Interestingly, when therapists do consider exercise interventions, heel raises/lowers off stairs seem to be the “exercise of choice”. Often such presentations are acute or “hot” and based on Craig Purdam’s work on tendinopathies, such exercises may be too advanced for significant progress to be made.

Now before I introduce some alternative exercises, I’d like to address the “One Toe Syndrome”. Patients with plantar sided foot pain, especially women for some reason, often present with this “syndrome”. They may indeed have five toes, as most of us do, but if you look closely the toes actually function as one unit rather than five individual units.

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The "One Toe" Syndrome

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Dewey Nielson wrote a nice post (Barefoot Training by Dewey Nielson) a while back that included how our feet should actually look like. Next time you’re at the zoo, check out the monkeys’ and the orangutans’ feet. Others have written about the barefoot trend in recent times as well but often with relatively little suggestions. That said, Patrick Ward and Charlie Weingroff have made some suggestions themselves, so here’s how they recommend integrating foot work in training.

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• Short Foot Posture by Patrick Ward
• Where to Start Barefoot by Charlie Weingroff

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Tissue extensibility dysfunctions seem to be common in such presentations as well so prior to exercise, I’ll commonly get the patients to perform self myofascial release on their calves, feet and anything else that might need “freeing up”. Again, only if necessary but here’s an example.

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Aside from the above, two specific interventions that I commonly prescribe are the Vele Forward Lean and the Reverse Tandem Gait. The Vele lean is Michael Jackson-like, or for those of you who ride the subway, similar to facing backwards as the subway enters the next station.

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Michael likely never had foot problems

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The Reverse Tandem Gait, on the other hand, is a simple eccentric exercise that integrates the intrinsic foot musculature with less load than other commonly prescribed exercises. The key is to ensure that the feet are actively engaged, with the heads of the first and fifth metatarsals firmly planted into the ground to create the tripod with the calcaneus.

Here are both exercises in a recent patient. Note that for those that suffer from the “One Toe Syndrome”, I’ll often use toe separators to bring the 2nd, 3rd, 4th and 5th toes back into action.

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The one thing I want to make mention of, is what happens the other 23.5 hours of the day. To put it bluntly, high heels do your patients no favors. Neither do narrow toe boxes. Some will also argue that footwear is generally too supportive but personally, I (again) think it’s context dependent. And apparently so does Alex Hutchinson. He wrote a nice post not too long ago on Why Normal nor Minimalist Running Shoes Will Disappear.

I do think we can transition toward less support so here are some suggestions for your active patients based on my own daily experience.

Vibrams when performing kettlebell exercises…

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Just don't look down

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Vivos when deadlifting, squating and performing other lifts in the gym…

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Squats and Deadlifts

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New Balance Minimus when treating patients 12 hours a day.

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My work shoe

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Again, what I do on a daily basis may not apply specifically to yourself or those you work with, but it’s what works for me personally.

If you would like more information on any of the above, check out Barefoot in Boston by Art Horne and Craig Liebenson’s DVDs.

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This circuit can be used by almost everyone, as I use this with cuff patients as well, but the key thing is to pay utmost attention to form.

The exercises shown in this video are:

• Bottoms Up Kettlebell Screwdriver for cuff stability
• Bottoms Up Kettlebell Armbar for cuff stability with scapulothoracic mobility
• Kettlebell Armbar for scapulothoracic mobility
• 1/4 Turkish Getup for scapulothoracic mobility and stability

*Note that for the “Getup”, I’ll always get them to perform the movement slower and post on the elbow but unfortunately I didn’t get it on video.

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*Disclaimer: I have not been formally trained in Kettlebells, so for those of you who are, your expert feedback is welcome.

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Sometimes good. Sometimes bad. But powerful.

Earlier this week I read a blog post, that in some minds was controversial. In my mind, irresponsible.

Here’s the link: Corrective Exercise for Disc Herniations

While suggestions were made to seek care from a health care practitioner, clearly the intent was to treat such conditions. Treatment can come in many forms, from medications to manual therapy to cognitive coaching. In this case, treatment was exercise. One problem with this is that each and every patient presentation is context dependent. And while this is so, there are certain rules that must be respected when it comes to discogenic presentations.

On the other hand, I also read another blog post this week from an educated and responsible non-therapist. Again context is important but in my opinion, this post was much more contemporary, responsible and educational.

Here’s the link: How to Lift with a Herniated Disc

I hope you see the difference and understand that my main message is that if you intend to educate, not only do you need to do your homework, but more importantly you need to accept responsibility.

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Muscle Imbalances Revealed – Upper Body

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Last year, you may have read several of my reviews on Muscle Imbalances Revealed – Lower Body, a dvd package put together by some of the top experts in the fitness industry. Well this year, I’ve had the privilege to contribute to the newest version of this product, Muscle Imbalances Revealed – Upper Body. Together with Rick Kaselj, Tony Gentilcore and Dean Somerset, we have essentially put together everything – well not everything but a whole whack-load of information – you need to know about the core, thoracic spine, shoulder, neck and arm. But for those of you really interested in what I had to say, well you probably won’t be surprised. So let me give you a quick run down:

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“Respiratory Control: Linking breathing with rehabilitation & training” 

This was my main presentation where I talked about the following:

• Nailing down your mobility and stability exercises with breathing
• “Money moves” for improved breathing
• The Stability-Motor Control Continuum
• Assessment techniques
• How to integrate breathing into movement

“Understanding Soft Tissue Management: Choosing the right tool”

This shorter presentation essentially discusses:

• The mechanism behind soft tissue injuries
• The 3 Phases of Healing
• Who’s who soft tissue world
• The “integr8r”
• The role of the Instrument Assisted Soft Tissue Mobilization in tissue recovery
• The most effective ways to foam roll the upper body

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But enough about me, what you really need to see is what the other guys had to say in Muscle Imbalances Revealed – Upper Body! Here are short clips from each of “the other guys’” presentations.

“Corrective Exercise Strategies for Athletes (and Meatheads, too)” with Tony Gentilcore

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“Myofascial Training for the Upper Body” with Dean Somerset

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“Unraveling Muscle Imbalances in the Shoulder” with Rick Kaselj

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Now I’m really excited about what we’ve put together. I truly think that regardless of whether you’re a manual & rehabilitation therapist, fitness professional, or just someone who loves to train, that you’ll benefit greatly from this package. In fact, I actually think that your friends and colleagues will benefit as well (so please spread the word)!  And the best part about it? You don’t have to spend your spouse’s hard earned money like I do and fly all over to get your con ed on. In fact, the cost is only $77.

Anyway…

-> -> HERE’S THE LINK <- <-

…and thank you in advance for your continued support!

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If you have had the pleasure of attending one of Dr. Liebenson’s seminars, you’ll know first hand that he utilizes a large battery of exercises to rehabilitate a patient with functional pathology. While many of us attendees wished we were looking at the patient through his own lens, often we’ll ask ourselves “how the heck did he know that that exercise was the key link”?

Well in my opinion and aside from his extensive experience, there are two primary reasons why Craig can pull a specific exercise out from the score keeper’s room behind the Green Monster (let alone left field) and instantaneously help a patient improve their dysfunction. The first being the Clinical Audit Process and the second being a continuum of exercise progressions.

In the sport performance world, exercise progressions are to athletic development as I am to continuing education. And frankly, I don’t think the rehab world should be any different. Now I’m not talking about 8 repetitions this week and 10 repetitions next, but more so utilizing a continuum of exercises with similar objectives but with varying difficulties for the purpose of matching the right exercise to the said patient.

For those of you familiar with the FMS, you will know that Gray and Lee have their priorities and progressions. Pavel Kolar and DNS is not different and while I myself have never taken the RKC, I am quite confident that Pavel and his army are no different.

So in the rehab realm, how do we choose the most appropriate exercise for our patients? Well recently, Dr. Liebenson released his new 3-DVD set that answers just that. But as always, we must first start with a functional evaluation. Because without this, as Dr. Liebenson says, “any training flexibility, stability, or performance training is no more than dumb luck”. For more on functional evaluations, I highly suggest you attend one of his seminars, as well as that of the SFMA and Stuart McGill.

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So with these dvds, it is important to understand that it is the principles upon which corresponding exercises are chosen. Remember, it’s not about the tools but the principles behind them.

Core Stability Training

• For those of you in the rehab world, you probably already use several of these exercises already. Some of you may use them as your “core” exercises and others may simply use them to troubleshoot a specific patient. What some people fail to realize, however, is that Dr. Liebenson has been around since the invention of such exercises. Take McGill’s “big 3″ for example. Did you know that Stu and Craig have worked closely together for many years? To me, if I’m using specific exercises for my patients, I want to make sure that they are being performed correctly. And with this particular dvd (as well as the other two), Dr. Liebenson does an excellent job instructing each exercise and providing the most effective cues during their performance.

Overall, these dvds set themselves apart from many others not only because of the creator behind the discs, but also because of their professional quality. Utilizing custom-created images as well as “live” dialogues, Dr. Liebenson takes the time to explain with detail the purpose behind each exercise series. Certainly many more exercises will be invented but like I said, the principles behind the process are what’s most important. And it is these principles that will stick around in our industry for many years to come.

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Matt Siniscalchi demonstrating regressions for the Reach Roll & Lift

I think this is a great idea.

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Mike Reinold discussing the TRX Serratus Slide

A great way to integrate!

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Following this post, I was asked on facebook to describe the “prone heel squeeze” exercise. So for those of you wondering, here is a modified version (with a pilates ball) I found on youtube.

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*please note that in the original paper, the description states that the hips are slightly abducted, the knees are flexed to approximately 70 degrees and again, no ball is used. The individual is instructed to press the heels together and slightly lift the knees off the table. This position is held for 3 seconds and the individual is asked to slowly return to the starting position.

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And how many of you get frustrated when patient-compliance is relatively low?

Most of the time you’ll blame the patient but how often do you blame yourself?

Well for the last couple of years I’ve placed blame entirely upon myself when patients tell me they haven’t done their exercises. Sometimes it’s because I’ve given them more than they can chew and occasionally it’s because the exercises I had provided weren’t relevant to their condition. And when the latter is the case, I’ll consider it lazy on my part.

However, over the last several years patient compliance has skyrocketed translating into more successful care. There are two reasons for this: 1) more appropriate exercise selection and 2) video.

In the former case, taking the time to identify which exercises the patient actually needs has definitely sharpened my exercise prescription skills. For the latter, using video for home use has helped patients perform their exercises with more accuracy. Now how have I done this? For exercise prescription, I take the time to perform a clinic audit process to identify the most appropriate exercise that will address the key link to their functional pathology and for video, well I’ve simply used the power of youtube and a sheet of paper to direct my patients to when they get home.

Just circle which ones you want them to do

But it seems like there might just be an easier way to use the power of video. I mean, sometimes patients will tell me that their dog “ate their sheet” and other times, they’ll confess that they lost it. But thankfully, Dr. Phil Snell has created myrehabexercise.com to make things that much easier.

Just watch the video below to see how easy this is.

Now unlike Phases, Phil has compiled a database of some of the most up to date rehabilitation exercises that actually gets you results. Granted, it is up to you to use your head a little and utilize the clinic audit process mentioned above to find the most relevant, patient-specific exercise along their own continuum. But once you find it, I’m sure Phil will have it on his site. And if he doesn’t, just let him know and he’ll film it.

*Note: Dr. Phil is currently having a promotion right now where subscribers who refer the most colleagues to the site can win an ipad 2! So here’s my promo code – promo46034 – subscribe, and get yours to refer to your friends. 

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This first exercise is one that I learned from Michal Truc. If you don’t own a pair of Valslides or a slideboard, you need to right now.

If you’re watching closely, you’ll notice that I need to improve stability of my own right shoulder girdle.

This second exercise is a commonly performed exercise using the TRX. However, the importance here is to maintain a packed position of the shoulder. The reason I am posting this exercise is to demonstrate that we can start to progress into upright positions via kneeling and eventually to standing.

As always, you can use any exercise you wish, but the principles that must stay the same.

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If you have any questions, just post them in the comments section or shoot me an email via the “contact me” link above.

Enjoy!

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“We’re having a injury-ridden season this year, and we’ve been trying to determine why. We do see very common trends among the men, and we believe it’s the guys’ lack of scapular stability and endurance in the stabilizer muscles, and general thoracic cage stability…We see a lot of mid-back injury and especially rib injuries, and very commonly rib stress-fractures.

Now, these guys have the best Strength and Conditioning team around, however the medical team feels that they’re…not getting enough stability and shoulder blade mobility exercises (they basically need to improve the stability of the scap to work in a large range of motion).

Anyway, I was wondering what you thought were the best couple of exercises for scap stability and serratus anterior activation. Now these guys are elite athletes, they’re amazing machines actually, so they can probably do some advanced stuff, but I think we need some activation exercise, and then followed by integrating this into some advanced functional movements!”

Admittedly, I have never worked with a rower in my life. However, having examined some of the current literature (Vinther et al, Warden et al) it seems as though the exact causal mechanism for such injury is not clear cut. That said, first things first.

Stress Fractures = Bone Resporption > Bone Repair

(at sites of microfractures secondary to repetitive loading)

While certainly stress fractures may be associated with abnormal (low) levels of bone mineral density and its associated factors, several causal mechanisms have been proposed to describe its etiology. Namely:

• Sheer forces resulting from co-contraction of the serratus anterior and external oblique
• Increased co-contraction levels of the serratus anterior and lower trapezius
• Poor eccentric control of shoulder flexion
• Faulty motor patterning (timing) between the lower body and the upper body
• Inadequate knee-extension strength to elbow-flexion strength ratios

From a training and periodization standpoint, it is quite easy for those on the outside to immediately suggest that such athletes are “doing too much too soon”. However, seeing that such fractures are quite common regardless of the level of athlete, we cannot simply point the finger at loading parameters. Anything and everything from biomechanics and motor control to poor nutrition to improper rest is fair game. Certainly a thorough assessment must take precedence but with respect to the above question posed, here are some recommendations for simultaneously improving scapular mobility and stability.

Scapular Mobility:

(I really like this video)

Assisted Push Pull / Twister (sorry, I couldn’t find a video on youtube)

Scapular Stability/Eccentric Shoulder Flexion:

With respect to motor patterning between the lower and upper of the body, I would consider utilizing such exercises as deadlift and jump squat variations, however, I will leave this for another post. Hopefully some of the above strategies will prove useful when incorporated into the overall training programs of these athletes. Certainly several of the exercises above are anterior chain dominant however, these athletes are exceptionally strong posteriorly and so ensuring balance between the two seems prudent. They are by no means definitive, but when indicated for the right individual, I think they can be helpful. What are your suggestions?

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When Larry Mather, one of Canada’s longest serving lifting coaches stated to me that “everyone has way more strength and power than they know how to use“ it clicked. Olympic lifting is a total body approach that requires every joint to contribute in order for work to be performed. Whether it be sagittal plane mobility or transverse and frontal plane stability, the requisite minimum for proper execution is adequate integrity in all directions.

From a motor learning perspective, olympic lifting is neuroplasticity. What we are getting our athletes to do during training is essentially computer programming.  Because as we focus on the how, naturally the how much will take care of itself. Let me say that again,

As we focus on the how, naturally the how much will take care of itself

If you’ve ever coached these lifts, you will most certainly understand that technique is of utmost importance. This is why so much emphasis must be placed on perfection. As Mike Boyle stated, “if it looks good, it probably is”. I really don’t think you can say the same for many other lifting approaches, save for, perhaps, kettlebells.

Olympic lifting is simply physics and biomechanics. The reality is, doing it the right way is the easiest way. And if the athlete isn’t doing it the right way, that is, if there is an error in technique, then it is likely a central nervous system motor program issue that must be addressed. Most certainly joint mobility and muscle imbalance may be a concern, but very often perceived lack of mobility (for example) is simply a result of faulty motor patterning. And therefore appropriate cuing may be all that is necessary. Just watch and experienced lifting coach in action and you’ll understand what I mean.

…and that is why I think Olympic Lifting is Motor Learning!

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