEL
Physical Therapy Treatment of Achilles Tendonitis
Tom started having pain in the back of his left heel after working out at the gym. He had no pain while exercising, running, or water skiing, but symptoms would occur later in the day. By the end of the summer, he was unable to walk a round of golf secondary to heel and lower leg pain. Tom was treated by his family physician with medications and rest, but the pain did not go away. He received two injections in the Achilles tendon that temporarily relieved his pain, but symptoms returned in two or three weeks. Tom was referred by his podiatrist to Fenton Physical Therapy for treatment of his Achilles tendonitis.
The left Achilles tendon was sensitive to pressure, and Tom had a build up of scar tissue in the middle of the tendon. His left ankle dorsiflexion range of motion (ROM) was half that of his right ankle. He had pain in his heel and the back of his left lower leg with attempting to rise up on his toes and with squatting. His physical therapy treatment consisted of ASTYM and a program of home stretching drills he performed three times a day. After six sessions, the pain was gone and left ankle active ROM was full range. Four months after discharge, Tom reports that he has been pain free and continues with his daily stretching exercises.
Inflammation and scarring in the Achilles tendon can be a debilitating and difficult problem to deal with. Over the last few years, aggressive conditioning programs involving repeated box jumps and obstacle course type races have brought more Achilles tendonitis cases to our physical therapy clinics. Achilles tendon problems often flare up and then go away with rest and icing. The repeated cycle of trauma and recovery results in a non-flexible scarring of the Achilles tendon. This is believed to be the precursor to a more traumatic Achilles tendon rupture. At our physical therapy clinics, we have found great success with the Augmented Soft Tissue Mobilization (ASTYM) method. ASTYM treatment consists of twice weekly treatment with specialized tools to aggressively mobilize the scar tissue that develops on the Achilles tendon and “kick start” the healing process. This approach encourages the patient to be active and engage in a functional stretching program instead of immobilizing and resting the lower leg. The ASTYM tools allow greater intensity and accuracy with manual therapy treatment of the lower extremity. The patient generally participates in eight sessions of therapy and is instructed on a home regimen of mobility exercises.
Fenton, Linden, and Milford Physical Therapy all utilize the ASTYM treatment technique. Fenton Physical Therapy was the first clinic in Michigan to offer the ASTYM method. We continue to bring our patients the most innovative and up to date Physical Therapy care.
Michael S. O’Hara, P.T., OCS, CSCS