Posts Tagged ‘Plyometrics’

Bump-Set-Ouch: Preventing Volleyball Injuries


by G. John Mullen, SPT, CSCS | mullen@myhousecallmd.com

Whether you’re Kerri Walsh or an annual beachgoer wearing 100+ sun block, you’re likely to get your hands on a volleyball during your next trip to the beach.  Beach Volleyball is a tough sport but remains omnipresent due to the ease with which newcomers can pick up the sport (almost anyone can hit a few volleys).  No matter your ability, injuries can occur which means that injury prevention should be an inherent part of your pre-beach routine.  You may remember the infamous kinesio tape on Ms. Walsh’s shoulder during the 2008 Olympics providing her the strength, stamina and the extra 6 inches (ok, maybe not the height) she needed to win the Olympic gold. The shoulder is the second most commonly injured site in volleyball, second only to the ankle.  (Read about the prevention and treatment of ankle sprains here).

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14

07 2010

The Achilles’: Your Weakest Link

by G. John Mullen, DPT 2011 | mullen@myhousecallmd.com

Achilles’ tendon injuries have been present since the time of the Greek Gods and Goddesses, (remember Achilles from Greek Mythology?).  Achilles’ is the burly, handsome warrior from the Trojan War legends who could only be harmed by a lethal blow to his Achilles tendon…and the name was born.  Contrary to popular belief, this warrior’s surname was not Pitt.  What we really want to know, however, is how does the Achilles tendon affect us today?

We all witnessed the devastating loss Michigan State suffered to underdog, Butler University, in the men’s NCAA basketball tournament. The Spartans put in a valiant effort despite the season-ending loss of Kalin Lucas, a pivotal player averaging 12.3 points per game.  Lucas tore his Achilles’ tendon during the game against Maryland (tragic, we know). Achilles’ tendon tears are not unique to the collegiate super-athlete; weekend warriors are just as susceptible to Achilles’ tendon tears as the pros.  An Achilles’ tear is debilitating, requiring surgery and extensive rehabilitation in most cases.  Successful surgery and rehabilitation of a torn Achilles’ tendon requires a thorough understanding of the anatomy, cause of the injury, patient’s unique health condition & lifestyle and patient’s athletic activities.  These factors are essential to preventing a re-repture of the tendon.

Stat Fact: Most Achilles’ tears occur 2-6 cm above the Achilles’ insertion into the calcaneus, the heel bone in the foot (3).


Anatomy

The Achilles’ is a complex tendon whose rarity is secondary to the fact that the tendon crosses two joints.  Multi-joint crossing places increased stress on the Achilles’, resulting in the tendon’s high injury rate.  Everyday activities like walking place repeated stress on the tendon.  The tendon is the composite of two muscles in the calf: the gastrocnemius (the medial and lateral heads which cross the back of the knee) and the soleus (the bulk of the calf). The tendon is surrounded by two sheaths (which are called “paratendon” and “mesotenon”).  The mesotenon is responsible for the nourishing blood flow to the tendon.  Diminished blood flow is seen at the bottom of the Achilles’ tendon and is responsible for the high rate of tears in this region. The majority of the tendon is made of Type 1 collagen (4).

Stat Fact: The Achilles’ tendon twists in a spiral motion as it wraps around the foot and inserts into the calcaneous.

Types of Achilles’ Tears and Risk Factors

Athletic Achilles’ tears are typically acute injuries caused by a “high rate of loading” associated with specific movements which include landing, pivoting or sweet juke moves on the field…talk about all-time backfires! Acute injuries commonly occur at the distal portion (i.e. the point farthest towards your heel) of the tendon where blood flow is diminished. Out-of-shape athletes returning to high-impact sports make up the largest portion of these injuries.  Trauma from a foreign object is another common cause of an acute Achilles’ tear (i.e. Tonya Harding action to the back of your ankle).  These injuries are not pretty, but if you’ve seen the movie, Saw, you may remember one of the hostages having their Achilles’ sliced to prevent escape.  Uncommon but horrific to say the least.  Tears during motor vehicle crashes are more typical and can be equally debilitating.  Chronic Achilles’ tendon injuries can also eventually lead to tears. Nagging Achilles’ tendonosis (chronic inflammation of the Achilles’ tendon) transforms the molecular properties of the tendinous collagen making the tendon soft and pliable.  Pliability is the Achilles’ kryptonite (not arrows as Hollywood would have you believe)!  As we age, we are more prone to tendon tears.  Two factors lead to increased Achilles’ tears as we age: 1) the transformation that takes place in your tendon’s cartilage and 2) hypovascularity (impaired blood flow) making previously injured, older athletes more prone to Achilles’ tears.

Stat Fact: The Achilles’ tendon is the strongest tendon in the body, absorbing up to 8x our body weight in force during athletic movements (2).

Surgery and Rehabilitation

Surgery is always the last option.  Debate surrounds the efficacy of surgery and rehabilitation in Achilles’ tears.  Studies show conflicting evidence in terms of recovery speed and re-rupture rates for individuals with and without surgery (5). There is further debate on the first phase of rehabilitation for both groups. One theory of rehabilitation promotes 6-8 weeks of immobilization via casting.  Casting is typically done in plantar-flexion (with your foot bent at 90 degrees to your calf) or in the neutral position (imagine your foot’s position as your leg hangs over the edge of the bed).  Immobilization is thought to allow collagen repair following surgery increasing stiffness and strength of the tendon. The other accepted method of rehabilitation is the exact opposite of immobilization: early mobilization. Early mobilization is believed to promote revascularization of the injured tendon. Revascularization is believed to enhance strength (4).  More importantly early mobilization is associated with similar functional gains and a low re-rupture rate (5).  These positive attributes make early mobilization an important variable for surgical and non-surgical treatment of Achilles’ tendon tears.

Rehabilitation regimens vary depending on the surgeon’s approach (early mobility vs. early immobilization).  Early mobilization seems to be gaining momentum with recent publications.  A typical early mobility rehabilitation protocol is listed below:

Postoperative Exercise Program (1)

Group 1 (early mobilization)

Time: 0-3 wk

  1. Flexion and extension of the toes in a supine position; 25 × 3 series

  2. Plantar flexion of the ankle and dorsiflexion to neutral in supine position

  3. Extension of the knee in a sitting position (hold 2 s); 10 × 3 series

  4. Flexion of the knee in a prone position; 10 × 3 series, 3 times daily

  5. Extension of the hip in a prone position (hold 2 s); 10 × 3 series

Time: 3-6 wk

Same as week 0-3

Time: 6-9 wk

1. Ankle flexion and extension exercises with manual help

2. Rotation of the ankles in both directions; 30 × 3 series, 3 times daily

3. Standing on the toes and heels alternately; 30 × 3 series, 3 times daily

4. Ankle extension exercises against a rubber strip; 20 × 3 series, 3 times daily

5. Ankle stretching exercises to flexion with the help of a rubber strip; 30 s × 5 series, 3 times daily

6. Stretching of the calf muscle by standing with the leg to be stretched straight behind and the other leg bent in front and leaning the body forward, with support from a wall or chair; 30 s × 5 series, 3 times daily

7. Stretching exercises for the toes and ankle against the hand in a sitting position; 30 s × 5 series, 3 times daily

Time: 9 wk

1. Raising and lowering of the heel, first with both feet at the same time and later with 1 foot; 20 × 5 series, 3 times daily

Exercises against a rubber strip for

Ankle extension 20 × 5 series, 3 times daily

Ankle flexion 20 × 5 series, 3 times daily

Ankle abduction 20 × 5 series, 3 times daily

Ankle adduction 20 × 5 series, 3 times daily

Stretching of the calf muscle against the wall; 30 × 5 series, 3 times daily

Standing with the knee somewhat flexed; 30 × 5 series, 3 times daily

With any surgery, you must take note of the potential complications. At the same time, the re-rupture rates in Achilles’ tendon tears are significant in the conservative non-surgical group.  A notable complication with Achilles’ Tendon surgical repair is sural nerve dissection.  The sural nerve is damaged in approximately 6% of Achilles’ tendon repairs.  Sural nerve damage can lead to impaired sensation to the dorsal (back) aspect of the heel (2).

Stat Fact: Non-surgical Achilles’ Tendon treatment has a re-rupture rate of 12.6%, nearly 4x the 3.5% re-rupture rate seen in the surgical repair group (2).

Prevention

While many people believe that stretching is the key to preventing Achilles’ tendon rupture, this may not actually be the case.  Stretching may reduce the number of tendon injuries, but a more thorough approach is needed to further minimize your risk of injury.  Most Achilles’ tendon tears are caused by high force movements.  As your coach always said, “Practice like your play!”  It only makes sense to practice these high force movements via plyometrics to train your body to adapt to these high levels of strain. Therefore a stretching regimen in combination with a light plyometric routine makes perfect sense.  A simple plyometric routine (for example, ankle hops progressing to higher impact squat jumps and then repeated hops) can be utilized before exercise to minimize your risk of injury.  Who doesn’t want strong enough Achilles’ tendons to dunk like Dwight Howard?

Questions? E-mail G. John Mullen: mullen@myhousecallmd.com

References:

1. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med. Jan 2007;35(1):59-64.

2. Molloy A, Wood E. Complications of the treatment of Achilles tendon ruptures. Foot Ankle Clin. Dec 2009;14(4):745-759.

3. Park D, Chou L. Stretching for prevention of Achilles tendon injuries: a review of the literature. Foot Ankle Int. Dec 2006;27(12):1086-1095.

4. Strom A, Casillas M. Achilles tendon rehabilitation. Foot Ankle Clin. Dec 2009;14(4):773-782.

5. Twaddle B, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. Dec 2007;35(12):2033-2038.

11

04 2010

Winter Training: Preparing for the Slopes

Killer Skiing

by G. John Mullen, DPT 2011

With Thanksgiving behind us and winter weather in full effect, snow has already begun to cap the mountains across America.  With a layer of white powder on the ground, everyone is counting the days until they can escape from work, school or writing anonymous cynical comments on message boards and hit the slopes.  Whether you snowboard, sled, cross-country ski or bare foot ski, with the rush of mountain adrenaline comes the risk for injury.  We’re here to help you train those hard-to-reach, unused muscles for the slopes so that you are prepared for anything the mountain can throw at you.

Stat Fact: Lower extremity injuries were the most common injury in the Utah slopes from 2001-2006 for both snowboarding (~27%) and skiing (~50%).

Little HerculesWhether you’ve looking for exercises to prevent future knee injuries, strengthen your legs for the slopes, or help make that knee pain from that 1960 football injury (quit living in the past) go away, you can utilize the exercises below to strengthen weak muscles and lengthen tight muscles. We’ll discuss some plyometrics and exercises you can use to mimic skiing or snowboarding. Even if you’re as big as Richard Sandrack (see Lil Hercules at left) your bulging biceps and six-pack abs won’t prevent lower extremity injuries…training those targeted muscles will.

STRENGTHENING:

There are hundreds of exercises that can be used to train for the slopes.  We are going to talk about the main muscle groups that will prevent injuries and go over our favorite exercises to strengthen these muscle groups.  Unless you’re like hip hop video girl Vida Guerrera, you, like most Americans, may already experience knee or hip pain (or at least feel a little weak when it comes to these joints), due to weak gluteal muscles,.  As stated, there are hundreds of exercises to strengthen these muscles…so we’ve boiled it down to some key moves to get you started:

Overview of Strengthening:

When you first begin these exercises, start with the beginner exercises in your training of  those gluteal muscles.  At the beginning start with 3 sets of 20 repetitions and after two weeks add weight and try 3 sets of 10 repetitions.  After two more weeks add more weight and go 5 sets of 5 repetitions.  After this progressive process, advance to the intermediate exercises and repeat the same amount of repetitions and sets.

Beginner:

1. Clams:

ClamsLie on your side and bend you knees to 90 degrees and your hips at 30 degree with your legs one on top of the other.  Now just lift your top leg open like a clam, brilliant!

Stat Fact: By increasing the amount that your hips are flexed during this exercise (by bringing your knees towards your chest thus changing the angle from 30 degrees to 60 degrees) you change the gluteal muscle you are working, from gluteus medius to gluteus maximus.

2. Bridges:

BridgesLie on your back with your heels on the ground, but your toes in the air (lifting your toes makes sure you don’t use your calves and helps you to better isolate those gluteal muscles!).  Next, lift your lower back and butt off the ground by pushing through your heels.  At this point only your upper back and feet should be on the ground.  Note: a band can be used just above your knees to keep your legs from coming together, but is not necessary.  However, keep your knees apart!

After you’ve mastered double leg bridges, you can advance to single leg bridges or double leg bridges with weights on your hips.

3. Side-lying Leg Raise:

Leg RaiseLie on one side with one leg on top of the other, keep both legs straight and raise your top leg towards the ceiling.  Make sure your leg doesn’t creep forward.  To do so, keep it aligned with your hip or back (you should form a straight line from your shoulder to your hip to your knee to your ankle).

Stat Fact: If done properly, with your leg in correct alignment, this exercise requires the most gluteus medius activation of the exercises without weight.

Intermediate:

Lunges:

We’re not talking about your run-of-the-mill forward lunges.  We need to use exercises that are as close to skiing as possible, thus the use of multi-directional lunges.

Transverse Lunge1. Transverse Lunge:

Start with your hands on your hips and both feet facing forward like your feet are facing 12 on a clock.  Now, with one leg take a large step towards 2 o’clock.  Make sure your back foot rises on its toes and you don’t allow your front leg’s knee to come in front of your toes!

2. Lateral Lunge:

Once again, start with your hands on your hips and both feet facing forward like your feet are facing 12 on a clock.  With one leg take a large step towards 3 o’clock.  Lateral LungeMake sure your back foot rises on its toes and you don’t allow your front leg’s knee to come in front of your toes!

To advance the lunges, you can hold weights (or anything that will add extra weight) in your hands or if you’re at a gym you can put a bar on your back.

Advanced:

1. Single Leg Squat:

Single Leg SquatStand on one leg and slowly lower yourself bending at your hip, knee and ankle until you can touch the floor with your middle finger without reaching your shoulder.  Remember to stick your butt out as you come down and try not to let your knee come in front of your toes.  To advance this exercise, you can hold weights in either hand.

2. Single Leg Deadlift:

This exercise is similar to the single leg squat.  Single Leg DeadliftTo begin bend your knee slightly (~10 degrees).  Now bend at your hip and bring your chest towards the floor, reaching with your hand to touch the ground.  To advance the exercise, you can add dumbbell weights in each hand.

Stat Fact: Single leg squats and single leg deadlifts have been shown to have the highest gluteus maximus activation of any non-weighted exercise…buns of steel, here we come!

STRETCHING:

It is hard to predict what muscles will be tight on each individual, but if we were to grab 10 people off the Red Line subway in Los Angeles and test their muscle flexibility I would bet a liter of cola that 9 of those people have tight hamstrings, piriformis (a muscle in your butt… that’s all you need to know), calves and hip flexors.  What do you say we try and loosen those bad boys up.

Overview of Stretching:

As you move through the stretches outlined below, remember to stretch both legs, completing each stretch twice for 30 seconds or more.  It is hard to overstretch these tight muscles, so the more you do the better.

Hamstring Stretch:

Hamstring StretchLie on your back, grab the back of your thigh of one leg and begin to pull that leg towards the ceiling.  If done correctly, you should feel a stretch in the back of your leg and possibly in your calf.

Stat Fact: It is estimated that 80% of persons suffering from low back pain have tight hamstrings.

Piriformis Stretch:

Piriformis StretchOnce again, lie on your back but this time bend one leg over the other.  Now push your bent leg towards the ground, without lifting your back off the ground.  If done properly, you should feel a stretch in your butt.   You have now officially located your piriformis muscle.

Calf Stretch:

Calf StretchBeing by standing facing a wall with one leg in front of the other. with the leg to be stretched extended behind you.  With your hands on the wall at the level of your head lean forward.  You should feel a stretch in your calf.  The more you lean forward, the more stretch you will feel.  Repeat these same steps on the other side as well.

Hip Flexor Stretch:

Hip Flexor StretchPlace one knee on the ground and lunge forward with the other leg, keeping your back straight.  If done correctly, you should feel a stretch in the front of your leg around your hip on the kneeling leg.  As you push forward with your pelvis, you should feel the stretching increase in this area.

Plyometrics:

Plyometrics are activities that enable a muscle to reach maximal force in the shortest possible time.  These exercises are meant to be explosive, but need to done carefully and under proper conditions (outlined below):

  • Good landing surface (grass field, suspended floor, rubber mats)

  • Plenty of space

  • Proper footwear (no flip flops)

  • Supervision, it is highly advised to do plyometrics with a training professional (personal trainer, physical therapist)if you are new to the exercises

Since this is a high intensity exercise we will start with one basic exercise as well as some strategies for plyometric training.  First, it is important to complete a proper low intensity warm-up.  Begin with skipping, marching, or jogging. The total amount of time you spend on these activities needs to be strictly monitored.  It is recommended that beginners do a maximum of 80 contacts.  80 contacts simply means each foot should only hit the ground 80 times including the skipping and jogging warm-up.  Anyone doing plyometrics should also include the appropriate amount of rest between exercises (at least a minute per exercise).  Below are a few examples of beginner plyometric exercises that mimic skiing and snowboarding.  We highly recommend doing these beginner exercises with an exercise professional (at least when you’re first starting off…the only thing worse that hurting yourself on the slopes is hurting yourself while training for the slopes).

Forward/Lateral/Diagonal Jumps:

Just as they sound, these jumps are performed with both feet together and you jump either straight forward, to your side or diagonally.  To begin start by jumping, landing and then jumping again.  As you progress you can begin performing multiple jumps in a row.

Now that you know what strengthening, stretching and plyometric exercises to perform, make sure you always warm-up first (at least fifteen minutes of cardiovascular work to get your heart rate elevated and muscles warm).  Perform these stretches exercises every day and the strengthening/plyometrics no more than three times a week.  When you hit the slopes tell Shaun White hello for us.

Shaun White

References:

Distefano, L., Blackburn, J., Marshall, S., Padua, D. Gluteal Muscle Activation During Common Therapeutic Exercises. Journal of Orthopaedic and Sports Physical Therapy.  2009 Jul; 39 (7): 532-540.

Torjussen J, Bahr R. Injuries among competitive snowboarders at the national elite level. Am J Sports Med. 2005 Mar;33(3):370-7.

Wasden CC, McIntosh SE, Keith DS, McCowan C. An analysis of skiing and snowboarding injuries on Utah slopes. J Trauma. 2009 Nov;67(5):1022-6.

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12 2009

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