Much of the recent research has suggested that it is best to warm-up prior to exercise to decrease risk of injury, deviating from the previously accepted practice of stretching. Mike Reinold's recent post discussed some of the disparities between the more recent and older research on the topic. One of the major factors brought up is that stretching less than 30 seconds is not associated with increased injury risk. In fact, stretching longer than 30 seconds is okay as well if combined with some form of dynamic exercise. The question of "why" arises. As we've discussed before, a stretch only changes tissue length after 30 seconds of static hold. In school, we were taught that when stretching, we should proceed to strengthen in the newly acquired range. This is important so that we can maintain that range and have control over the joint. Without strengthening/neuromuscular training in the new range, the joint loses stability. We really shouldn't be trying to increase muscle length prior to any competition, especially since the muscles/joints are weak at those points. Our theory is that stretching less than 30 seconds or combining stretching with dynamic exercises activates or maintains some neuromuscular tone/reflex that protects the joint in end range by decreasing perceived stiffness. Fatigue has been shown to play a role in stretch reflex inhibition, thus decreasing performance (Ross et al, 2001). Just as concerning, prolonged passive stretches have been shown to an effect on the tendinous tissue, such as stress relaxation and plastic deformation (Avela et al, 2004). By keeping stretches under 30 seconds or adding dynamic exercises, this protective reflex is not lost. Many PT schools teach that ballistic stretching can be hazardous to the tissue, but with these findings, do you think that type of exercise actually does have a role in performance enhancement/injury prevention?
Avela J, Finni T, Liikavainio T, Niemelä E, Komi PV. (2004). Neural and mechanical responses of the triceps surae muscle group after 1 h of repeated fast passive stretches. J Appl Physiol. 2004 Jun;96(6):2325-32. Web. 11 Aug 2013.
Avela J, Kyröläinen H, Komi PV. (1999). Altered reflex sensitivity after repeated and prolonged passive muscle stretching. J Appl Physiol. 1999 Apr;86(4):1283-91. Web. 11 Aug 2013.
Chalmers G. (2004). Re-examination of the possible role of Golgi tendon organ and muscle spindle reflexes in proprioceptive neuromuscular facilitation muscle stretching. Sports Biomech. 2004 Jan;3(1):159-83. Web. 11 Aug 2013.
Ross A, Leveritt M, Riek S. (2001). Neural influences on sprint running: training adaptations and acute responses. Sports Med. 2001;31(6):409-25. Web. 11 Aug 2013.
The average adult breathes 12-20x/minute, which accounts to over 20,000 breaths/day. Ideally, the diaphragm is the major muscle of inspiration. When abnormal breathing patterns develop, accessory muscles (scalenes, SCM, upper trapezius, pectorals) are forced to be used more. In other words, these muscles have the potential to be used improperly >20,000x/day. Scary right?!
While various breathing pattern abnormalities exist, a commonly seen pattern is the "chest breather." The chest breather does not fully engage his/her diaphragm and often has decreased lung volumes. These patients often incorporates their anterior accessory muscles of inspiration which can pull them into a forward head and rounded shoulder posturing: a posture we see in many of our clients. Their imbalances go deeper than what is seen by observation alone. Because the chest breather has decreased lung volumes, he/she may be in a constant sympathetic state to supply sufficient oxygen to the bodies tissues. Consequently, they may have increased muscle tone, anxiety, and a variety of other PNS and CNS symptoms. In a post written by Mike Reinold in late April, he highlights two studies that show the importance of proper breathing. One study interestingly discovered increased EMG activity of the scalene and trapezius muscles while typing. As students, who spend most of their day at a computer, this is something to consider. This could be contributing to neck pain and stiffness that so many students have. Additionally, breathing exercises maybe a good place to start for your sedentary office worker with chronic neck pain.
Reinold also mentions several treatment strategies to initially assess breathing technique:
1. Breath Holding Test. Decreased breath holding my demonstrate an intolerance to CO2 build-up.
2. Belly/Chest Test. Have the patient place one hand at their naval and their second hand at the sternum. Assess which hands moves further. Is there a change is sitting vs. supine? With a deep breath, ~90% of motion should come from the lower hand, indicating good diaphragmatic breathing. This test can later be used as an intervention. It is a simple way to provide external cueing to the patient to activate their diaphragm.
3. Seated Lateral Expansion. Have the patient place a hand on either side of their thorax. Take a deep breath in and feel for rib movement symmetry. Again, if one side is moving differently than the other, hand cueing + manual facilitation can act as a good treatment intervention early in the POC.
Below is a basic video demonstrating diaphragmatic breathing:
Here are 2 other good resources we found off Dr. E's website (The Manual Therapist) on breathing:
1. 5 Techniques to try with Diaphragmatic breathing
2. Assessment and Treatment for Diaphragmatic Breathing by: SPT Fred Charles
Thanks Mike Reinold and Dr. E for the great posts!
Mike Reinold recently had a post about the sleeper stretch - a stretch that is commonly prescribed to increase glenohumeral internal rotation ROM. Mike discusses how the sleeper stretch actually is more likely to stretch the posterior capsule. With the frequency instability is seen in the clinic, increasing that instability with capsular stretching should not be a goal of ours. In fact, if you take a step back you might realize that the sleeper stretch looks very similar to the Hawkins-Kennedy Impingement test (just on it's side). Any time an exercise is the same motion as a provocative test, we should rethink the reasoning behind that exercise, especially with how overly aggressive patients can be with this particular exercise. Finally, Mike also discusses the instances where the sleeper stretch may actually be appropriate (young athletes that don't have anyone to stretch them and people that truly have posterior capsule tightness) and provides a video/explanation of how to properly perform the motion, along with alternatives to the exercises. Check it out!
We do not frequently see patients until pain is an issue; however, that does not mean that everyone with pain-free motion is without dysfunctional movement. In fact, it's probably safe to say that most people without pain are lacking normal mobility/stability somewhere in their bodies. In Gray Cook's latest post, he discusses the adaptations our bodies make given certain activities in which we regularly engage and how we might not want to be so eager to correct these dysfunctional patterns. An example he uses is a common one: tight hamstrings in runners. He reasons that our bodies change to best perform the repetitive task. The body is used to functioning with limited hamstring length, and in a way, relies on those restrictions for stability. If we suddenly choose to alter that restriction, we open up the body to new motions and stresses for which it is not prepared. In the example of the runner, yes we want to stretch those tight hamstrings, but we must also include stability training in that new range! Check out Cook's post for more detail on the topic.
So how do we address these differences? Shirley Sahrmann discussed this topic in a lecture that we highly recommend listening to. Instead of focusing on the side with increased stiffness, we should address the side with decreased stiffness. Strength training has been found to increase muscle stiffness (Magnusson, 1998). By bringing both sides of the body to symmetry (equal stiffness), an equal distribution of forces prevents any abnormal stresses on the body. Stretching still has its place, of course, but we must be sure to distinguish between muscle stiffness and adaptive shortening when choosing to apply the intervention. Next time you're measuring muscle length, check for stiffness and muscle length!
Magnusson SP. (1998). Passive properties of human skeletal muscle during stretch maneuvers. A review. Scand J Med Sci Sports. 1998 Apr;8(2):65-77. Web. 10 June 2013.
Mizuno T, Matsumoto M, Umemura Y. (2013). Decrements in Stiffness are Restored within 10 min. Int J Sports Med. 2013 Jun;34(6):484-90. Web. 10 June 2013.
Mizuno T, Matsumoto M, Umemura Y. (2013). Viscoelasticity of the muscle-tendon unit is returned more rapidly than range of motion after stretching. Scand J Med Sci Sports. 2013 Feb;23(1):23-30. Web. 10 June 2013.
There are various types of stretching techniques: sustained, ballistic, proprioceptive neuromuscular facilitation (PNF), etc. They have the common goal of increasing musculotendinous length. Before considering which type is best, we must consider the properties of muscle. Muscles are composed of viscoelastic characteristics that can be influenced by stretch. The elastic component refers to the fact that a muscle has built in memory of it's original length. Just like the elastic part of your socks, given a temporary stretch, a muscle (or sock) will contract back into its resting length. That being said, with proper technique, a more permanent (or plastic) change in muscle length can be achieved. One of these techniques is a sustained stretch. But how long do we hold this stretch? In a classic study by Bandy & Irion, the researchers examined the difference in muscle length over time period of 6 weeks following sustained stretching programs based on time periods of 15, 30, and 60 seconds. A control group of no stretching was also followed. The study had several interesting findings. No significant differences in muscle length were found between the no stretching group and 15 second stretch group. This begs the question, what is the point of wasting time on a 15 second stretch, if there are no lasting effects. The results also found that significant gains were achieved with both the 30 second and 60 second groups, but minimal increase was found for the 60 second group. This means there isn't really a point of holding a stretch for 60 seconds either. The impact of this study displays the importance of reinforcing 30 second holds for stretches during a HEP. We often see our patients say they are holding a stretch for 30 seconds when in reality they are counting to 30 practically in one breath. It's no wonder they aren't seeing changes!
As we mentioned before, there are several different methods of stretching with the most common being ballistic, sustained, and PNF. Ballistic stretching is not usually performed or recommended by health care practitioners due to its link to injury. The theory of ballistic stretching is to exceed the normal constraints of the muscle in order to achieve length increases, which suggests damaging the muscle. In regards to deciding between PNF and sustained stretch, there is still ongoing debate as to which obtains better results. O'Hora et al performed a study that looked at the immediate effects of 1 bout of PNF versus sustained stretch versus no stretch. The PNF stretch was a contract-relax maneuver of the hamstrings for 6 seconds. They found both PNF and sustained stretch to have significant changes in length following 1 bout. PNF changes were found to be greater than sustained. In the discussion, the authors reviewed the discrepancy in the literature regarding differences between PNF and sustained stretches, reminding the readers that there are many studies that have found each to be more effective than the other. An obvious issue with this study was the fact that the authors only looked at immediate effects of stretch and did not examine long-term effects. What can be taken from these findings and the discussion is that both 30-second sustained stretch and contract-relax can result in increases in muscle length. The debate goes on in regards to which is more successful. A combination we like to use is 3 sessions of contract-relax at end range, followed by a 30 second sustained stretch.
Bandy & Irion. (1994). The Effect of Time on Static Stretch on the Flexibility of the Hamstring Muscles. Phys Ther. 1994 Sep;74(9):845-50. Web. 6 April 2013.
O'Hora J, Cartwright A, Wade CD, Hough AD, Shum GL. (2011). Efficacy of Static Stretching and Peripheral Neuromuscular Facilitation Stretch on Hamstrings Length after a Single Session. J Strength Cond Res. 2011 Jun;25(6):1586-91. Web. 6 April 2013.
This is part 1 of Dr. E's blog post on treatment options to improve the overhead deep squat. Many components are involved in the deep squat which makes understanding the true cause of an inadequate performance difficult. The motion requires adequate hip extensor length, thoracic extension, ankle dorsiflexion, stability of the scapulothoracic musculature, and more. Both mobility and stability must be present in order to successfully complete the movement. With adaptive shortening of the hip extensors (especially the hamstrings), you often see difficulty maintaining proper lumbar position, leading to an excessively forward flexed torso. Thoracic extension and shoulder mobility combined with scapulothoracic stability are crucial for maintaining an upright posture while descending into the deep squat. Again, a deficit in this area often involves a forward flexed torso. Ankle dorsiflexion is necessary to prevent heel rise during the deep squat. We often see an adjustment for this in the FMS using the 2x6 wooden board to bring the ground up to the heels. Core stability is an obvious necessity as it contributes to maintaining proper posture during the movement. The components required for completion of the movement go on, but these are some common impairments.
Dr. E outlines 5 treatment options:
1. Thoracic spine manipulation to help improve thoracic mobility and glenohumeral motion.
2. Subscapularis Release for shoulder mobility.
3. Psoas Release: He demonstrates a great new video on a new psoas technique that is much less invasive and utilizes the principles of the neurophysiological effects of muscle tone.
4. IT Band Release using the edge tool to help increase hip mobility
5. Tibial Internal Rotation Mobilization with Movement for both knee and ankle mobility. He describes how the lower leg often is put into relative external rotation due to hip weakness, medial rotation of the femur, and pronation of the foot.
He demonstrates each of these techniques with good clarity. Although he is using these techniques in relation to the overhead deep squat, you can see how they would apply to any patient with deficits in that region.
Similar to the Core Muscle Activation article we posted earlier, this research report demonstrates which exercises elicit the best muscle activation during therapeutic exercises. It also has good visual demonstrations of each exercise.
A few highlights:
-Sidelying Hip Abduction elicited the greatest Gluteus Medius activation, followed by Single Limb Squat and Lateral Band Walking.
-Single Limb Squat and Single Limb deadlift promoted the greatest Gluteus Maximus Activation.
-Notice the relatively low Glutues Medius Activation the Clamshell Exercise at 30 degrees and 60 degrees Hip Flexion despite being one of the most used Gluteus Medius strengthening exercises we have seen in the clinic. Looking at the graphs in the article, you can also find several other exercises that are much more functional than the clamshell.
Keep in mind how you would progress each of these ex
It has been estimated that Plantar Fasciitis occurs in approximately 2 million people and can account for between 8% and 15% of all foot pain complaints. While the term "-itis" is often associated with inflammation, there is growing evidence that there might not be an inflammatory state, but rather a degenerative process occurring in the plantar fascia. Because of this growing belief, authors are saying a more appropriate term would be "plantar fasciopathy" or "plantar heel pain."
Plantar heel pain is best described as a sharp pain in the patient's rear foot that is worse in the morning (usually the first step out of bed) and at the beginning of a weight bearing activities. The pain typically lessens with continued activity, but often increases toward the end of the day. Individuals most susceptible to developing heel pain are middle-aged women, obese individuals, athletes, and runners. Clinically, you will see excessive pronation and a depressed longitudinal arch in many of these clients. Some extrinsic factors contributing to the pathology include training surfaces, shoe wear, and poor training methods. Understanding the anatomy makes it clear why this population is at an increased risk. The plantar fascia runs from the medial tuberosity of the calcaneus and inserts into the metatarsophalangeal joints, the proximal phalanges, and the flexor tendon sheaths. The fascia is responsible for supporting the longitudinal arch of the foot and assisting in dynamic shock absorption. The attachment of the plantar fascia to the medial calcaneal tuberosity explains why patients often experience pain upon palpation of that area.
Diagnosis of plantar fasciopathy is often made on a clinical basis. Due to degenerative changes and tendon thickening, the diagnosis may be made with an ultrasound as well. Current treatment methods include rest, modalities, stretching, strengthening, manual therapy, splinting, orthotics, surgery, and more. New research is constantly being published due to the high incidence of the injury. This review will take an in depth look at several of the available treatment techniques for plantar fasciopathy. Many of the studies we looked at included strengthening and stretching in the treatment plans along with some other intervention. Improvement was often shown in both groups, but we were unable to find any studies that specifically looked at one type of strengthening exercise compared to another. Some of the most common barefoot exercises seen in the clinic include towel scrunching and picking up marbles. Due to the biomechanical theory of the plantar fascia aiding in the support of the medial arch, it would seem logical to include strengthening of the posterior tibialis in rehabilitation. The posterior tibialis is the prime muscle for raising the medial longitudinal arch and can take stress off the plantar fascia. As noted in our previous posts, the exercise to most effectively activate the posterior tibialis is resisted forefoot adduction.
A study we looked at compared the effects of stretching and orthotics vs. e-stim, stretching, and orthotics. Both groups improved, but there was not difference between the two groups, so e-stim appears to have no additional benefit.
With the recent boom in barefoot running, there has been a movement to begin incorporating barefoot or minimalist exercises/training into rehabilitation of plantar fasciitis. The theory involves placing increased forces on the intrinsic muscles of the foot, so that they can be retrained to support the arch and take stress off the plantar fascia. A study we looked at how the addition of Nike Free 5.0 shoes could affect the patients' complaints. The Nike Free 5.0 shoes offer a flexible midsole that somewhat mimics barefoot training. In the study, two groups were assigned an exercise protocol that involved balance training, stretching and strengthening exercises. One group wore conventional shoes, while the other wore the Nike Free 5.0 shoes. At the end of the study, both groups had a significant decrease in pain, the Nike Free 5.0 shoes more so. Due to the poor design, the results of this study must be looked at closely. At 24 participants, it was a small sample size and there may have been a psychological effect, since the Nike group received new shoes, while the conventional group used old shoes. Along with other factors, it is not clear if minimalist shoes can enhance rehabilitation for individuals with plantar fasciitis. It would be interesting to see the effect of more minimalist-type shoes (New Balance Minimus, Vibram Five Finger, etc.) could have on therapy in a properly done study.
One of the more common interventions that is performed is stretching. A study we looked at compared the results of the standard achilles tendon stretch to a sitting plantar fascia stretch. For the plantar fascia stretch, the patient would cross his/her legs and place the affected foot on the opposite knee. The patient then grasps the toes (especially the big toe) and maximally dorsiflexes them until a stretch is felt in the foot. In the study, the patients would perform their stretch first thing in the morning and before getting up after sitting for awhile. The study found both interventions to be successful, but the plantar fascia specific stretch more so. It should be noted that the study had no true control to rule out the patients' improvements due to natural healing processes.
Dry needling is still a limited treatment technique for physical therapists; however, patients can have access to acupuncture on a wider basis. One article compared two groups to see the effect of acupuncture on plantar fasciitis. Both groups received standard treatments, such as icing, stretching, intrinsic foot strengthening, and NSAIDs. One group received acupuncture, additionally. Both groups found improvements in pain. There was no difference between the two groups after 4 weeks, but the acupuncture group was slightly better after 8 weeks.
A treatment technique that is gaining popularity involves Instrument Assisted Soft Tissue Mobilization (IASTM). There are many products out there that fall under the category of IASTM: Graston Technique, ASTYM, Edge Tool, etc. The theory is generally the same behind them in that, through use of the tools, a healing inflammatory phase can be initiated by stimulating blood flow, nutrients, and fibroblasts to the area. Through proliferation of the fibroblasts, healing and formation of collagen can begin. The soft tissue mobilization can additionally aide in reorganization of the collagen fibers to proper orientation. This study in particular was a preliminary look at Graston Technique, discussing the theory, protocol, initial evidence, and some case studies. As plantar fasciitis is a soft tissue pathology, IASTM could have useful implications for patients with this disorder. When further research is performed on the subject, it may be found that IASTM has a very important place in treating these patients.
Abd El Salam MS, Abd Elhafz YN. "Low-dye taping versus medial arch support in managing pain and pain-related disability in patients with plantar fasciitis." Foot Ankle Spec. 2011 Apr;4(2):86-91. Web. 10/13/12.
Bassford, Jeffrey. "A Randomized Controlled Evaluation of Low Level Laser Therapy: Plantar Fasciitis." Arch Phys Med Rehabil. 79. (1998): n. page. Web. 8 Oct. 2012.
Beyzadeoğlu T, Gökçe A, Bekler H. "[The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis]." Acta Orthop Traumatol Turc. 2007;41(3):220-4. Web. 10/13/12.
Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. "Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up." J Bone Joint Surg Am. 2006 Aug;88(8):1775-81. Web. 10/12/12.
Hammer, WI. "The effect of mechanical load on degenerated soft tissue." J body Mov Ther. 12.3 (2008): 246-256. Web. 8 Oct. 2012.
Hyland, Matthew. "Randomized Control Trial of Calcaneal Taping, Sham Taping, and Plantar Fascia Stretching for the Short-term Management of Plantar Heel Pain." Journal of Orthopaedic and Sports Physical Therapy. 36.6 (2006): n. page. Web. 8 Oct. 2012.
Karagounis P, Tsironi M, Prionas G, Tsiganos G, Baltopoulos P. "Treatment of plantar fasciitis in recreational athletes: two different therapeutic protocols." Foot Ankle Spec. 2011 Aug;4(4):226-34. Web. 10/13/12.
Lee SY, McKeon P, Hertel J. "Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis." Phys Ther Sport. 2009 Feb;10(1):12-8. Web. 10/10/2012.
Renan-Ording, Romulo. "Effectiveness of Myofascial Trigger Point Manual Therapy Combined with a Self-stretching Protocol for the Management of Plantar Heel Pain: A Randomized Control Trial." Journal of Orthopedic and Sports Physical Therapy. 41.2 (2011): 43-51. Web. 8 Oct. 2012.
Ryan, M, S Fraser, K McDonald, and J Taunton. "Examining the degree of pain reduction using a multielement exercise model with a conventional training shoe versus an ultraflexible training shoe for treating plantar fasciitis." Phys Sportsmed. 37.4 (2009): 67-84. Web. 10 Oct. 2012.
Stratton M, McPoil TG, Cornwall MW, Patrick K. "Use of low-frequency electrical stimulation for the treatment of plantar fasciitis." J Am Podiatr Med Assoc. 2009 Nov-Dec;99(6):481-8. Web. 10/13/12.
Tendinosis, Tendonitis, Tendinopathy... what is the correct term? This article written by Mark Reinking critically analyzes the tendon structure and it's response to exercise.
Abstract: Overuse related tendon pain is a signiﬁcant problem in sport and can interfere with and, in some instances, end an athletic career. This article includes a consideration of the biology of tendon pain including a review of tendon anatomy and histopathology, risk factors for tendon pain, semantics of tendon pathology, and the pathogenesis of tendon pain. Evidence is presented to guide the physical therapist in clinical decision-making regarding the examination of and intervention strategies for athletes with tendon pain.
-Human tendons demonstrate minimal hysteresis. Most stored elastic energy is released when the tensile load is removed.
-The degradation of collagen that happens after exercise is greater than the increase of collagen synthesis that occurs.
-There is an up-regulation of Vascular Endothelial Growth Factor (VEGF) in pathological tendons. VEGF factor stimulates neovascularization. This process decreases collagen strength and creates micro-tears.
-Some new evidence supports eccentric strength training in the management of non-insertional achilles tendinopathy, patellar tendon pain, supraspinatus tendinopathy, wrist extensor tendinopathy, and posterior tibial tendinopathy (check out some of our previous posts on the topic!).
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