Technique Tuesday 7- Hip abduction in side lying

Hi everyone,

Here’s the latest edition. You know the drill.

Until next Tuesday or a new post

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

Eccentric Hamstring Strengthening

Hello

This blog post had a very organic origin. In the last few weeks I have seen/heard of too many people ‘pulling their hamstrings’ then I can recollect. In my little world, it seems to have reached epidemic proportions (not quite really, but thanks for indulging me). So let’s intervene. Now this is a big topic to tackle. For the purpose of keeping it short, we will only discuss exercises here. Before we start though I would like to make a disclaimer for my non-physio readers, please consult your physio  if you have already injured your hamstrings. These exercises may not be the best approach to your rehab goals depending upon what stage of recovery you are at. For the rest of you proactive people who have no pain and want to train for injury prevention or just try some new exercises and are tired of the same old hamstring curls etc, give these a shot.

For the most part, hamstring injuries are seen more in a ‘generally’ active, athletic population. Research seems to indicate that most of the hamstring strains occur not when the muscle is contracting (concentric) but when it is lengthening under tension (eccentric). An example during running would be when the heel of the forward leg is about to hit the ground. During this motion, the hamstring muscle is lengthening under tension.

Now logic dictates that we train this muscle similarly (eccentrically). Over the years, more and more research seems to indicate that eccentric exercises are a good option for injury prevention and hamstring  strain rehabilitation (other muscle strains too). Plus, your athlete patients will love the challenge as it breaks the monotony and are difficult to perform. So start slow and gradually progress. If it hurts, do listen to your body and stop.

 

So here goes-

  1. Hamstring walkouts –

 

 

 

2. Bilateral hamstring sliders-

 

 

 

3. Single hamstring sliders-

 

 

 

4. Eccentric hamstring on physio ball-

 

 

 

5. Eccentric hamstrings on TRX

 

 

 

 

5. Nordic Hamstring Curls- This one is modified/ scaled down to make it easier. Its a difficult movement to perform so I begin performing this by not going down on the floor completely. Start small as you develop control and strength and then work through the full range of motion.

 

 

 

Worth a try? Now work those hammies.

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

References-

  1. Woods, C., Hawkins, R.D., Maltby, S., Hulse, M., Thomas, A. & Hodson, A. (2004) The Football Association Medical Research Programme: an audit of injuries in professional football – analysis of hamstring injuries. British Journal of Sports Medicine. Vol. 38, No. 1, pp. 36-41.
  2. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculotendon dynamics during stance and swing phases of high speed running. Med Sci Sports Exerc 2011;43:525

#Technique Tuesday 4- The Lunge

On this edition of #techniquetuesday we will discuss the Lunge. The lunge is a great  lower body exercise that works some of the major muscle groups of the legs- the Quads, the Hammies and the glutes. In addition to this, it also trains dynamic single leg stability and motor control and depending upon the variation you chose to perform one could also throw in half kneeling stability work and eccentric quadriceps work into the mix. All in all its a great exercise.

However, it doesn’t seem to be the most enjoyable exercise as many seem to hurt themselves while doing it. So lets try to do em right.

Avoid these common mistakes-

 

 

WATCH OUT FOR-

  • Knees going past the toes
  • Heel lifting of the floor

 

 

 

 

WATCH OUT FOR-

  • Knees going past the inner border of the foot (aka excessive valgus)

 

 

INSTEAD TRY THIS- 

 

TRY TO –

  • Shift your weight back on to your heel with the heel of the front leg flat on the ground.

 

 

 

TRY TO –

  • Keep your knees aligned over your feet

 

VARIATION-

The above lunge exercises seem to work the anterior chain with the focus on quadriceps (Don’t get me wrong, you are still working all the muscles). As a variation, to get more of my posterior chain muscles (Hamstrings, glutes) or to avoid straining sore knees/quads I like this variation-

 

Keep at it, do it right and do it often. Until next time

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

 

 

#Technique Tuesday 3- The Plank

Welcome back,

The week ahead is long and there is much to do, its only Tuesday. So we like to keep it short and sweet on #techniquetuesday. Today we discuss the plank.  Plank is a great core exercise but often faulty techniques negates the true benefits of the exercise. In my mind, the true purpose of the plank is to engage the core to brace and protect a ‘neutral’ spine. However, I often find when performing a plank that the hold time supersedes good form. There’s a lot of excessive arching, ribs flaring out,  more than desired hip flexion, cervical extension etc all for the sake of getting that extra 30 seconds. Here are some example-

In the pictures below you will see (clockwise)-

  1. Excessive thoracic kyphosis (Rounded upper back), rib flare, excessive  cervical protraction (chin sticking out).
  2. Excessive thoracic kyphosis (Rounded upper back), excessive lumbar lordosis (arched lower back), rib flare, excessive  cervical extension (head turned up).
  3. Excessive hip flexion.

WATCH OUT FOR THESE COMMON MISTAKES!

 

Try this instead-

 

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Remember, the spine is not perfectly straight so a little ‘natural’ arching is acceptable. A cue I often use is to gently pull the front rib cage down towards the feet, I’m not a big fan of the cue ‘drawing the belly button towards the spine’ because it interferes with normal diaphragmatic  breathing (which is important for proper core engagement).

If the plank off the feet/toes is hard, regress it to ‘off the knees’ like this-

 

Do it right and do it often. Until next time

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

Speed and Agility Drills

As I have mentioned before many times, my masters in exercise science was just what I needed after completing my bachelors in physiotherapy. To over simplify it, It gave me an insight into exercise selection, administration and prescription which was only brushed in my bachelors of physiotherapy program. I believe this was for good reason, the bachelors degree in physiotherapy is focused on rehabilitation. Not as much on improving performance or training otherwise healthy adults. It brushes over it, but not thoroughly enough in my humble opinion. No wonder physios in countries like the US and Canada often go through this path of exercise science/ Kinesiology before entering physio school. I went the other way, but the bottom line is, there was a lot to learn and it is fascinating.

One of the facets of training which I was fairly unfamiliar with was training for speed and agility. Before we proceed, this is what the NSCA describes in its book ‘The essentials of strength training and conditioning’ speed and agility in terms of training-

Speed- the skills and abilities needed to achieve high movement velocities.*

Agility- the skills and abilities needed to explosively change movement velocities or modes.*

Most athletes need these attribute, the ability to get from point A to point B fast, this could be chasing a football/soccer ball, a run up for a fast bowler, sprinting to the finish line etc. Also, the ability to accelerate, change directions, decelerate etc. like in tennis or basketball. The ability to produce force fast in a certain direction would still require baseline/foundation strength. But we must also train for that quick first step in a sprint or that quick change in direction which must be practiced with drills. Just lifting heavy things might not help with that. These drills reinforce the ‘brain-to-muscle’ connection that we often talk about that is learnt with repetition.

One of the common drills I often saw being used by strength coaches as a warm-up or on a low training volume day is ladder drills. Here is a video of one of my colleague performing some basic (not simple) drills on the ladder. She has a track and field background in high school and collage and has practiced these drill many times over the years.  Enjoy-

  1. Forward sprint
  2. Forward sprint (Variation)-
  3.  Lateral In and out’s-

    4. Icky Shuffle-

    5. Cross behind forward-

 

I also use some of these drills in our senior population. After all, what is one of the major reasons for falls in seniors with balance issues? I think its one of them is the inability to contract muscles fast enough to prevent a fall. An example would be if they have one of their legs caught in the cable/carpet at home, its the inability to put the other leg forward to prevent a fall. Why not train them to move faster or to be able to maneuver around objects at home with ease. It can also be a great multi-planer cardio-vascular exercise for them. But of course at their own pace, keeping their medical history in mind and keeping these drills simple. There are many more drills and exercises which I will discuss in later blogs. What are some of the drills that you like? Feel free to share.

Until next time

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

 

 

# Technique Tuesday 2- The Pushup

On #techniquetuesday part duex, we discuss pushups.
In the 1st video you see some of the common mistakes when performing a pushup. Elbows are not close to the body but flaring out, not going deep enough and not going down and coming up as a whole but instead bending and arching from the back which might be indicative of weakness or improper engagement of the core.


2nd video shows corrections for the above along with finding a proper neutral starting position for the pushup

 

image1.jpeg

 
If you are unable to perform a push-up with proper form, regress by doing it off a bench, table or mats as demonstrated in the 3rd video.

 


4th video is another regression of the pushup off the wall. 


Do it right and do it often. Until next time

Pursue excellence-

Abhijit Minhas

(BPT,MS,CMP,FMT)

My current thought process on fixing Scapular Winging

Since my blog post on shoulder part 1 and 2 that you could read Here and Here, I have received a lot of questions on scapular diskinesia and recommendations on managing it. As I did not really cover it in my previous blog post, this blog post will be dedicated to just that.

Scapular dyskinesia, which means abnormal movement of the scapula can present itself in different forms but most commonly manifests itself as ‘winging’ of the medial or inner border of the scapula. ‘Winging’ means that the inner border of the scapula lifts off the rib cage. This could happen during a simple overhead arm elevation (open kinetic chain) or during an exercise like a pushup (closed kinetic chain).

In an ideal healthy shoulder complex, the scapula and the ribcage work like new lovers; always close to each other and ‘almost’ inseparable. The important task to kindle this romance is primarily bestowed upon the serratus anterior (SA) along with the rhomboids and lower traps. However, sometimes these muscles misbehaves creating some trouble in paradise in this relationship. The serratus anterior is supplied by the long thoracic nerve and on observation of winging in your patient, its prudent to check for some kind of long thoracic nerve issue by doing a neck screening.

However, in my experience if there is no H/O traumatic injury, systemic illness etc that might effect the long thoracic nerve; we might be dealing with an inhibited SA. In the past I would quickly get to work by strengthening SA with some of these classic exercises for strengthening.

  1. Theraband SA punches
  2. Theraband and pulley Rows
  3. PNF for lower traps
  4. ‘Y’, ‘T’ exercise.

This strategy could be a hit or a miss. It could work for some deconditioned/older patients who have general muscular weakness and strengthening the SA, rhomboids and lower traps  could fix the problems. Makes sense right. However, very often its a miss. Picture a client who is fit, could perform pushups until the cows come home, and is nowhere close to having muscular weakness but still shows signs of winging with arm elevation or with other CKC exercises. What do we make of this??

What this means to me is that the SA is unable to reflexively hold that medial border and inferior angle down on the rib cage during certain movements. In other words, its unable to provide the stability through the full ROM. It could be either an inhibited muscle unable to generate enough force to hold that shoulder blade down due to bad ribcage-scapula position or maybe a timing issue where its not firing well at certain periods through the ROM or more likely a combination of both. Hard to be exactly sure here.

But the key here is stability. In Human kinetics, I believe this means the ability of the body to hold the correct form through full ROM. And here lies the problem. Almost all the above exercises work on a single plane at about a 90-120 degree of arm in flexion. Hate to state the obvious but are they functional? Will they train the muscles to hold that scapula in a good fixed position on the rib cage in a overhead position in OKC exercises? My experience is mostly negative. How about you?

So where do we go from here? Below are some of the strategies that I have incorporated recently that I find extremely useful and better than the traditional exercises stated above. I demonstrate this in videos below on (1) myself  as I have some left scapular winging with arm elevation and (2) on my colleague and fellow Physio who is involved in competitive dragon boat racing.

In the video below, I do a Dumbell press of 40lbs with a plus (protraction) to demonstrate how my left SA struggles to hold the load compared to my right.

 

 

Below is a video of me doing an arm elevation test which demonstrates winging and how I correct it.

 

 

By pushing on the wall and protracting my shoulders, I am getting into a ‘locked ribcage’ position and reflexively activating my SA to hold that medial border down by creating a good congruent ribcage shoulder blade position. No theraband exercises to strengthen the muscle might be needed in my case. Just a favorable position for my SA to work reflexively.

Need another example? Sure. My colleague is a perfect example of a candidate who is not weak, in fact she is very strong and trains hard to compete in dragon boat racing. You think she’d have a weak serratus? Or that you could fix her winging with a theraband? I’m sure you know the answer.

 

 

Here I must report, she does not have any pain, just C/O weakness. Her winging does not seem to be excessively abnormal, it could be well within a certain normal range of winging which most of us might have but asymmetrical to the other side.

 

Now, I like to be a little more specific depending upon the clients needs when prescribing exercises to tackle scapular instability. To give a few examples, I’d prefer more OKC exercises for swimmers, volleyball players, rowers, cricket bowlers etc and CKC for gymnastics. Often, both as the situation demands. Here are some examples of my preferred exercises-

Closed kinematic chain-

  1. Cat Cow

 

 

 

 

2.  Quadripod knee lift

 

 

 

 

3. Plank plus-

 

 

 

 

4. Pushup plus

 

 

Open Kinematic Chain exercises-

  1. Kettlebell press supine

 

 

 

 

2. Kettlebell Overhead press- Now for some of my favorites, the press. Another excellent way to fix a winging problem if noted in a OKC movement is to load that pattern and let the shoulder fix the abnormal pattern by itself. Sound a little like RNT? I think so true. (While I don’t demonstrate winging with a press but more with arm elevation, I’m sure you have seen clients that show instability with pressing. If there is no pain, the best way to fix the instability is by… thats right, pressing but with a load. Try it out

 

 

 

Not convinced that pressing heavy load will fix shoulder winging/ instability during flexion? Watch the next video and reassess your thought process. Hopefully I can convince you to give it a shot.

Kettlebell press with opposite arm-

 

 

So, What do you think?

 

3. Arm bar-

 

 

 

Watch those muscle trying hard to reflexively stabilize. Its oddly satisfying.

 

Time to wrap this up guys, but before I leave you here’s something to ponder about. For long we have thought of scapular instability to be closely related to sub acromial impingement. Not trying to be the devil’s advocate here but recent research has shown that scapular instability might not have a major role in impingement or pain in the shoulder (https://www.ncbi.nlm.nih.gov/m/pubmed/24174615/?i=2&from=/16015238/related). However, I take this with a grain of salt and always keep in mind that there are fallacies and shortcomings with research and this does not mean that it cannot be a cause of the above. Alas, such is research. I will still work on fixing this problem with my patients as I am looking for symmetry on both sides of the body not just for injury prevention but also for better performance.

Hope this blog helps.

 

Until next time-

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

 

Reference-

1. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. Ratcliffe E, et al. Br J Sports Med. 2014.

MY CONTINUOUS LEARNING CURVE- REACTIVE NEURO-MUSCULAR TRAINING

Often introspecting my strengths and weaknesses within the realm of the rehab world, I had realized that one area that I needed to put some extra work into was to innovatively select and prescribe exercises for my patients. For a very long time all my attention and energy was focused upon learning new manual therapy techniques and improving my diagnostic skills. However, it didn’t take me too long to realize when I first started working as a physical therapist in NYC that simple SLR’s, knee extension and back extension exercises etc were not going to cut it when dealing with a relatively active clientele. I had to be able to prescribe progressively challenging exercises and to give clear cues and master the nuances of proper exercise execution. I was also in awe of some of my american physio colleagues  that I worked with. They were so easily able to progress or regress an exercise, tweak it to their patients needs and provide alternative exercise options to train a certain body part. I wanted to be able to do all of this and not be restricted to being just a ‘manual therapist’.

While on this path I came across RNT. It stands for reactive neuromuscular training. I have found it very beneficial and find myself prescribing it often. So lets start by describing the main principle behind it. We often find our patients falling into a dysfunctional movement patterns when performing exercises. To correct them,  we rely on verbal or visual cues. Often these cues are enough to correct the dysfunctional pattern. However, sometimes even though our patients understand these cues, the body is still unable to correct itself. We are so used to moving in a certain way that its hard to break that dysfunctional neuro muscular pathway that is embedded in our brain. This often manifests itself when our patients might say something like ” I understand what you are asking of me, but I just can’t seem to be able to do it” or “my body just refuses to move that way”. This can often lead to disappointment and frustration for both you and your patients. If you have found yourself in this position, RNT can be extremely useful.

Instead of relying on cues that might not work or may sometime be too complex and confusing, we can use external force to push the body even more into that dysfunctional pattern! Yes, you read it right, physios and trainers often describe this as “feeding into the dysfunction”. By doing that, you now let the body figure it out on its own what it needs to do to get out of that dysfunctional movement pattern. The body reacts to this external force by self correcting itself by firing the right set of muscles to seek stability and control. What a novel way to retrain a movement patterns and neuro muscular pathways. The external force can be applied either manually, using elastic therabands etc. They are plethora of possibilities and it gives you many opportunities to get creative. Below are two examples of applying RNT to two popular exercises- the lunge and the over head squat (OHS). Ok, so less writing, more watching. Here goes-

The Lunge-

 

 

 

The Over head squat-

 

 

These are just two examples to begin with. I’ll cover more exercises in a following blog post. What are your thoughts on this form of training? Do you incorporate this in your practice? If you are interested to send some of your own videos of using RNT in your practice and would like them to be featured on this blog in the following post, please leave a comment and we can talk more.

Keep the dialogue going, I like where this whole thing is headed! I have interesting thing lined up for you in the next few blog entries. Stay tuned and if you like the content, subscribe to get the next post to your email.

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

The science of training (strength matters 2)

Welcome back,

Ready to go down the rabbit hole?

Today’s blog post is a follow up on the last blog post ‘Strength matters’ where I wrote about why its a great attribute to work on strength and its benefits. If you didn’t get a chance to read it, I recommend going through it first (You can find it Here). What is the difference between hypertrophy, strength and power and how to train for each of these attribute? Let me give this a shot-

Hypertrophy– it is a form of resistance training which primarily focuses on increasing muscular size. The by product of this is also an increase in strength no doubt. It is most often seen in the sport of body building where the competitors are judged based upon biggest muscular development, definition etc. This training can help athletes during off season to gain some mass and is can be utilized by athletes to jump to a higher weight classes in sports like wrestling, boxing etc. Also, a great option for patients recovering from injury or individuals who have no prior experience with weight training. This training ‘generally’ utilizes isolation exercises to focus on very specific group of muscles like dumbbell chest press for pecs, bicep curls for bicep brachii, tricep extensions for triceps, hamstring curls etc etc. Most of us our fairly familiar with this kind of training. Here’s a good example of someone training for hypertrophy.

 

arnold
Remember this guy!

In my opinion most of us are fairly comfortable with prescribing exercise for hypertrophy, but know this, the most ripped guy is not the strongest or fastest, he just has better muscle definition and less body fat then the rest. This does not dictate improved athletic performance.

Here is where it gets interesting!

 

Strength –  in its simplest definitions means the ability of the muscles to generate/produce force to overcome resistance. This form of resistance training is different from hypertrophy in a way that it helps build strength in a person without gaining a lot of muscle mass. In other words, here the primary focus is on getting stronger, not bigger (muscles). The intention of this training is force production and activation of neuro-muscular pathways. The strength is generally measured by the amount of weight a person can press (bench, overhead press), lift (squat, deadlift) etc. It is generally trained with compound multi joint movements which are specific to the athlete’s sports.  Strength training is given preference during off season (few months prior to games, series, matches) as it utilizes high intensities and loads. Here is a video of a strongman competition from Europe. Notice how these guys are not ripped and muscular like Arnold but they could outlift most of the bodybuilders. These are the men that break world records and are also summoned by Queen Cersei, queen of the seven kingdoms and the protector of the realm to be her queens guard (hope you recognize the giant from game of thrones. I’m sure he will put his strength to display this season cracking some more skulls).

 

 

Power– is work done per unit of time. Earlier, I would often use the terms strength and power interchangeably but know that both are not the same. The key difference is that power training requires generation of force as fast as possible (Strength training focuses on force produced but not the speed). This form of training has great benefits in athletic performance as it works on explosiveness. When does an athlete need the above mentioned power you ask? They need it the most in the first 2-3 seconds of a hundred meter sprint as soon as the shot is fired, the sprinter’s lower body must produce the maximum amount of force as fast as possible, they need it to produce enough speed to throw a short put or a javelin  as far as possible (upper body strength alone wouldn’t be enough), a batsman needs the upper body explosiveness to swing the bat hard and fast on a relatively slow/spin bowl to make it go the maximum distance and cross the boundary. There are many examples as most of the sports require some sort of explosive power. Some exercises that can be used to develop power are Olympic lifts (snatch, clean and jerk), plyometrics (box jumps, lateral hops, clap push ups, broad jumps etc) However, unlike hypertrophy and strength training which can be very beneficial for our patients and the average joe/jane, power movements are highly skilled movements (as you will see in the videos below) which require weeks if not months of training and are generally used to improve athletic performance. This kind of training does not carry as much benefits for the patient population. Here are a just a few examples of power exercises-

 

 

Understanding these concepts is great but lets discuss  how can we train for these attributes individually in terms of sets, reps and weights lifted. What I present to you below are NSCA general guidelines (slightly modified) that are followed by most of american college level strength and conditioning coaches, physical therapists and personal trainers.

Type of training             Load (%1RM)             Repetition           Sets

Hypertrophy                   65-85                           6-12                        3-6

Strength                           > 85                              < 6                          2-5

Power                               85-95                            1-3                         2-5

(Needless to say, one must calculate the 1 repetition maximum of a person before prescribing the above.)

I don’t know how you feel about all of this information, but the first time I was introduced to all of these concepts I was bewildered but extremely excited. I realized I knew so little and there was so much to learn. After all, up until I started to delve into this subject had someone asked me to train a high school basketball or cricket team for sports specific fitness, I would have most likely advised the team to go hit the weights in the gym doing bodybuilding exercises like bicep curls, leg extensions and other fairly unproductive isolation exercises along with some running around the cricket field to train cardio. This would be just very bad exercise prescription on my part which would barely improve any physical preparedness for these school athletes.  Lets be honest, in college we learn how to treat low back pain, knee pain etc etc but as physios we are often expected to prescribe training protocols to athletes and I know that a lot of us are not fully prepared for this. I also want  to reiterate that even though I have been harping about athletes, using strength training safely on our patients has tremendous benefits.

My hope with this blog post series is to help shed some light on this aspect of our work so we can be more multi faceted physiotherapists. We have just barely scratched the surface here, in the following blog posts in this series I would like to talk about what exercises have the maximum influence on increasing hypertrophy, strength and power and how they can increase athletic performance; training cycles, sports nutrition etc etc, the list is endless. Meanwhile, I hope this blog will stir some discussion which is mutually beneficial to everyone as I would love to hear inputs from other sports physios who are already in the trenches. Leave a comment.

As always my friends

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)