Brian Schiff’s Blog

So, I was meeting with a 14 y/o soccer player referred to me by a physical therapist today who is need of sports performance conditioning (return to play) work after a lateral release.  This talented female athlete suffers from a shallow trochlear groove, thereby making her more prone to patella subluxations.

Such an incident led to two recent surgeries and nearly a year away from the soccer field.  She has returned to soccer, but has been referred to me for prevention and performance work.  I have been thinking about her program, history and all the athletes I have trained in recent memory with knee problems.

I also recall reading an email this weekend from a past intern asking me if there was a single leg training certification out there as she saw me do so much of it at my facility.  These thoughts lead me to my post today.  If you are a jumping, cutting or competitive athlete using your legs to perform, you should absolutely be integrating single leg training into your conditioning programs.

Why, do I say so?  The answer is rather simple in my mind.  The human body is often out of balance.  The brain is so adept at mastering movement, it learns to compensate for even the slightest deficits on one side.  Over time, you end up grooving improper motor patterns and these tend to lead to small imbalances or even overuse issues.

Ever hear about stretch weakness or adaptive shortening?  Maybe you are familiar with the terms overactive and under active muscles?  Regardless, I can assure you that at any given moment, your body may be susceptible to these patterns.

 Through a poper single leg assessment, I see many issues come to light that may otherwise be hidden with two legged squats, lunges, leg press, etc.  Let me go back to the young lady sitting in my office this morning.  She has bilateral shallow trochlear grooves, yet only one knee to date has given way.  Why so?  Will the other one follow suit?

There is no way to definitively predict if her other knee will become problematic.  But, my hunch is there were some single sided imbalances that may have led to her current injury history.  It is now my job to try my best to prevent such an episode on her other knee, as well as make sure she does not have issues on the surgically repaired side.

Anything short of a program heavy on single leg work would be a mistake for her (and many others like her).  You see, we often reinforce imbalances and poor technique with heavy squatting, lunging and dead lifts seen in traditional programs.  I am not oppose dot these lifts – in fact they can be great for strength and power development.

However, we MUST address and correct the single sided imbalances first.  We must also always include some single leg strength work with our athletes to ensure there is no asymmetry developed unknowingly.  Most athletes compete using their own body weight.  We must train in such a way that we foster control, power and mastery of movement with each limb.

This focus and approach will be most helpful in reducing injuries like ankle sprains, ACL tears, muscle strains and common overuse issues in the lower extremity.  So, next time you think about performance training, I want you to consider the importance and relevance of single leg training.  No program is perfect.  But, I will tell you my track record is pretty solid with prevention, performance and return to play training I have done that relies heavily on this approach to conditioning.

Stay tuned as later this week I will unveil my latest DVD as well as review how traction with footwear affects lower limb joint loading.

Core training is common terminology thrown around in fitness circles today.  However, not much research has specifically addressed more advanced stability ball exercises and muscle activation until now.

A recent article released in the May 2010 Journal of Orthopedic & Sports Physical Therapy looked at 8 stability ball exercises and maximal voluntary isometric contraction (MVIC) versus traditional bent knee curl ups and crunches.

The 8 stability ball exercises studied with EMG were:

1. Roll out
2. Pike
3. Knee up
4. Skier
5. Prone hip extension left
6. Prone hip extension right
7. Decline push-up
8. Seated march right

Pike (end position)

All exercises were performed with a cadence of 1/1/1.  A metronome was used to ensure uniform repetitions and holds.  Researchers concluded that the pike and roll-out were the most effective exercises based on EMG activation.  However, keep in mind that these also require the greatest effort and pose a high degree of difficulty.

Why is this stuff important?  Research done by Cholecki and VanVliet concluded that no single core muscle can be identified as the most important for spinal stability.  Additionally, they believe that the relative importance of the muscle varies based on the direction and magnitude of the load imposed on the spine.

We have known for years the spine is least stable and most vulnerable in trunk flexion (as in the knee bent curl up), and that no one muscle contributes more than 30% to overall spine stability.  Choosing more demanding core exercises also typically increases spinal compressive forces as well.  This may be contraindicated in some populations.

Therefore knowing your client and condition is essential.  For example, flexion is often contraindicated with active disk pathology, whereas it may be indicated in those with facet arthropathy or spondylolisthesis.  Over the past decade or so, much attention has been placed on the transversus abdominus muscle. 

The prevalent thinking has been that it is a major contributor to spinal stability, although this is somewhat controversial and has not been unequivocally validated with science.  Another flaw here is that isolated contractions of it have not been demonstrated in higher level activities (e.g. sports). 

So, where is the functional tie in here?  The transeversus abdominus has shown similar activation patterns (within 15%) to the internal obliques with exercises similar to those in this study.  The highest activity from internal obliques was during the pike, roll-out, knee up, skier and hip extension left exercise.  This may indicate that transveresus abdominus activation is also high, but further research will need to be done.

The last critical piece of data involves looking at hip flexor activation as the psoas generates remarkable spinal compression and anterior shear forces at L5-S1.  This can be especially troubling for individuals struggling with lumbar disk pathology.  The exercise in this stud that demonstrated moderate hip flexor activation were:

• Bent knee sit-up
• Pike
• Seated march
• Hip extension exercises

So, if you or your client has a weak rectus abdominus and/or obliques or lumbar instability, these exercises may be contraindicated.  In the end, know that the stability ball provides much greater muscle activation compared to traditional bent knee sit-ups and crunches on the floor.  The caveat is identifying which ones are appropriate and most efficient in your case.

As a general rule, I suggest that you avoid long lever arm action with the legs in the presence of active disk pathology and instability.  You may opt for stability based exercises in a neutral spine position like planks as there is minimal shear and compressive loading here until clients develop more stability and strength.  With healthy and mroe advanced clientele, many of the stability ball exercises studied would be good alternatives to traditional crunch work to build muscle strength for the core.

Whether you are for or against running, its popularity is likely at an all time high.  People run to lose weight, stay fit, compete or simply escape from the stress of the world.  Unfortunately, running often brings injuries for its participants. 

So, what are the risk factors directly associated with injury?  Researches in the Netherlands recently performed a prospective study with 532 novice runners (306 females and 226 males).  The runners trained for a 4 mile event and were advised to run 3 times per week (Monday, Wednesday and Saturdays) at a comfortable pace.

They were randomized into 8 and 13 week training programs.  There was no difference in findings among the different training groups so they were counted as one for the puprose of the study results.  The results are interesting.  Risk factors for running related injuries (RRI) in males included:

1. Higher BMI
2. Previous injuries – those with previous injuries are 2.6 x more likely to suffer an injury
3. Type of previous sports activities – those participating in axial loading sports were less likely to be injured than those who participated in non axial loading sports (cycling and swimming for instance)

Predictors of RRI in females were:

1. Increased navicular drop – this in turn leads to increased pronation and femoral internal rotation thereby increasing the risk of developing medial tibial stress syndrome

Some hypothesize that limited joint mobility leads to injury with the repetitive nature of running as force is dissipated unevenly along the kinetic chain.  Interestingly enough, lack of range of motion in the ankle and hip were not found to be related to RRI in novice runners.  Type ‘A’ personality influence in terms of pain resistance was also ruled out as contributing to sustaining an injury in this study.

What are the takeaways here? 

• The key thing to see is that males and females have different risk profiles. 
• Males that carry more weight may be comparatively at a greater risk for injury than females. 
• Pronation and proper foot mechanics may be a bigger issue in females as they are much more prone to develop stress fractures
• Further research is needed to better predict female risk factors
• There are several limitations in this study such as: inconsistent training days, different running surfaces, different running speeds/intensity and weather to name a few

In my mind, it also further illustrates the need to fully rehabilitate injuries, prepare the body for events thru smart progressive axial loading and to target the hips with strength and power work in runners to better control femoral internal rotation and reduce ground reaction forces.

For more info, read the full article in the February 2010 edition of the American Journal of Sports Medicine.  Stay tuned this week, as I will review another running research article discussing the impact of slope (hill) running on the body.

Well, with Turkey Day nearly upon us, I am gearing up for a 4 miler on Thursday morning.  I have run 5Ks, 10Ks and half marathons, but this will be my first 4 miler.  They give you a bottle of wine at the end of this one so it is pretty popular in my neck of the woods. 

As I expand my own running and train more and more runners, I often find that many lack good single leg stability and hip strength.  If you are a runner and not doing any strength training or simply focusing on traditional machine-based exercise, you need to shift gears and incorporate single leg exercises to maximize performance and prevent injuries.

In today’s post, I am going to give you an excellent progression of single leg hip drives or lifts to improve stance leg stability, gluteus medius strength and swing leg hip flexor strength.  In addition, this exercise will improve knee stability and ankle proprioception thereby reducing excess tibial rotation/pronation along the way.  That matters if you have experienced IT Band issues or shin splints along the way.  The exercise sequence is as follows:

1. Single leg hip drive holds (3-5 seconds)
2. Supported single leg hip drive
3. Unsupported single leg hip drive
4. Unsupported single leg hip drive with resistance
5. Unsupported single leg hip drive (unstable surface)

You should progress through this sequence of training to ensure best results.  I suggest 1-3 sets of 10-15 reps of each sequence.  The unstable or most advanced version is suitable for cross country runners, runners with poor ankle stability (chronic sprains or hypermobile) or those with poor closed chain mechanics from the ground up.  I have included a few sample reps of these in the video below:

I hope you can put these exercises to good use.  They are great for increasing stance leg strength and stability, while simultaneously improving swing leg strength and mobility. Happy running and have a great Thanksgiving everyone!

I am often asked when is it safe to go back to play after an injury.  In most cases, I am dealing with lower body or back injuries with my athletes, so for the purposes of this post, I will address a lower body functional return to play paradigm.

The tricky part about this question is that no two injuries are created equal.  Sure, I will be the first to acknowledge that I have general approaches to certain injuries and have a sense of how long it should take most of the time.  But, over the past 13 years I have seen enough irregularity and differences to say that everyone heals and recovers differently.

For example, I have had athletes with a simple grade 1 ankle sprain not go back to sport for 6 weeks, whereas those with much more severe grade 2 or even grade 3 sprains go back in much less time.  Why?  There may be several reasons including compliance, body structure, previous medical history, fitness, pain tolerance, and the quality of the rehab to name a few.

In the end, rehab professionals and strength coaches must have sound knowledge of pathophysiology, tissue healing, and program design that ensures maximal progression with optimal tissue loading.  Messing up the stress gradient (too little or too much) will slow the return to play process.  Below are some major milestones my athletes must clear in order before we even get to what I term “functional rehab” or preparatory movement prior to controlled practice:

1. Full active range of motion
2. Normal strength on muscle testing
3. Normal walking gait
4. Symmetrical squat and lunge patterns
5. Single leg squat (back, hip or knee injury) and/or calf raise (ankle injury) within normal limits compared to uninvolved side
6. Single leg hops in place x 10 equal to uninvolved side with no pain or instability
7. Normal running gait on treadmill x 5′ without pain or instability
8. Lateral gait cycle within normal limits (shuffle, carioca and cross stepping)
9. Planned and predictive controlled agility without pain or instability
10. Low level plyometrics in 3 planes without pain or instability

After moving through this fundamental progression (may take days or weeks), the athlete may then begin to perform more demanding neuromuscular work.  This would involve more rotational work, full intensity sprints an cutting, and gradually the transition to reactive agility and speed drills.  Once the athlete completes this process, he or she is ready for controlled practice.

This is an area where I see student athletes get in trouble. They get “cleared” so to speak by the MD and go back to practice.  Cleared to a coach means full go, right?  The athlete should ease back into practice even after a carefully prescribed rehab plan like the one I just laid out.  However, too often, I see athletes rushed back to full practice too soon.  In the case of soft tissue and stress reaction injuries, this often sends them back to the training room or sideline much sooner than the coach or athlete would like.

What is the answer?  Controlled practice progressions with the idea of first increasing volume (total minutes) prior to restoring maximal intensity.  Athletes know what is hard and what hurts.  We just need to communicate with them.  Allow them to do the easier drills and fill up time with those prior to ramping up the intensity for the entire practice.

Let’s take soccer as an example.  Dribbling, passing and light shooting are lower level drills.  In contrast, set pieces and small sided games are much more demanding.  Athletes and coaches must use discretion when returning form play to avoid re-aggravating an injury.  Measuring pain before, during and for 24 hours afterward is crucial in determining how the body is absorbing the force and responding to the training stress. 

If soreness is lingering for more than 24 hours, this is a red flag that the volume and/or intensity is too much.  I educate all my parents, coaches and athletes to follow this simple 24 hour rule.  I have found if you do, you end up with predictable results in terms of recovery and return to play.  So, if you have suffered an injury, be sure to consider moving through a set functional progression and be sure to used a controlled return to play approach to ensure you make a full recovery.  Have questions?  Leave a comment or shoot me an email.