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Knee

Heads Up

The Downside Of Upside Down Exercise

H_HoudiniExercise 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.

Esophageal Reflux
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.

Bottom Line
Apart from going blind, having a stroke, and developing an incurable cancer, you should be fine.

Michael S. O’Hara, P.T., OCS, CSCS

The Lunge No One Loves

The simple drop lunge is an exercise that will improve your hip mobility, enhance athletic performance, and reduce the chances of injury to the knees and lower back.  The drop lunge trains a movement pattern you have to perform in nearly every sport.  To play tennis, basketball, or even bowling, you must be able to efficiently cross the one leg back and behind the other leg.

The reason most people do not utilize the drop lunge is that it requires consistent practice, a degree of single leg balance, and lots of hip mobility to achieve any level of proficiency.  It is not a muscle isolation, bodybuilding type exercise, so you will not find it highlighted in Mega Muscle magazine.  The more you struggle with the drop lunge, the more you need to include this essential movement pattern in your training program.

In physical therapy, we use the drop lunge with most of our lower extremity patients.   In programming for fitness clients, I use the drop lunge as a movement preparation drill and rarely add extra resistance.  The drop lunge can be loaded with a medicine ball, barbell, or with a pair of dumbbells.

Drop Lunges
Stand with the feet at shoulder width.  Step with the right leg behind the left leg and drop into a squat position.   How far you lunge across with the right leg will depend on the length of your legs and your mobility.  The heels will be off the ground and you will have to come up onto the balls of your feet.  Keep the torso tall and the abdominal muscles braced.   Return to the starting position.   Perform the next repetition with the left leg reaching behind the right.  Alternate legs and perform five on each side.   If you find one side is more proficient than the other, perform extra repetitions on the limited side in an effort to train away the movement asymmetry.

Common Mistakes:
Keeping the front knee too straight and failing to perform a full lunge,  losing your balance,  allowing the torso to fall forward,  looking down at the floor.

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.

No Squishy
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.

Training Acceleration
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
Functionally relevant.
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

 

SINGLE LEG STANCE OPPOSITE
 ARM REACH AND ROW

A Long Name For A Great Exercise

In life, most of the challenging tasks happen in either single leg stance or with much more of our weight on one leg.  We must be able to support, decelerate, and change directions with one leg.  Our muscles are aligned so that the hip is mechanically linked to the opposite shoulder.  In physical therapy, we know that having one side of the body function efficiently and the other side falter sets you up for injury.  Your exercise program should revolve around training to meet these physical demands.  One of my favorite life enhancing exercises is the single leg stance opposite arm reach and row.   

Exercise Benefits
Fall preventative activity that helps improves single leg balance.
Sure cure for the epidemic of gluteal amnesia.
Gives athletes the hip to opposite shoulder connection they need for performance.
Identifies any asymmetry in single leg control.
Enhances the single leg deceleration skill necessary for injury prevention.
Makes you stronger when you lift, carry, push, and pull.

Single Leg Stance Opposite Arm Reach and Row
You need a cable column machine or resistance tubing anchored at knee level or lower.  Hold the tubing or cable handle in the right hand and stand on the left leg.  You must be at least five feet away from the attachment point of the tubing or cable.  Initiate the movement simultaneously at the ankle and hip and reach forward with the right hand.  Attempt to get the hand down to knee level.  Return back to standing and pull the handle toward the body in a rowing motion.  Perform five to ten repetitions and then repeat on the other side.

Common mistakes are bending at the hip only and slouching over at the spine.  The ankle, knee, and hip all move together, and the spine should stay stable.  Holding the handle on the same side instead of the opposite side.  Performing repetitions past the point of technical failure.  If you start wobbling around, stop the exercise.  Getting the arm and legs out of sync.  Do not reach with the arm and then move the legs—the motions should happen together.  Remember to come all the way back up to a tall standing position before starting the next repetition.  Start with light resistance and try to create a steady smooth pattern before adding more resistance.  Watch the video  and give this exercise a try.  

Michael S. O’Hara, P.T., OCS, CSCS

THE WALL SQUAT

Turn Around And Improve Your Squat Performance

For most people, wall squats are an exercise that involves placing your back against the wall (or on a physioball placed against the wall) and performing squats with a supported torso.  The assistance from the wall permits you to stay up taller and shifts much of the workload onto your quadriceps.  While this exercise will make the muscles in the front of your thighs burn, it does little to improve your mobility or strength.  My advice is to turn around and face the wall to develop better squat mechanics, balance, and functional mobility.   

The ability to perform a full squat is an important basic movement pattern.  The overhead squat is one of the seven critical tests in the Functional Movement Screening process used to assess an athlete’s readiness to compete.  Squatting is a basic mobility pattern that is important for long term independent living, a healthy lumbar spine, and a calorie hungry metabolism. The restoration and preservation of the ability to move through a proper squat pattern should be a part of every fitness program.

As infants, we mastered a full, steady squat.  A baby must develop control of the squat in order to progress to the next level of mobility–standing and walking.  Prolonged sitting, weakness in the muscles that stabilize the pelvis, and the lack of basic spinal and hip mobility in daily activity restricts our ability to move into this basic pattern of movement.  Add in some well meaning but mobility reducing fitness activity and you produce an environment that fosters immobility.

Wall Squatting 101
The wall serves as instant feedback to prevent most mistakes.  If you let the knees collapse inward, slouch over at the spine, or lean the head forward ,you hit the wall and are unable to descend any further.   

Face the wall and position the toes twelve inches away from a wall.  The toes should point out no more than thirty degrees.  A mirror that provides a side profile can be helpful for visual feedback on your performance.  The basic wall squat starts with the hands placed across your chest or out to the side of your shoulders.  Push the hips back and lower into the squat.  The wall keeps your posture tall and forces the knees out.  If you find the wall squat difficult, then you need to perform it often and improve you performance.  Start with three or four sets of five to ten repetitions.

As your mobility improves, simply move closer to the wall.  Holding the hands behind the head or holding a band overhead increases activation in the thoracic spine and shoulder girdle muscles.  You can add resistance by holding a kettlebell suspended from both arms.  Watch the video that accompanies this article.  

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

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