An article by Professor Lederman (2010) entitled “The Myth of Core Stability” raised serious questions regarding the efficacy of prescribing core stability exercises for patients with back pain. This was a controversial paper at the time and has been hotly debated over the last 2-3 years, with Pilates advocates jumping to the defense of core training. If your interested in core stability I highly recommend you read Lederman’s paper
I have summarized below the major conclusions from the article:
1. The division of the trunk into core and global muscle systems is a reductionist fantasy – these muscle groups work together to stabilize the spine and it is next to impossible (and pointless as it wouldn’t be functional!) to isolate these individual muscles.
2. Weak or dysfunctional abdominal muscles will not lead to back pain.
3. Tensing the trunk muscles is unlikely to provide any protection against back pain or reduce the recurrence of back pain.
4. Core stability exercises are no more effective than, and will not prevent injury more than, any other forms of exercise.
5. There may be potential danger of damaging the spine with continuous tensing of the trunk muscles during daily and sports activities.
It would appear that core stability training is no more effective in treating or preventing back pain than any other form of exercise and, if performed incorrectly, may be injurious to the spine. Indeed, the improvements in back pain seen with core stability programs is more than likely due to the positive effect of exercise rather than any improvement in spinal stability. With this in mind, why perform complex core exercises, that can often be dull and monotonous, when general exercise is just as effective at treating and preventing back pain. My advice, whether injured or not, is to find a sport or exercise that you enjoy and perform this on a regular basis. This is likely to be a lot more fun, more effective, and easier to sustain over a longer period of time!
So what about training your core to improve sports performance?
When training to improve any activity, we must practice that specific activity. For instance, if we want to learn to play the guitar we must practice playing the guitar, or if we want to improve at football we must practice with a ball – this is the specificity principle of training. So will performing core exercises, lying on your back, improve your performance? Well, it’s likely to improve your performance of those specific exercises, but unlikely to have any knock on effect to your overall sporting performance.
The muscle activation for trunk control is different for each specific activity we perform i.e. the trunk control required for throwing a ball is different to the trunk control required for swimming and there is no one specific exercise (or series of exercises) that will meet all the needs of every sporting activity. So is it possible to train trunk control specifically for an individual sport? Yes, but you need to forget about the notion of trying to isolate your core muscles through specific core stability exercises and instead focus on sports specific training. As you play and train in your sport, your trunk muscles will adapt and strengthen in line with the specific requirements of that sport.
One of the most common causes of shin pain or “Shin Splints” is Tibialis Posterior tendinopathy, also known as Posterior Tibial Tendon Dysfunction (PTTD). This is usually caused by overloading the Tibialis Posterior tendon during running or other sporting activities, which leads to a gradual degeneration and weakening of this tendon. This post looks at the Tibialis Posterior and how to strengthen it. I will discuss the various types of shin pain and their treatment in a later post.
What is the Tibialis Posterior?
The Tibialis Posterior is a muscle that attaches to the posterior aspect of the Tibia and runs down the back of the lower leg.
It forms a tendon which passes behind and under the medial malleolus (the bump on the inside of the ankle) and attaches to the bones of the foot.
The Tibialis Posterior has a number of key roles –
helps maintain the arch of the foot
inverts the ankle (turns the foot in)
plantarflexes the ankle (points foot down)
The following exercises strengthen the Tibialis Posterior and can be beneficial for preventing or treating conditions associated with a weakness of this muscle, such as Posterior Tibial Tendon Dysfunction, Plantar Fasciitis or a fallen arches. Just a word of caution, if you are currently experiencing pain it is best to get an accurate diagnosis from a Health Professional before trying these exercises.
Exercise 1 – Isometric Contraction
Stand with the inside of your foot against a step. Try to push your foot inwards against the step – there shouldn’t be any movement of your foot. Hold the contraction for 5 secs and repeat 10 – 15 times. This is a very basic exercise that is most beneficial when pain or weakness do not permit you to perform the more active exercises.
Exercise 2 – Arch Lift
Stand sideways on a step with your foot halfway over the edge. Lower your arch off the step and then raise it back up as high as it will go. The movement should be slow and controlled.
Exercise 3 – Calf Raise
Stand sideways on to a wall, with both feet flat on the floor and your arches held in a good neutral position (i.e. not collapsed onto the ground!). Place one hand against the wall to assist with balance. Push up on to the balls of your feet, hold for a second at the top of the movement, and return slowly to the starting position. Make sure that when your feet return to the ground you do not allow your arches to collapse inwards.
Exercise 4 – Single Leg Balance
Stand on one leg, whilst maintaining a good arch on your foot, and attempt to balance on that foot. Hold this for 30-60 secs. Progress on to doing this with your eyes closed. It is essential you maintain a good arch throughout this exercise.
Exercise 5 – Single Leg Calf Raise
Stand sideways on to a wall, on one foot, with your arch held in a good neutral position. Push up onto the ball of your foot, hold for1 second at the top of the movement, and return slowly to the starting position. Make sure that when your foot returns to the ground you do not allow your arch to collapse inwards.
Exercise 6 – Single Leg Calf Raise with Balance
Stand balancing on one foot with your arch held in a neutral position (as with exercise 4). Raise up onto the ball of your foot, hold for 1 second, and return slowly to the starting position. Make sure that when your foot returns to the ground you do not allow your arch to collapse inwards.
Exercise 7 – Eccentric Knee Reaches
Stand facing a wall, on your injured leg, approximately one arms length away from the wall. Your good leg should be bent at the knee so that your shin is parallel with the floor. Place your fingertips on the wall for balance. Bring the knee of your good leg forward so that it touches the wall whilst bringing your upper body slightly backwards so that it remains over the foot of your injured leg. Return to the starting position. Bring your knee forward again towards the wall but this time move it towards the left hand side (again leaning slightly backwards). Return to starting position. Finally bring your knee towards the wall again, this time moving it to the right hand side. Complete the repetition by returning to the starting position.
All these exercises should be performed in a slow and controlled manner. If you are currently experiencing shin pain you should contact a healthcare professional before starting these exercises. They will diagnose your injury and advise on the appropriate exercises and the number of sets and reps that you should perform.
A recent study by Falvey et al (2010) examined the anatomy of the IT band on 20 cadavers and tested various IT Band stretches. Their findings raise questions regarding the efficacy of many traditional treatment methods for conditions such as Iliotibial Band Syndrome and Patellofemoral Syndrome.
What is the Iliotibial Band
The ITB is a thick fibrous band which is an extension of the Tensor Fascia Lata muscle, but also receives most of the tendon of the Gluteus Maximus. It runs from the Iliac Crest to Gerdy’s tubercle on the lateral Tibia and has an attachment along virtually the full length of the femur (Falvey et al, 2010). It also connects to the Patella as it passes the knee.
What Falvey et al Found
The main finding of the research was that, even with an ideal IT band stretch, there was virtually no elongation of the IT Band – only about 2mm, which was an overall change in length of less than 0.5%. So basically, the IT Band is like an old piece of leather that is extremely rigid and resistant to stretch. The authors emphasize that current treatment protocols focusing on reducing tension in the IT Band are inappropriate and, that if our goal is to reduce tension on the lateral aspect of the thigh, we must focus on treating the muscular component of the Band.
So What Should We Do?
We need to STOP smashing our IT bands with massage and foam rollers, STOP trying to stretch the IT Band directly (which was extremely difficult to stretch correctly anyway!), and START focusing on the muscular component of the Band (Tensor Fascia Lata and Gluteus Maximus) which can be easily elongated by massage and stretching. I’ll be looking specifically at what the research says about Iliotibial Band Syndrome and Patellofemoral Syndrome in upcoming posts.
In July 2012 the Advertising Standards Agency (ASA) upheld a complaint against LimbVolume’s (t/a Kinesio UK) claims regarding the benefits of Kinesio Tape. The complaint challenged whether the following claims were misleading and could be substantiated:
The description of the therapy under the heading “How does Kinesio Taping Work?”
The efficacy of claims that the therapy could be used for “Lymphoedema treatment, Sports Injuries, Hand Therapy, Paediatrics, Scar Taping”
The claim “Kinesio Tex® can assist many conditions including: TMJ Dysfunction; Headaches (tension), Whiplash, Torticollis, Shoulder Impingement/Subluxation, Rotator Cuff Tear, Biciptal Tendonitis, Tennis/Golfers Elbow, Compartment Syndrome, Trigger Finger, Forward Shoulder, Thoracic Outlet Syndrome, Shin Splits, Foot Drop, Herniated Disk, Sciatica, De Quervains, Low Back Sprain/Strain, Sacroiliac Sprain/Strain, Piriformis Syndrome, Quadriceps Strain, Toe Cramps, Sprained Ankle, Meniscus Tear (minor), Osteoarthritis of Knee, Calf Cramps, Plantar Fascitis, Bunions, Post Operative/Traumatic Oedema, Hamstring Strain, Bells Palsy, Headaches (Migraine), Tinnitis (SCM cause), Frozen Shoulder.”
The claims that the therapy could “Reduce Swelling, Alleviate Pain and Manage Oedema” and subsequent description “The taping method can substantially aid sufferers of Lymphoedema by increasing the body’s ability to drain lymphatic fluid to healthy lymph nodes. This is achieved using Kinesio Taping® techniques which have been designed specifically to aid lymphatic drainage”.
In response to the complaint LimbVolume provided 47 case studies, articles and clinical trials, which they believed substantiated their claims. After a careful examination of the research, the ASA upheld all four of the complaints against LimbVolume.
Does this mean there are no benefits to Kinesio Tape, and as such, should we all stop using it? Well it’s not quite as simple as that. In many cases the research shows some benefits for its application, however, a lot of these studies are of poor quality, poor design or have very small numbers. Therefore, the ASA failed to find enough good quality research to substantiate the many claims made by the LimbVolume. This is not the same as saying Kinesio Tape doesn’t work, it means that a lot more good quality research is required before claims can be made about its’ effectiveness. For a detailed explanation of why the ASA upheld the complaints, take a look at the ASA report on the matter.
Although I’m very skeptical about many of the claims made regarding the benefits of Kinesio Tape, I do feel it has a role to play in Physiotherapy. Where I’ve found it to be most effective is when using it to offload soft tissues, as you would do with traditional taping techniques. This can be extremely useful when trying to reduce the forces on healing tissues with many different types of injuries, from acute muscle strains to chronic tendonopathies. The benefit of using Kinesio Tape over traditional tape is that it tends to adhere better to the skin and therefore stays on for longer. It also appears to be a lot more comfortable to wear.
Over recent years there has been growing interest in barefoot running using either minimalistic shoes or no shoes at all. To explain the surge in popularity, we must first look at the biomechanics of running, specifically the way in which the foot strikes the ground. In doing this we can identify three types of runner:
Rearfoot (Heel) Striking
Heel lands first, then the forefoot comes down.
Heel and ball of foot land simultaneously.
Ball of the foot lands first, then the heel comes down. This differs from sprinting, where the runner stays on the ball of the foot and the heel never comes down.
Why is running style important?
According to Lohman (2011) 75 – 90% of distance runners who wear shoes habitually heel strike, however, most barefoot runners tend to avoid landing on the heel (as it is extremely painful) and instead land with a forefoot or midfoot strike. Most forefoot and midfoot strikes do not generate the sudden, large impact forces (Impact Transient) that occur when you heel strike. The diagrams below show the forces generated through the foot during running. The first diagram shows heel striking when barefoot and the second diagram shows heel striking in a shoe. Diagram 3 shows forefoot striking.
Consequently, runners who forefoot or midfoot strike do not need shoes with highly cushioned heels to cope with these sudden, high transient forces that occur when you land on the ground. Therefore, barefoot and minimally shod people can run easily on hard surfaces without discomfort from landing. If impact transient forces contribute to some types of injury, then this style of running might have some benefits.
What does the research say?
There is no conclusive evidence that either proves or disproves the benefits of barefoot running. Despite all the work showing how impact forces and loading rates are reduced when barefoot, it remains to be proven that this leads to lower injury rates. There are plenty of plausible theories as to why barefoot running may reduce injury rates and improve performance, but the evidence will only come from long-term, prospective studies.
Is Barefoot running good for you?
The evidence so far suggests that barefoot running produces some potentially beneficial changes related to how running style is altered without shoes, however, there appears to be a large number of people who, when running barefoot, appear to have an increased risk of injury. This is especially in the early stages of barefoot running with people who either, continue to heel strike, or try to force a forefoot landing leading to huge strain on the calf muscle and Achilles tendons.
It’s important to recognize that some runners adapt very quickly to minimalist shoes or barefoot running and are able to throw away their shoes very quickly. At the other extreme, there are runners who will find it very difficult to make the transition from shoe to barefoot – if indeed they can make the change at all.
Although there is very little research at present, there are certainly some plausible theories to suggest why barefoot running may be beneficial for athletes. If you are thinking of changing to barefoot running, it is important to recognize that everyone will adapt at different rates, with the process often taking 3-6 months – if you push too hard to soon you will invariably end up getting injured. Is this lengthy adaptation period worth all the effort when the evidence is still inconclusive? That’s for you to decide!
If you are interested in learning more about barefoot running, Dr Irene Davis has posted an excellent video lecture on the subject.