To squat or not to squat: What we've been told and what we believe.

It's not uncommon to hear that when people go to the gym, they avoid their legs at all costs...

"My legs are already too fat..." is probably the most common reflection, and equal among males and females (maybe in not the same words). I used to hate the feeling of working legs because I felt I had to put so much effort into lifting. Plus, I'd have to buy new jeans after a few weeks of leg work!

Chest and biceps. That's the workout that everyone needs right? Summer time is here, and I would be darned if my biceps aren't squeezed by the sleeves on my two-size too small t-shirt. Gotta look pumped!

The man whose arms exploded.

Your legs are a huge part of your body strength as a whole and unless you play sports in a sitting position, they are essential to your training. Even those of you who are just looking for easy functional exercises, most of what we do in life is squat, walk, deadlift, and even lunge every so often.

So the few of you that do leg workouts, good job! You have already taken the first step towards a brighter future full of rainbows and Mr. Tom Platz (Not endorsing his steroid use, but obviously works out his legs!):

What do you do for your leg workouts? "Well, I use the quad extension machine, the hamstring curl machine, and the machines for my inner and outer thighs." Better than nothing, yes, but when asked about squats, deadlifts, lunges, and serious exercises: "Oh no! I can't do those! My knees are very bad. The doctors have looked at my x-rays and say that I've got horrible degeneration. It's a blessing that I can still walk!! Squatting is bad for the knees! I hope you're not going to get me doing squatting exercises, because I won't!"

So that's a little exaggerated, but you'd be surprised what I hear...

Kelly Starrett of SFCF shows a poor squat position (L) and a good position (R). Knees are pushed out, decreasing the valgus load on the knee.

Squats bad for our knees? Since...1961: Karl Klein and Fred Allman wrote in "The Knee in Sports". In a study, they found that the squat could negatively impact an athlete's knee stability. BFS (Bigger Faster Stronger - a great resource) explained that his results could never be reproduced.

Exerpt for BFS:

"...Further, peer-reviewed papers, such as one by Fleck and Falkel published in Sports Medicine in 1986, showed exactly opposite results--- weightlifters and powerlifters tended to possess tighter knee joints than athletes in control groups, and were less susceptible to knee injuries..."

Did that just blow your mind? If it didn't, you should read it again.

Less susceptible to knee injuries? That sounds great to me! If you tell an athlete or anyone else that "I'm going to give them an exercise that will make you less susceptible to injury," do you think they would say: "No way?"

So, let's say you squat, whether thats with 300lbs sitting on your shoulders, or you are doing air squats (just body weight). Do you think the way you squat is important?

Do you want your knees to pass over your toes? Why not? Who told you not to? Do they know why?

Kinetics of the parallel squat: by McLaughlin in 1978 tell us why not. Shearing forces upon the tibiofemoral joint were substantially more when the knee passed over the toes, and were better when the shank remained practically vertical.
McLaughlin, T.M., Lardner, T.J., & Dillman, C.J., Kinetics of the parallel squat. Research Quarterly. 42(4), 1978. 

Their findings are true, but what you may realize is that the knee is build to physiologically and anatomically accept that load. Toes over the knees creates a quad dominant exercise.

BUT, I didn't just give you a free pass to do squats with knees over your toes. When the knee is positioned further back and the shank is more vertical, forces are placed significantly more on the hip. The hip is more stable, and stronger than the knee. If you want to have a stronger squat, you'll have to practice the 'sit back' technique. Glut dominant movement will be where you get your power.

How low do you go when squatting?

Having your thighs pass the parallel line will further engage our posterior chain muscles: hamstrings and gluts. These are strong muscles, lets use them! Working the upper range of the squat works great for our quads and heavy loads (>1RM) can possibly create stronger bones (osteogenesis), but we are then encouraging quad dominance, and therefore creating imbalances and can lead to pathology. Athletic standards are based the parallel squat so if you ever want to be in professional sports, it's a must.

Do you think it's important to work on the 'full squat' position (heels down)? 

Muscles work best in their inner range, not their limits. If you practice staying in a full squat position for a minute or two you will, 1. get us more comfortable with coming down to a parallel position when we do the real deal and 2. try to engage further range in your joints so that the parallel squat is now an inner range movement. BE SMART: the full squat can significantly increase the pressure upon the lower lumbar vertebrae if the back curves too much! If you are getting back pain while trying this, don't push through it. Try to push your back into an arch position, and if you can't: that's something we have to work on - book an appointment!

How much should my toes be turned out?

Toe position affects the ability for our hip and pelvis to stabilize. The more your toes are turned out, the less effective are our small hip stabilizers because they are in a short position. Sometimes this out turning is inevitable because of poor ankle mobility, but this means that you have something to work on too!

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The squat is a multi-joint functional movement. Appropriate ankle, knee, hip, pelvis, and spine mobility (also the shoulder in those overhead squats) is required to be able to perform this exercise to max. Proper technique is a must, and sometimes technique will differ based on training goals, or cross-over into sports. Do not be afraid of the squat, but do do some reading about how to do a proper squat. BFS publishes a great book (by the same name: 2nd ed) that you should have in your library.

Do you have knee pain when performing the squat? Does it gets worse when you even try to practice? Book an appointment with me at Paragon. We can assess the situation and perhaps recommend  some pre-squat exercises for you to work on.

Other myths need busting about the squat? Check out this site.

CrossFit Competition Plyobox x2 - Complete!

Just finished building my very first plyo boxes!

At Everest Training Centres, we have recently been doing a lot of circuit training, as well as different Crossfit workouts. Box jumps are a regular request of these workouts, and I've been trying to help with the rehab of some athletes that require to develop leg power so it's about time to have these.

Not knocking Rogue Fitness (or any fitness supplier), but the cost of ordering plyoboxes online is just ridiculous if you are close to a Home Depot and have some handy skills.

My boxes were built with 3/4" maple plywood - 1 sheet per box - and used flooring screws for ultimate stability. Although it looks like an easy build, it was still a four power-tool job (skill-saw, drill/driver, router, and jigsaw).

These boxes are obviously not the angled-stacking style (which can be better in case of slipping), but these are just more functional. These are to Crossfit competition regulation: 20" x 24" x 30".

The first took a few hours (to make a box, I know) to complete, but we were going on no plans, and wanted to make sure it was the most stable, and the most square. The second box took a mere 30 minutes.

Total cost of the 2 boxes: sheets ($54.99 x 2) + screws ($7.99 x 2) totalled just about $120 after taxes. Pretty good seeing the cost from rogue would have been $161.60 + $35.50tax.

Plus I got the chance to build something with my Dad. Quality time for the father's day centre of attention. Thanks Dad, good times.

Hydration Practices for Marathon Runners: The Risks of Drinking Too Much Water (Exercise-Associated Hyponatremia)

Here in Winnipeg, days are counting down to the 34th annual Manitoba Marathon which takes place this weekend (3 days!). Weather has been great in the last few weeks, and so I expect that athletes have had a chance to train in the hot & humid weather before this race. If this race turns into a scorcher, we have to really think about water intake levels aka: hydration!

So what do you think I'll tell you? Make sure you are drinking plenty of water before and during the race, and that if you feel thirsty it's already too late and that you are probably dehydrated? Until very recently, I would have probably stated just that. A couple weeks ago, I was brought up to speed by a great therapist in Dartmouth, NS, Daniel Crumback with Paragon Sports Performance (great clinic name Dan!).

With exercise, most of us think if we are going to be doing heavy endurance work over extended periods of time, we will have to consume much water so that we do not dehydrate. If it is really hot out, we think that we need above and beyond what we would normally need. Some may think that we must also hydrate substantially the days before the run.

The question is, can we really drink too much water? Can we be too healthy? Can we actually be hindering our performance in sport and may even be putting our lives at risk?

We may have the best of intentions for our health, but we may have been psychologically conditioned to think that we require copius amounts of fluid when exercising.

History

Before 1969, athletes were regularly advised to avoid drinking water during exercise. Even olympic marathon runners from the early 1900's were quoted writing: "I know from actual experience that the full race can be covered in creditable time without so much as a drop of water being taken or even sponging of the head."

In 1957, Jim Peters (previous 4 time world record marathon runner) trained in this same way. Minimal to no water for training.

Take a step back in time now. 1924. South Africa. Arthur Newton (then ultramarathoner and marathon record holder) created the first sports drink ever! Named, the Corpse Reviver was the drink to have for runs over 26 miles!

Alright, jump forward again: 1965. Dr. Robert Cade, a nephrologist from University of Florida, developed the second sports drink known today as, what else, but GATORADE. Basic fitness tests used in Cade's study then showed that increased fluid uptake by football players reduced the risk of developing heat stroke.

Four years later (1969), a pair of physiologists had a questionable study that said concluded that higher body weight losses during racing must inevitably cause heat stroke. Runners were then told by their athletic association, to consume as much water as felt necessary based on thirst.  This study has since been proven to have errors and incorrect causation.

During this time and until the present, sports drinks have been a massive industry among athletics. Growth was estimated at $217M in 1985 to $2.69B (yes, billion) in 2003.

In 1996, the American College of Sports Medicine (ACSM) had implemented a 'zero percent hydration' rule that dictates: the weight lost during exercises must be replaced if health is to be protected and performance is to be optimized.  It was portrayed that fluid ingestion was the be-all end-all of exercise induced heat illness. They noted that the thirst mechanisms in humans was slow, and that athletes regularly drink too little prior, during, and post exercise. Also, every athlete, regardless of weight, height, etc. was to have the same fluid ingestion guidelines. These may have not been exactly evidence-based.

Hyponatremia

What is it?

Hyponatremia is the state in which there is a low concentration of sodium in the serum. It is not as you think though. It is not exaclty a loss of overall sodium in the system (though we will lose some through sweat and urine), but it is often induced by too much hypotonic fluid uptake. We are essentially diluting the body's serum. Symptoms may or may not be present. Some indiviuals may be symptom-free in early stages, though it may progress to cerebral edema, noncardiogenic pulmonary edema, altered mental status, and death.

History:

The term Exercise-Associated Hyponatremia or EAH was put onto paper by non-other than the wonderful South Africans (yet again!). It was a condition that was described in a handful of superathletes that competed in events over 7 hours.

A recent study in 2002 (of Boston Marathoners) found that of their sample size of 488 runners, that 13% developed EAH (purely diagnosed by serum levels).

There have been a number of accounts of death due to EAH:

• 4+ deaths in the military between 1989 and 1996 - recruits were encouraged to consume 1.8L of fluid per hour of time spent in temperatures above 30C.
• 2 USA physicians - too healthy??
• 2002 had 2 female runner deaths, one each in Boston and Washington Marathon
• 2 college students died participating in a hazing requiring downing gobs of water
• 2007 - a 28 year old female died while competing to see if she could drink 2 gallons in a short period of time, without going to the bathroom

 Who's at Risk?

A couple of nephrologists from the University of Virginia have outlined some of the risk factors based on current evidence:

• Exercise duration over 4 hours, or slow running/exercise pace
• Female gender - postulated that it may be moreso due to body mass
• Lower body weight
• Excessive drinking (>1.5 L.h) during the event
• Pre-exercise overhydration
• Abundant availability of drinking fluids at the event
• Use of NSAID anti-inflammatory medications
• Extreme hot or cold environments

What do we do? Drink or no drink?

If you are serious about running in a race, you will have to practice your long distance runs before the race date. Weigh yourself before your run, monitor exactly how much water you have ingested during your run (drinking only when feeling thirsty), then weigh yourself immediately after the run.

There should be a net loss of body weight or an unchanged body weight. If your weight has increased during the run, you have consumed too much water and are at risk of EAH. Try to figure out the amount of fluid you will need through the run with this test.

DO NOT overhydrate the day before the race. During the race, I was explained that you should grab the small amounts of electrolyte solution (small amounts, to maintain the small amounts of salt lost), and take the water handed out and throw it onto your head (helps cool you down!).

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This seems like a topic that I can write forever upon! I normally would write up the reference list, but wil hold off for now, because it has gotten pretty late! If interested, send me a message and I'll compile the list for you!

TO ALL THE WEEKEND RUNNERS:

Thanks for reading!!

Back to Basics, Repair at the Cellular Level: Phases of Healing

Essential to guiding any client's rehabilitation is a strong knowledge about the phases of healing.  This is a very complicated process that we will separate into three stages:

1. Inflammatory Phase
2. Proliferation Phase
3. Remodeling Phase

Inflammatory Phase

• Begins upon tissue damage (mircodamage) - lasts 0-96 hours
• Blood vessels and cells are damaged, chemicals are released. Ultimate result is pain and swelling.
• This phase is portrayed by:
• Pain
• Produced by chemical reactions on the damaged nerve endings, and by the increased local pressure.
• Swelling
• Chemicals are released locally that make blood vessels lose more fluid (not necessarily blood) into the damaged area. With this fluid, lymphocytes (our immune response) are carried.
• Heat/Redness
• Damaged cells release chemicals that open up local blood vessels. Blood flows more freely to these areas and it becomes warm and pink. There may also be bruising.

• Goals for therapy:
• The body's reaction to damage is primitive. The inflammation phase is usually dragged out too long, and so we try to diminish some of its effects. We want to reduce bleeding, swelling and pain. 
• PRICE principles are in effect: Protection of the damaged area from further damage. Rest the area (if you have blown out your ankle, don't keep walking on it). Ice will be our go-to for the next week or so. Compression may be appropriate, but must not be overly restricting - speak with your physiotherapist about this! Elevation - try to keep the injured area above the heart. This will help reduce swelling (works especially well with ankles/feet).
• Other interventions will be maintaining your pain free range of motion, and possible use of anti-inflammatory medication/rubs.
• Also available for treatment in this early phase is ultrasound (swelling), some electrophysical agents (pain), and acupuncture (pain and swelling).

Proliferation Phase

• Lasts roughly from day 4 - day 15
• The all very important scar formation. Fibroblasts (scar cells) were brought in through the inflammatory phase and begin laying down scaffolding for other healing cells to move on.
• Fibroblasts mature into myofibroblasts that then close the edges of the wound - scar contraction.
• Important to note is that the scar is laid down in a very mish-mash way. The scar is weak and not normal tissue!
• Swelling still persists, but it is less than during the previous phase.
• One of the main signs during this phase is loss of motion - the scar contraction affect your available range of movement severely!

•  Goals for therapy:
• We have to make sure that we are gently loading the scar through range of motion exercises. The integrity of the scar is such that makes it weaker than regular tissue. Our goal is to stretch and load the scar, but not so much that we damage the site again and restart the inflammatory phase.
• Loading of the scar helps us develop the orientation of the fibers of the scar - as the fibers align, the scar becomes stronger, and closer to normal tissue.
• Ultrasound (in-vitro) has been shown to increase collagen production (scaffolding) and thus increasing the scar strength.

Remodeling Phase

• From day 15 to month 6 (and upwards of several years)
• The scar was full of blood vessels in the previous phase - it now has very few.
• The scar is fully laid down, but is still weak.
• Goals for therapy:
• Achieving full range of motion through passive ROM, mobilization or manipulation of soft tissue.
• Strengthening exercises (especially eccentric loading)
• Sometimes, scar transverse friction massages will help with final orientation of the scar.

A therapist demonstrating transverse friction massage for tennis elbow

May is National Physiotherapy Month!

The Canadian Physiotherapy Association (CPA) is again celebrating the physiotherapy profession!


Have you been keeping up with the NHL this year? Hockey Night in Canada games had previously been airing physiotherapy commercials to try to bring the profession to light with the public.

If you have missed the advertisements, you can see them on this link to YouTube!

Simply Inspiring.. Elephant with Amputation

Elephant who gets his foot destroyed in a hunter trap, gets a new lease on life!

Check story here: http://worldblog.msnbc.msn.com/_news/2011/11/04/8633536-wounded-elephant-walks-again-thanks-to-jumbo-sized-false-foot?lite

Away with the flat feet! AAF Beware! - Adult Aquired Flatfoot (AAF) and Posterior Tibialis Tendon Dysfunction (PTTD)

Adult Acquired Flatfoot - aka AAF - is a deformity of the foot and is a result of a number of different pathologies. In practice, the most common reason for the development of AAF is Posterior Tibialis Tendon Dysfunction (PTTD). We're done with the abbreviations for now...

Bilateral Posterior View

Taken from: http://www.podiatryandchiropodycentre.com/flatfeet.html

Bilateral Anterior View

Taken from: http://www.foottalk.com/d_flatfoot.html

Unilateral (R) Posterior View

Taken from: http://test2.aaos.org/oko/description.cfm?topic=FOO017

AAF is a technical way of saying that over time, your arches have collapsed. This can lead to significant pain in the foot, but because of the position the ankle is held it can also contribute to knee hip and low back pain. The foot being in a fallen arch position also leads to further degeneration of the joints of the foot and can make simple walking very uncomfortable.

PTTD is one of a number of ways to progress into AAF. The posterior tibialis muscle holds up the longitudinal arch of the foot, stabilizes the midfoot, and plantarflexes/inverts the foot. This tendon/muscle can become damaged with high-impact sports of jumping/landing/running (basketball, soccer - made worse by the fact that there is absolutely no support in soccer shoes!). Other risk factors for development include being a woman over the age of 40, previous injuries to the ankle, diabetes and high blood pressure. Obesity is also a huge contributing factor (no pun intended?).

Taken from: Travell and Simons

Predominantly, PTTD is treated with custom foot orthoses or ankle-foot orthoses along with a stretch and strengthening routine. This treatment regime was substantiated by a number of articles that were released and published by Kulig from the University of Southern California (Physical Therapy), one being: Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial published in 2008. It described a 12 week program comparing three categories of regimes: orthotic wear with stretching (1), orthotic wear with stretching and concentric exercise (2), and orthotic wear with stretching and eccentric exercise (3). Best outcomes came from the third group - the orthotic/stretch/eccentrics.

So how to we train the posterior tibialis muscle/tendon? Finally the meat and potatoes! Kulig is rampant with the research, and published another paper describing firing patterns of different muscles of the foot/ankle with different resisted movements. She found that the resisted movement that engaged the posterior tibialis muscle maximally without significant contribution of other foot muscles was planted foot adduction.

Images taken from: http://blog.runnersroost.com/blog/?p=840

You can see that she is seated (the knee has to be at 90 degrees to allow rotational motion at the knee joint) and that her heel remains in contact with the floor at all times. Concentration is emphasized on slowly releasing the elastic from an adducted position. This being an endurance muscle, we will train it as such: 3-4 sets of 20 reps.

 

Another great isolation exercise to add into the rehab of clients requiring it!

References:

Kulig, K et al. (2004). Selective Activation of Tibialis Posterior: Evaluation by Magnetic Resonance Imaging. Medicine & Science in Sports & Exercising, 36(5), 862-7.

Kulig, K et al. (2006). Non-operative management of posterior tibialis tendon dysfunction: design of a randomized clinical trial. BMC Musculoskeletal Disorders, 7(49), 1-7.