1. Author Bias

First off, always be wary of author bias: the actual conclusion of the article as I read it is that there is really no appreciable difference between surface and injury rate. But this doesn’t make for a good headline, so the story gets a spin put to it. As I read the story and the research, it is simply that different surfaces create different demands. The headline could have just as easily been “For runners, different surfaces are different”, but that really doesn’t attract one to read the article does it? I have to admit a bias; personally I prefer trails. Professionally, I believe that variability of physical task demand results in the end product of a more robust system and is therefore a desirable trait in any physical or mental training program. Soft or uneven surface will create more variability in the demands on the system. That being said, the most important take home point is probably that if you are going to make a change, you need to do it slowly and prepare for it. Interestingly, that is also a take home point of a similar ‘myth buster’ article, Skip the Pre-Run Stretch, it Doesn’t Prevent Injuries

2. Biomechanical Demands

Secondly, softer or uneven surfaces (trails) do present different biomechanical demands. This must be recognized and trained for. In running, generally softer surfaces will correlate with more uneven terrain. Even if a softer terrain is not uneven, the body still has to find minimum amount of stability in order to maintain balance. So, in either case, the dynamic balance demand is increased. Theoretically softer surfaces would require more mobility, neurological awareness and strength in the foot and ankle as well as increased strength at the hip in all ranges of motion. Harder surfaces will require more strength in the knee and hip muscles that cushion landing. Based on these assumptions, soft surfaces may yield more injuries to the ankle joint, knee joint ligaments or hip soft tissues. Hard surfaces may yield more injuries to the foot structures, knee joint and tendons, knee & hip cartilage and spinal discs. All of these are structures that could receive excessive pressure if sufficient dampening of ground impact shock is not achieved. I am not aware of studies that have looked for these long term correlations; this is just based on biomechanical theory.

3. Adaptation

A final thought, we do know from research that the body will adapt running mechanics around impact force, and this article references that concept. The research into barefoot running and minimalist shoe design supports this theory. It forms one of the underlying tenants of why minimalist shoes can prove beneficial to some individuals. We do not know what the ‘optimal force’ is for an individual, but we do know that people adjust to find what their body ‘needs’. As people go to less cushioning in a shoe, they generally adapt their running form to absorb more impact. Some people adapt well, others not so well. There is a lot of information about what the variables are that determine these adaptations and why the adaptations are needed. To fully explain would take a small book, not a short article. However, I take all of this information and reach a different conclusion than “But with no evidence that softer surfaces prevent injuries, there is no reason to run on softer ground unless you like to” I think there are many valid reasons; they just have to be done strategically with proper preparation.

“I’m looking for a little advice about how to manage a driving trip this weekend. I’ll be in the car (driving) for 4-5 hours, depending on traffic. Any suggestions?”

This question was from a person recovering from lumbar disc surgery, but the answer is applicable to anyone with back pain aggravated by sitting.

There is a simple answer, but it is often harder discipline oneself to implement than it should be.

Are you driver or passenger? Either way, the answer is to not be in any one position for very long. Ideally move every 20-30 minutes. If passenger, it is easy, adjust the seat back to multiple angles so you are in many positions. If driver, it is more challenging. Ideally you would stop every hour, get out and move. It can be as simple as pulling off of an exit ramp, getting out and walking around the car a couple of times. The simple act of standing, walking, moving the spine through a comfortable, gentle range of motion will restore circulation, relieve pressure to the spinal discs and joints, and help a lot.

20-30 minutes extra on a trip beats the heck out of 2-3 days of discomfort and needless suffering.

Let’s you know how long you have been on the computer and gently reminds you each hour with a Tibetan bell…get up!

How many of us need this?

Features for an Ergonomic Seated Office Task chair:

• Adjustable seat height
• Adjustable seat pan depth, seat pan with a waterfall front edge
• Adjustable back support, either adjustable via the entire seat back or adjustable lumbar support within the existing seat back
• Arm rests adjustable in height and width.
• Seat pan should have forward and backward tilt capabilities with the ability to lock in position and free float.
• Seat pan and seat back should tilt as one unit so that the relationship of the pelvis to the spine is maintained.
• Tilt tension should be adjustable.
• Headrest (if desired) should adjust in both height and forward and back. Headrest height adjustment should be independent of seat back height adjustment

General chair adjustment and work positioning considerations:

• Armrests should be adjusted so that when you rest your arms the weight of your arms is unloaded from your shoulders and neck. Armrests are rests, not works. When you are working on a keyboard or with a mouse your arms should hang freely, not supported on the arm rests.
• Seat pan height should be slightly higher than knees when feet are flat on the floor
• Seat pan depth should reach to within 3-4 finger widths of the back of your knee when your pelvis is firm against the backrest of the chair.
• Keyboard tray should be adjusted so that your elbows are bent slightly greater than 90 degrees, forearms angled downward toward the hands. Wrists should be just slightly bent so that the back of the hand is inclined a little relative to the forearm.
• Monitor placement so that the center of the screen is resting focal distance (28-32”) from the eyes at a declining angle of 10-20 degrees from the eye height.
• Prolonged forward reaching work should ideally be performed with the chair seat inclined forward and weight placed through the feet on the floor.
• When work allows, reclined positioning of the chair should be used for ‘relative rest’ breaks. Having easily adjustable tilt is necessary for this.
• If you are able to work in a reclined position, a headrest is recommended.
• A keyboard and mouse tray that is easily adjustable to multiple positions allows for the maximum utilization of multiple chair positions.

Editorial opinion: Spend as much money as you need to buy what feels absolutely best. It can be your throne, treat it as such. Most office workers will spend more hours in a week with their body in the office chair than anywhere else, except the bed. Some people spend more time in the chair than the bed, but that is another problem. The office chair and the bed can have a greater impact on the body than all the gym memberships, exercise equipment and therapies. Invest wisely in yourself in those areas.

A: With each footfall during running, the chain reaction between our body, the ground and gravity begins from the ground up. This means that core stability starts at the foot and moves up through the knee, hip, pelvis and then the spine. If there is a weak link in the chain, stability above that link cannot happen; i.e. if the hip is weak, strong abdominals are not enough to compensate. Our abdominals require a stable pelvis to complete their task of keeping us erect while providing rotation of the spine to keep the opposite arm and leg moving forward.

Gluteals are the dominant controlling musculature of the hip. The deeper gluteal muscles (gluteus medius & minimus) control the lateral (side to side) and rotational positioning of the pelvis on top of our legs.  By controlling the pelvis, the glutes are also controlling our center of mass. Running is a motion dominated by a forward direction, but it also contains lateral and rotational components. These components are often neglected in training, thus fostering an imbalance and further exploiting any weaknesses. This results in inefficiencies, numerous injuries or sometimes just the inability to maintain good running form especially later in a run.

Physical therapy can help you to discern your body’s pattern and begin to go about changing it. In your initial visit, we’ll get video of your running form, complete a good functional screen and a thorough physical evaluation.

Call our office at 919.942.0240 to schedule your appointment!

Chad Flickinger, MPT is a physical therapist working with Balanced Physical Therapy in their Carrboro location. Chad is a previous collegiate runner and lacrosse player who currently enjoys running, biking, backpacking and playing ice hockey in his free time. Chad enjoys teaching clients to move in new ways to comeback after injury or decrease pain with daily living.

“A proactive visit to a physical therapist can reveal the muscle imbalances and inefficient movement patterns that cause injury. The therapist can provide a regime that corrects those problems while enhancing endurance, balance, strength and weight control.”

Remember:

A MD referral is not needed in NC for someone to use the services of BPT. Most insurance plans will cover some portion of the PT fees. If insurance does not cover, our cash fees are $100 evaluation and $80 followup, all for an hour of individual attention.

We have trainers at BMS that can continue PT programs  and progress them to general fitness goals.  BPT can also serve that role with other trainers in the community if someone has a relationship established with another trainer.

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.

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.