Interesting research being done about the function of connective tissue.

In order to resolve and prevent these and other similar conditions, it is helpful to have an understanding of the healing process and the role of eccentric strengthening in promoting the healing of connective tissues. An eccentric activation of muscle is one that occurs while a muscle is being lengthened. The lowering of the weight phase of a biceps curl is a simple example of an eccentric activation, whereas the lifting of the weight to the shoulder is the concentric phase of the exercise. The muscle and tendon is still actively controlling the load and under tension as it lengthens during the eccentric contraction phase. Due to the nature of muscle and tendon, it is possible for these structures to tolerate greater loads (tensile forces) during eccentric activation than they can produce during concentric activation. This information can be applied to help resolve nagging injuries such as plantar fascitis or Achilles tendonitis.

The common difficulty with these “-itis” injuries is that the tissues form scar tissue to heal microscopic structural tears when we are at rest, but with activity and tensile loading of the tissues, the structural tears recur. This is why you often feel the pain first thing in the morning, but after you have been walking for a little while you feel better. As you rest, the tissues heal in a shortened and weakened position, then when you walk, you tear apart the healing that occurred during the nights rest. In order to heal fully, you have to balance stretching and strengthening through a full range of motion with controlling for not overloading the structure and perpetuating the injury. It is easy to tell when overload occurs; you will feel the return of your pain. Of course, simply doing nothing may keep you out of pain, but it will not rebuild the strength and flexibility needed in the tissues to return to full activity.

The Three mechanical components for healing are inflammation control, restoration of tissue flexibility and restoration of tensile loading strength. Ice and anti-inflammatory medications are standbys for the first component. For flexibility, gentle prolonged progressive stretching in a pain free range is required. For weight bearing structures such as the feet, this can be accomplished by holding a weight bearing stretch for 3 minute plus intervals. Restoration of tensile load strength without damaging overload can be accomplished by focusing on eccentric exercises. It is important that the exercise be performed through the full range of motion available. In the case of the plantar fascia and Achilles tendon, this means doing strength work such as calf raises (plantar flexion) from a position of fully up on the ball of the foot and lowering till the heel is lower than the ball of the foot and the limit of flexibility is reached. Obviously to accomplish this the weight must be on the ball of the foot with the heel hanging off the edge of whatever you are standing on. Initially start with lifting up using both legs and holding on for balance, then shifting more weight to the painful side and lowering with an emphasis on that leg. One should do repetitions to fatigue, but never load the leg with so much weight that you provoke your pain. In this case, stretching before the strength work and icing afterwards to control for inflammation are critical.

These same concepts can be applied to other tendon or connective tissue injuries in the body. If these steps do not help to fully resolve problems, then seek out a therapist, podiatrist or other professional that can perform a detailed biomechanical assessment of your whole body and evaluate if other options such as orthotics may help. If you work on the feet diligently and the feet don’t get better, it is probably not the fault of the feet. Everything is connected and the whole system must function smoothly for it to remain pain free.

Brian Beatty, PT, CSCS rides when he can and complains of not riding enough when he can’t. He also talks incessantly to anyone who will listen about biomechanics, physics and experiential learning. When not riding he can be found from too early in the morning till too late at night hanging around Balanced Physical Therapy and Balanced Movement Studio in Carrboro and Durham.

Dr. Michele Ferrari, Lance Armstrong’s trainer, as quoted in conversation with Daniel Coyle in Lance Armstrong’s War. p.124.

A week’s vacation in Nags Head is a great place to relax, breathe deeply, and catch up on some reading. I took along a couple of books, the new book on Lance (noted above) and a textbook by Stuart McGill, PhD, one of the top biomechanics researchers on spinal disorders. The latter is not everybody’s pick for beach reading, but I admit to being a geek. While breathing in ocean air after my morning rides, I was struck by a recurring theme.

Dr. McGill’s book contained some interesting new research and ideas relating breathing to spine stability. One of the interesting findings in people with back pain is the inability to maintain spine stability when they performed stabilization drills while breathing heavily.

This research raised interesting questions for me. If the ability to breath without compromising stability is important for health, how can we tie that into better mechanics of breathing for performance? If, as Dr. Ferrari seems to suggest, there is improvement to be gained in oxygen exchange, then it would seemed appropriate to study the basic mechanics of breathing and stability first. The logical goal would be to gain a foundation of skills and awareness that could be used for exercises and gaining insight into breathing techniques that could improve the oxygen exchange process. The oxygen exchange topic will be explored in a future article, some basic breathing concepts are introduced here.

To inhale with force, the diaphragm and muscles between the ribs must contract. To exhale forcefully, the abdominal muscles and other muscles between the ribs contract. The diaphragm is shown in the accompanying pictures. It has a unique dome shape, and attaches to the lower ribs and lumbar spine. Study of the diaphragm’s attachments suggests that if the diaphragm is held rigid, it could provide stability between the spine and upper torso. However, this would obviously have a detrimental impact on breathing performance.

There seems to be a large amount of discussion in exercise about what is the core and what stabilizes the spine, but not as much about the muscles used for breathing. The fact that Dr. McGill & other’s research shows that an impact on stability is often seen with heavy breathing suggests that we may be inappropriately restricting the breathing muscles when performing core strength exercise in an attempt to create the desired stability. The same abdominal muscles that we are commonly instructed to hold tight during core exercises are actually required to expand and contract to achieve maximum breathing efficiency. If we are holding the breath and not moving the diaphragm during core exercise, the implications for poor control during aerobic events is even worse.

Another interesting fact from McGill’s book is that spinal stability can be increased with the internal pressure of maximal inhalation. During maximal inhalation, the diaphragm is contracting downward and the abdominal muscles bulge outward (not ‘suck it in’ to the spine). Maximal spinal stability is achieved when the abdominal obliques engage to initiate exhalation from this expanded position of full inhalation. Dr. McGill suggests that functional spinal stability for athletic performance or heavy work conditions cannot be achieved until one has mastered the ability to separate heavy respiration from the muscle patterns used for core stabilization. This month’s Core Corner contains a basic exercise idea that incorporates this concept. This idea also questions the efficacy of a body building routine that suggest always inhaling or exhaling with a certain portion of a lift. Training the body to be reliant on one specific pattern may not have functional carryover into athletic activities requiring elevated heart rate and respiration. A deep breath with proper control can enhance your strength; so don’t be afraid to let the diaphragm work and the torso and belly expand.

The important information for predicting spine problems is the ratio of endurance strength measured in how many seconds one can hold the test posture. The three test positions used for the research are shown in the accompanying photos.

The Flexor Test involves holding a straight spine at a 60-degree incline in a sit-up type position. The normal lumbar curve (lordosis, as if one where standing) is held throughout the test. If the spine curves, or the torso drops 10 degrees (about 3 inches), the test is over. Knees and hips are flexed 90 degrees and arms folded across the chest.

In the Extensor Test, the torso is held out over the end of a bench or table while the pelvis and legs on the bench. The feet can be either hooked under a strap or held by a partner. Arms are again across the chest with hands on opposite shoulders. The test position is held until the body drops below the horizontal.

The Lateral Musculature Test uses the side-bridge position, supported on the elbow and forearm. Both legs are fully extended with the top foot in front of the bottom foot. The top arm folded with the hand supporting the lower shoulder. The entire body is lifting to form a straight line and the position is held until the pelvis drops and the line is lost.

The following ratios are suggested as ideal:
Right side bridge / left side bridge endurance > 0.05
Flexor / Extensor endurance > 1.0
Side bridge (either side) / extensor endurance > 0.75

These test positions can also be used as strength building exercises for a healthy spine. The side bridge / lateral test is an excellent exercise for most people. However, the Flexor and Extensor test positions may not be appropriate for people already experiencing spinal pain. If you choose to use these positions as exercises, know that unlike an endurance test situation where you hold a posture for as long as you can, when using a static posture as a strengthening exercise, you should only hold the posture for 8-10 seconds. Holding a static load longer than this can create oxygen deficient in the muscle-tendon unit as the contraction restricts blood flow. To avoid this problem and maximize gain, perform multiple repetitions of the positions held for 8-10 seconds, relaxing the position and taking a recovery breath between each repetition. Repeat for as many repetitions as you can do with good form. Make sure that you can maintain a normal breathing rhythm while holding each position. Without oxygen there is no endurance. But that is a topic for next month.

• Increase intensity to > 70% of aerobic/lactate threshold or >14 on 7-18 perceived exertion scale (i.e. until you are breathing heavily).
• Dismount and assume a side bridge posture as shown. The body should form a straight line from head to floor. For intermediate level, balance on elbow and knees, advanced level on one hand and feet.
• Hold the posture as you breathe deeply and recover your heart rate.
• Return to the aerobic task for a couple of minutes of recovery, then increase heart rate and repeat.

Step 1: Find your balance with arms resting on your chest.

Step 2: Engage your torso and shift your weight to one hip so that the opposite foot can lift without rolling your pelvis. Alternate lifting the legs.

Step 3: Once you are comfortable with step 2, coordinate raising the opposite arm over your head as you alternate lifting one leg.

• Kneel on an unstable surface. You can use a folded blanket, foam pads or devices such as balance discs, core board or bosu. Bring your pelvis forward so that your hips center over your knees.
• Bend your knees so that your feet are lifted off the floor.
• Have a partner toss you a ball at overhead height, which you catch and toss back, keeping the arms fully extended overhead at all times.

You can use a basketball, soccer ball, stability ball or weighted medicine balls. To perform the exercise solo, just bounce the ball off of a wall. For an advanced solo workout, toss and catch a medicine ball using a rebounder.

1. Lie prone on a weight bench with your pelvis toward the end of the bench and wrap your arms around the bench for support.
2. Bend the knees to 90 degrees and do a light contraction of the abdominals to create some ‘set’ or tone in the torso and engage the spine. The contraction should not be so much that it actually moves the spine.
3. Use the glutes to lift your legs and pelvis into the air and allow the lumbar spine to move into extension to lift the pelvis. The whole spine should gently curve, with the shape of the curve and force of the movement evenly distributed throughout the lower spine.
4. Gently lower the legs to the starting position.

When you first start the exercise, have the pelvis and even the top of the thigh slightly on the bench. To increase the intensity of the exercise, slide backwards so that more of the pelvis is off the end of the bench.

So, what does this have to do with exercise as they get older? As we have written in previous articles, the muscles of the core, abdominals and gluteals, set up the position of the pelvis and affect the efficiency and overall strength of the hip and lower extremity muscles. This efficiency leads to less strain, and better force production/reduction. The end result is a more efficient athlete with fewer injuries. Usually, this leads to a life long athlete and exercise participant.

So, how do we encourage our children and instill a joy of exercise without training them like we are coaching a future Olympian? Simple, we follow a very old and well-established principle of learning, variability of practice. Expose children from a very young age to a variety of activities in a variety of places. Just create a safe environment were they can trip, fall, roll around and get up again without being harmed. Yes, that includes when they are infants. Let your child run, jump, hop, skip, bounce, and roll. Let them learning to pedal, balance, and walk on a beam. These are all activities that can start by the time they are 2 years old. When your child is about 5 years old and can follow directions, get them involved in organized activity that is not too competitive. Let them experiment with many activities and watch them gain self-confidence. Just remember to make it fun. Go on family hikes or walks and mix in skipping and running. Children love to laugh. If you can make them laugh and do exercise, you are well on your way to creating a love for the activity.

What about swimming and running? Once a child can follow instruction, involvement in organized exercise is fine. The goal is to build a love for activity and lifelong skills. Let your child choose the activity, this will help them gain self-esteem. From a Physical Therapist’s perspective, varied experience leads to better retention of skills. This leads to more efficient muscle use, better balance, easier skill acquisition, and less injuries. Overall that means more fun, better self-esteem and a lifelong love of being active.

As a final perspective, let me say that the most effective way to get children interested and engaged in activity is to let them model yours and other adult’s positive behaviors. This is really what children want to do. Now, lets get out and train our future Olympians.

During activity performance, multi-tasking with the Iillio-tibial Band (ITB) in the hip and leg can lead to a variety of problems and performance deficits. The most common complaint with the IT band is excessive tightness. There is a variety of IT stretches that many of us do regularly; yet still complain about tight IT bands. This excessive tension often can’t be helped, since functionally we are asking the ITB to multi-task during running or cycling activity. This functional multi-tasking is inefficient and stressful to the physical structures.

The IT Band is a thick fibrous tract of tissue that originates from Tensor Fascia Latae (TFL) muscle on the most superior and lateral aspect of the hip. The IT band covers the outer portion of the thigh from the above the hip to below the knee. The role of the TFL and ITB is to provide a broad stable attachment site for the Gluteus Maximus muscle. The glut. max. is the primary power muscle for extending the hip, i.e. driving the leg backwards to propel the body forward in space. The TFL & ITB are also positioned so they can provide lateral support to hold the pelvis erect during single leg stance. However, this should not be the primary role of the ITB & TFL. The deep, central buttocks muscles, the Gluteus Medius & Minimus are responsible for holding the pelvis upright so that the pelvis doesn’t drop to one side or shift out to the side excessively when you are extending the hip with the Glut Max. If the gluts are not working properly, then the ITB must multi-task, becomes excessively strained and becomes problematic.

A simple exercise to help overcome these problems is shown. In keeping with the theme of this article, the intention for this exercise is to focus on the posterior hip musculature.

Start position: Stand on one leg and lift the opposite knee allowing the arms to swing as if running.
Finish position: Squat down on the stance leg by sitting back with the pelvis. Extend the hip to straighten the leg that was in the air behind you while reversing the positions of the arms.
Maintain an erect torso as you do the squat. If you desire more load, do the exercise holding dumbbells.

The work should be felt primarily in the glutes in the back of the hip. If you feel strain in outside of hip and down side of thigh, then you are using ITB/TFL too much for stability. To correct this, shift the pelvis left or right while focusing on maintaining the top of the pelvis level until you feel the deeper gluts in the back of the hip. If the work is mainly in front of thigh/quadriceps instead of the gluts, then the knee joint is contributing too much. To correct, bring knee further back relative to the foot and drop the pelvis further backward as you squat till you feel the work in the center of the buttocks.