Foot problems can be a nightmare for anyone who exercises upright. The fact that the foot must interface with the ground consistently can jeopardize your workouts (and therefore your health) when there is a problem there. Plantar fasciitis is a common foot problem that effects people that engage in all kinds of activates; from recreational walking to higher impact versions of exercise.
Plantar fasciitis is an inflammation of the plantar fascia-the thick webbing of fascia at the bottom of the foot. The symptoms are most commonly felt at the heel where the plantar fascia and the Achilles tendon mesh with one another. The pain is usually sharp and progressively gets worse over days or weeks. Plantar fasciitis does not occur overnight.
The symptoms are usually the worst when the foot first hits the floor in the morning. But symptoms may also be triggered after standing following long periods of sitting. In both instances there is a “pulling” at the attachment on the heel. Very often the symptoms lessen after the foot and body have been warmed up. This is because the fascia must lengthen when the foot is flat on the floor and tighten as we push off. “Warmer” tissue will be more compliant to lengthening and therefor create less pulling at the heel attachment.
Traditional exercise interventions for helping treat or prevent plantar fasciitis involve stretching the calf. This is because both calf muscles (gastrocnemius and soleus) attach to the bottom of the foot and plantar fascia via the Achilles tendon. Flexibility in the calf transfers to improved flexibility in the plantar fascia. But the only way to effectively stretch both calf muscles is to stretch with the knee straight and bent. Bending the knee releases the gastrocnemius and allows better application to the small, deeper soleus.
If we take an integrated look at the body as we do at Function First, we can see that the tightness in the plantar fascia can be connected not to just the calf, but to the hamstrings and all the way up the lower back. And we must also realize that the calf muscles don’t only get tight in a front to back motion. They also can be tight side to side when the foot pronates or supinates. Therefore, for many people the calf stretching exercises they do provide limited or temporary help.
Muscles should never be stretched cold. And if you are experiencing plantar fasciitis symptoms this is even more critical because as you attempt to stretch the cold muscle you can actually do more damage. With plantar fasciitis you must also be very careful not to stretch to the point of pain. It should be a gentle, comfortable pull. If you do not have plantar fasciitis it is OK to stretch to the point of mild discomfort.
Try this dynamic calf stretch that functionally elongates the structures from the bottom of the foot to the lower back and through the side to side dimension:
Stand facing a wall with the toes of one foot elevated 3-4” off of the floor using a book or the like. Make sure the foot is pointing straight ahead. Place your hands on the wall for balance. Lift the knee of the other leg straight up toward your chest. From here, bring the leg straight back behind you. As the leg is moving behind you the torso should lean forward toward the wall. This should cause the knee to straighten more on the leg that you are stretching. As the knee straightens more the stretch should become more noticeable up the back of the entire leg. Immediately bring the knee back up toward the chest and repeat. This is a dynamic but controlled stretch so there is no hold. Do this for about 10 repetitions.
Next, lift the knee again and hold the leg up so that the thigh is parallel to the floor. From here, move the knee across your stance leg and then all the way to the other side like a gate that is opening and closing. Your hips/pelvis should turn as you do this. Repeat this movement dynamically 10 repetitions to each side.
The final motion is bend the knee of the support leg about 15 degrees. The stretch should be felt lower and deeper on the calf now. From here repeat the side to side motion 10 more times to each side.
We all know stretching and creating mobility does not sell as “sexy”. But there is no denying the role it plays in moving better, more comfortably and preparing for activity. The unique motion of the Core-Tex™ provides a completely different experience to improving mobility.
The motion of the Core-Tex™ encourages and guides the body into positions that address the tissue 3 dimensionally with ease. The mobility exercises with the Core-Tex™ are its “secret weapon” and one of the favorite applications of Core-Tex™ users.
Note: This post was originally published on PtontheNet.com
Anthony B. Carey M.A., CSCS, AHFS
Objectives:
1. Establish a working definition of corrective exercise
2. Set reasonable expectations for a corrective exercise program
3. Introduce a corrective exercise model
Corrective exercises have become a foundational part of the fitness landscape in recent years. As the understanding of human motion evolves, the fitness community has embraced the opportunity to help their clients move better. This article will present a framework for a model of developing comprehensive corrective exercise programming. This framework is based on both scientific principles and the author’s 20 years of experience with corrective exercise.
For the purpose of this article, it is beneficial to establish a working definition of corrective exercise: Corrective exercise is the use of movements and/or postures to produce desirable changes in movement strategies, thereby minimizing or eliminating compensation and producing efficient movement patterns. Corrective exercises should precede more integrated exercises because they can cue the client’s motor system to respond in a more desirable way and assist in removing or improving biomechanical constraints.
Fitness professionals should be reminded that any reference or attempts at treating and/or diagnosing injuries is outside of the professional boundaries and should be the domain of licensed medical professionals.
It is of this author’s opinion that the various forms of myofascial and trigger point release play a significant role in the overall corrective strategy; however, they are not classified as “exercises” and will not be included in this article.
From one perspective, human movement is based on “reward” or “punishment” feedback. The positive feedback, known as the “reward”, most often goes unnoticed because these are the efficient, presumably pain-free movements. The “punishment” is the negative feedback we get in the form of aches, pains, soreness, stiffness, etc. The body will always take the short term reward despite the potential for longer term punishment. For example, if your patella is not tracking properly and leading to low-grade irritation (punishment), you alter your gait to avoid the provocative motion (short term reward). But as a result, the rest of the kinematic chain is affected and potential damage manifests elsewhere (punishment). Slouching in a chair (short term reward) is another example. The reduced effort required for slouching takes precedent over the stress applied to the tissue during that moment in time and cumulatively.
The reward/punishment model along with all motor learning is part conscious and part unconscious. Lemon stated, “Motor learning is a consequence of the co-adaptation of the neural machinery and structural anatomy.” Therefore, we must fully realize that the brain drives the body but the body’s structural adaptations will feed right back into the brain. For example, excitation of the motor nerve from the spinal cord determines how frequently the muscle is excited, but how the muscle actually contracts and relaxes is determined by the physical properties of the muscle tissue (Brooks).
An effective corrective exercise program must, therefore, influence both the structural anatomy and the neurological system via the efferent and afferent pathways. The efferent pathway carries nerve impulses from the brain to the muscles – the brain driving the body. Whereas, the afferent pathway carries nerve impulses from the muscles to the brain – the body communicating back to the brain. This is a departure from a corrective exercise paradigm based purely on “tight” muscles that must be stretched and “weak” muscles that must be strengthened.
The model proposed here as three driving principles:
1. Logical sequencing of the individual corrective exercises facilitates
immediate neuromuscular adaptation,
2. Positive cascading events related to the quality of motion will occur when a strategy is developed to address a hierarchy of associated dysfunctions, and
3. Beneficial and immediate short term changes in biomechanics and motor control will occur within a given session completely independent of any hands-on intervention.
Sequencing of Individual Corrective Exercises
Progressing exercises is a common component of effective exercise program design. Exercise progressions are typically defined by an increase in variables such as intensity, duration, frequency, tempo, load or volume. In other words, exercise progressions are quantitative and a broader component to exercise program design.
Exercise sequencing, on the other hand, has more to do with the relationship between exercises in a given series of exercises within a program. Sequencing looks at the effects of each exercise in the program in relation to others within the same program and is more qualitative (Carey).
As with all programming, a corrective exercise program should have a major objective. To borrow from business and personal growth guru, Steven Covey, “we should begin with the end in mind.” Sequencing is a way in which to create mini objectives, or stepping stones, to moving the neuromusculoskeletal system toward the main objective.
Having a series of mini objectives or routines within the program allows you to audit your progress through the program. The audit is necessary to ensure that the mini objectives are met. If not met, the program is not on target to meet the main objective. One exercise should prepare the body for the next and never cancel the benefits of a previous exercise.
The final exercises within the corrective exercise sequence should also be congruent with the main objective and adequately transition the client to their next stage of activity. For some clients, that may mean the session continues into a more traditional fitness program. Or this may mean leaving the session, walking out the door and getting into the car. In either event, at completion of the corrective exercise program, the client should be integrated into a vertically loaded position versus descending the program back to the floor.
Positive Cascading Events Related to the Quality of Motion
The 80-20 Principle is a principle historically applied to economics, production, engineering, and management. It states simply that 80 percent of the effect is a result of 20 percent of the causes. The corrective exercise model described here applies the 80-20 principle to the resultant movement dysfunctions we see in our clients.
If we agree the human organism is a highly integrated structure, then it is clear that no biomechanical event occurs in isolation. As a result, a change in motion of any joint in the body can create a change in motion of joints above, below, and/or far removed from the joint in question. This cascade often leads to regional symptoms or areas of limitations that the client does not even associate with the origin of the cascade. For example, a client that sits at a desk with a landline phone may continually hold their phone on the right side, between their shoulder and ear, because the phone is located on that side of the desk. As a result, there is continuous tension on the right side spinal musculature. The cumulative effects are chronic hypertonicity of the muscles and associated lateral flexion of the spine to the right. The shoulder elevated to the ear, while on the phone, eventually depresses during normal standing as the cervical spine laterally flexes left to reorientate the eyes to the horizon. This individual is susceptible to a myriad of mechanical stress that will be present as localized symptoms at the neck and shoulder, as well as from the thoracic back to the feet. The catalyst of all this was the ergonomics of their phone use. As a result, many fitness professionals may end up working with clients who were treated in the painful area of the body and cleared for exercise only to have the problem or associated problems resurface.
Returning to the 80-20 Principle, identifying the hierarchy of dysfunctions (the “20”) will assist us in formulating the program design. Programming objectives should emphasize the most influential structures and move out from there. This is in contrast to a corrective exercise program design that might assess multiple movement/postural dysfunctions and then create a corrective exercise program with exercises for each individual dysfunction.
Beneficial and Immediate Short Term Changes
The movement dysfunctions and limitations seen in clients can be multi-factorial. They may be a result of previous injuries, current pain and/or apprehension, genetics, pattern overload from work or recreational activities, psychological state, or any combination of these factors. If we return to our reward/punishment model, despite what the client might say- their body is behaving this way because there is a reward. Some examples of the reward are:
1. Pain avoidance.
2. Lower metabolic demands. The metabolic cost is too high for local
muscle groups or overall on the body and therefore it
is easier to continue with current strategy.
3. Conscious effort. The movement can only be influenced cognitively
and therefore other intellectual demands supersede the conscious
processing needed to influence their movement patterns.
4. Deficient motor control. No other options are available because their
motor system cannot assimilate the necessary steps to do it differently.
If we are to create qualitative change in the way a person moves, we must understand what is driving their movement strategies. A movement or motor strategy can be thought of as a way a person has learned to execute a movement. Gait is a fundamental movement strategy used by anyone who can ambulate.
Assessments of movement strategies are generally inferred by observing kinematic variables. For example, if you assess a person’s squat, the observations you are making are based on joint motions and segmental positions because we cannot see what the nervous system is doing. Even if we could see the nervous system, 10 squats that look very similar kinematically could be very different neurologically. This is because the nervous system is capable of producing very similar results through different combinations of motor unit pools, timing and contribution. This is referred to as kinematic redundancy.
Muscle synergies represent a library of motor subtasks, which the nervous system can flexibly combine to produce complex and natural movements (Safavynia et. al). Think of them as building blocks of a movement strategy (Torres-Oviedo and Ting). As building blocks, muscle synergies are more easily influenced than a complete movement strategy. From this perspective, we can see how the appropriate sequencing of the corrective exercise program can affect positive change.
Inherent to creating immediate positive changes in the quality of the movement is appreciating the variability intrinsic to any repeated movement. Variability in execution can be viewed as an advantage and not as a nuisance during execution because the variability leads to adaptation that was not previously present within the muscle synergies (Schöllhorn et. al.). With the proper corrective exercise program design, new (and presumably improved) muscle synergies can be stimulated within a session using the body’s own intrinsic variability. As a result, the various muscle synergies interact to create changes in global movement that serves as a “reward” to the body.
The results can also be of tremendous value to the chronic pain client. This client very often associates familiar movements as pain producing. By facilitating muscle synergies that produce a movement outcome in a novel way, it helps that client disassociate those movements from a familiar pain producing movement.
This change is short term since a learning effect likely did not occur within an hour session. But since changes were produced independent of the trainer or therapist, the client/patient can reproduce the results daily on their own.
Progressions within a program are made not by adding repetitions or load to the same exercises, but instead creating variability within the sub routines of the program that continue to work toward the main objective(s). We do this through graded exposure. Graded exposure in this context is applied to the amount of variability and novelty the client can successfully handle without pain and compensation. By doing so, the neuromusculoskeletal system is continually challenged by the quality and not necessarily the quantity of the input.
Conclusion
When structured properly and with a clear understanding of potential for change, corrective exercises can create very powerful adaptations in the quality of movement in our clients, athletes and patients. The model proposed in this article is part of a very successful approach that has helped clients from around the world.
References
Brooks, VB The Neural Basis of Motor Control. New York: Oxford University Press 1986
Carey, A. (2005). The Pain-Free Program: A Proven Method to Relieve Back, Neck, Shoulder and Joint Pain. New York: John Wiley and Sons.
Gelsy Torres-Oviedo and Lena H. Ting, Muscle Synergies Characterizing Human Postural Responses; Journal of Neurophysiol 98: 2144–2156, 2007.
Lemon, R.N. (1993) Cortical control of the primate hand. The 1992 GL brown prize lecture. Exp. Physiol. 78, 263–301
Seyed A. Safavynia, Gelsy Torres-Oviedo, Lena H. Ting, Muscle Synergies: Implications for Clinical Evaluation and Rehabilitation of Movement; Top Spinal Cord InjuryRehabilitation. 2011; 17(1): 16–24
Wolfgang I. Schöllhorn, Hendrik Beckmann, Keith Davids, Exploiting system fluctuations. Differential training in physical prevention and rehabilitation programs for health and exercise. Medicina (Kaunas) 2010;46(6):365-73
What’s more important: Your assessment or you intervention? Seems like a pretty simple question. And I would not be surprised if many of you are immediately thinking of one the standard responses-responses that I preach myself.
1. If you’re not assessing, you’re guessing
2. Your intervention is only as good as your assessment.
It is response #2 that has gotten me thinking of late. Through my years of learning, I have observed some amazing therapists, orthopedist, medical doctors, chiropractors, Ph.D.’s soft tissue specialists and fitness professionals perform some of the most extensive, problem- solving neuromusculoskeletal assessments you could imagine. I’ve watch them spend from an hour to several hours seeking out hidden clues, uncovering critical information and sleuthing way beyond the standard protocols.
In statement #2, if your intervention is only as good as your assessment you would think it stands to reason that if your assessment is incredibly thorough and accurate, then so should your intervention? In my observations, that this is not always the case.
In my humble opinion, if the identifying of critical “big rocks” is so challenging I find it hard to believe that generic protocols for that region of the body would suffice as an intervention. It would stand to reason, the more challenging the big rock is to find, the more complicated the surrounding compensation patterns will be. In the way the training the core has been the panacea for everything from low back pain to giving sight to the blind, I have to scratch my head at the absence of specificity in program design to match that of the assessment.
To me, specificity does not mean working with a body part or structure in isolation. It means organizing building blocks that guide the body down a path of successful motion through novel movements that fly below their existing thresholds.
Forgive this next statement as it is blatant self-promotion: I believe that I am awesome at asking great questions. Getting the right answers not always so easy…..
By asking better questions we broaden our perspective and therefore the possibilities of the underlying problems. By doing so we are able to frame a better strategy for our problem solving.
If you think about it, this applies to all of us regardless of what our level of experience or what we are trying to sleuth about our client or patient. For me, it is movement related issues. For you, it might be why they can’t lose those last 5 lbs. or why they can’t stay consistent with their sessions.
At Function First we have always prided ourselves on the unique and strategic corrective exercise programs our clients are given. No two programs are ever exactly the same because no two clients are exactly the same.
Therefore, I would suggest that if you are going to assess with the precision of a diamond cutter, don’t design your intervention around a jackhammer.
What do you think?
Committed to Raising the Bar,
Anthony Carey M.A., CSCS, AHFS
In a recent Youtube comment on one of my Core-Tex™ videos, the commenter stated, “I’m in the fitness industry myself, and it still disappoints me that we continue to develop stuff like this when we need to be out in the outdoors challenging our core for real.” On the same day I read a very similar comment regarding another product on a different web site. These comments are in addition to the multiple comments with the same point of view that appear from fitness professional daily on Facebook.
Really? Is that your earth shattering insight into making the world a fitter more functional place? All these back to nature workouts would be great if our society was not what it is today. Our movement repertoire has “devolved” in the last 20 years or more.
As the modern history of fitness shows us, the pendulum always swings way too far in one direction before sanity returns. Most outdoor-only, “natural” movement purists have not been around long enough professionally to have seen the evolution of where the industry is today. We leave behind that which has no value and we utilize all options at our disposal in the best interest of our client.
Don’t get me wrong. I am all for getting outside and using the body in the many forms of play or workouts. When we started Function First way back in 1994, we were doing what we called “Adventure Workouts”. These consisted of full body workouts at a local high school obstacle course, trail runs and strength stations we created in Torrey Pines State Park and full body beach workouts-all of which preceded the boot camp boom that came many years later. We were doing outdoor functional movements long before the word “boot camp” was part of the fitness vernacular.
The facts are, you cannot do everything you want to do with all of your clients all the time outside with no tools to add to the mix. To imply that we just need to get outside and move lacks a thorough understanding of the client/athlete that we all work with.
Why do we need Olympic Training Centers with state of the art strength and conditioning facilities? Why don’t those with back injuries just go out and chop wood for rehab? I’ll give you my top 7 reasons why we need more than just a get-back- to- nature workout. From the practical to the technical, here’s why we need our tools:
7. Your clients won’t want it all of the time. Sure, they might enjoy one or two workouts outside a week. But if that is all you have to offer, I can guarantee they are going somewhere else for their workouts on the other days. And if they do only want to train outside, you have an extremely small customer base to draw from.
6. Weather. If you do outdoor only workouts in Minnesota, how’s business in January? How about Phoenix in August? Not likely that these places are very conducive those times of year for outdoor exercise. If we want to help instill consistency in our clients, we need to be consistent in our offerings.
5. Perception. Let’s face it, a bare bones workout in the middle of park can be perceived as a bare bones budget. People can do push-ups, planks and body weight lunges at home. Clients might perceive a lack of individuality and customization to their programming.
4. Gravity. There are limits in determining the force vector best suited for the client. Gravity is the constant as we know, but gravity alone limits what direction we want the force vector to act on the body. Sure, the more fit the participant the more possible options. But again, you limit your market size and still have a finite number of movements.
3. Variety. The mind and body love variety for learning and engagement. If you would like to compare your outdoor-only exercise library with my exercise library just let me know. How many ground based push-varieties can you come up with? Regardless of your answer, introducing one of any number of pieces of equipment trumps that because we can do all of yours plus those with equipment.
2. Not-so-natural. As someone who works with clients with musculoskeletal challenges, what is often referred to as “natural” movements isn’t so natural anymore. Years of dysfunction are layered on top of and intertwined with muscles and connective tissue. And even though the nervous system determines when and to what extent a muscle fires, the physical characteristics of the muscle and its surrounding fascia determine whether or not it can execute. Send that feedback to the nervous system regularly and it adapts accordingly. We see 35 year olds who can’t decelerate down stairs without a handrail. Not a chance they can successfully execute walking lunges across a field.
1. Specificity. To be able to provide the best possible programming requires designing around the client’s needs, goals and limitations. We do this by manipulating the environment. If we know what the body needs/wants but it can’t get there on its own, we create the environment for success using the tools in our toolbox. Whether it’s influencing a joint position, increasing the load or adding novelty to the proprioceptive system, the right tool for the right job makes all the difference in the world.
All too often a client’s body is asked to cash a check it does not have the funds for. With the right tools and mastery of the training environment, we can lead our clients down a path to movements of all kinds in all places. So many great tools are conducive to outdoor workouts and others are not. We should not limit ourselves through a single-minded philosophy. It’s not about us. It’s about the person writing that check to us.
What happens when a practitioner places their hands on a client or patient in a purely professional manner? Just like anything else, it depends on your perspective AND the expectations of your client or patient. A chiropractor is likely to respond that that is the only way they can perform an adjustment. A cardiologist may say that she has no need to touch the patient. Exercise professionals may say that it helps facilitate what they are doing with their clients.
The power of the human touch cannot be underestimated. To the client/patient it may bring a sense of connection with you, confidence in your ability and reassurance. The opposite may be experienced by the patient whose doctor provides a diagnosis only through oral communication and visual observation and never touches the patient.
I believe that some good and some bad come from the hands on approach. The chiropractors, physical therapists and massage therapists clearly have a need to contact their patients with their hands to practice their disciplines. The hands are used as both an assessment tool and to deliver an intervention. The accuracy of a skilled practitioner is used for reducing joint subluxations, mobilizing joints and relaxing and manipulating soft tissue. All of which have been scientifically proven to be beneficial to the patient.
The exercise professional may need to place their hands on the client for assessment purposes such as measuring body composition or pelvic landmarks. Some trainers will also use their hands to provide manual resistance for certain exercises and over-pressure to aid in flexibility. And at times, the hands are placed on the client to guide them through desired movement patterns.
With so much to gain how can there be a downside? What if the question was not what was provided to the patient with contact but instead, what is the patient being deprived of? And this question can completely change our perspective on the “hands on” approach to care.
Whatever is provided to the patient/client by the practitioner removes the need for the patient/client to do it themself. We obviously don’t want people going around adjusting or attempting to adjust their own necks or manipulating their own gleno-humeral joints. We do want an attitude and belief system that ALL practitioners are simply adjuncts to the individual’s own abilities. We are facilitators.
Could chiropractic care and manual therapy create learned helplessness? Do clinics relying predominantly on passive modalities like ultrasound and electrical stimulation fool the patient (and themselves) that the modality is making them better? Is a client psychologically and emotionally dependent on the trainer if she refuses to work out unless the trainer takes her through a workout?
If I ask a client what he does regularly for his health and he tells me chiropractic care, I respond by telling him that is what the chiropractor is doing for his health care. I then ask again, “What are YOU doing?”
Could this kind of learned helplessness and dependency even be contributing to the obesity epidemic? It may not be that big of a leap from the dependent patient to the obese individual. If my healthcare consists solely of people doing something to me, how can I be expected to eat right and exercise on my own? The psychosocial behavior of anyone who is not responsible or response-able for their own musculoskeletal health will ultimately suffer from comorbidities.
This certainly is not a knock on any kind of manual care. I’ve personally benefitted from chiropractic care, manual physical therapy, acupuncture and Structural Integration. Of course I also have a specific corrective exercise strategy I follow along with my general fitness routine.
I believe one of the greatest gifts we give our corrective exercise clients at Function First is the ability to produce the same result at home that we produce with them in our facility. That is why we only need to see our clients once a week. They are expected to continue with their home program daily. If they don’t do their homework-they are fired. This is an expectation of all our clients before they begin with us for a corrective exercise program.
For this reason, the referral from me to a chiropractor is much easier than the referral from the chiropractor to Function First. Our clients are already engaged in a comprehensive corrective exercise program. The chiropractic or other manual care is an adjunct to the exercises and can often help us expedite the results.
A referral to Function First often requires a complete paradigm shift for the person referred to us. They now have to go to work on themselves. And quite frankly, many long-term recipients of manual care just aren’t willing to do that.
We might say people are lazy and don’t want to do the work. Or, can we say that people have been conditioned that they don’t need to do the work?
A non-technical explanation of the Hip Twist exercise for the person using The Pain-Free Program: A Proven Method to Relieve Back, Neck, Shoulder and Joint Pain
Heel Lifts with Strap is an exercise many of your clients will benefit from. It is one of the exercises in the Pain-Free Program that has helped people from all over the world feel and function better.
