You only have 24 Hours per Day!

This blog will mark the first of many blogs to come with the theme of focusing on the “other 23 hours” spent outside of  the gym or whatever your favorite sports or physical activity might be.  Simply put, even if the one hour you spent [...]]]>

You only have 24 Hours per Day!

This blog will mark the first of many blogs to come with the theme of focusing on the “other 23 hours” spent outside of  the gym or whatever your favorite sports or physical activity might be.  Simply put, even if the one hour you spent exercising daily was done with perfect form, posture, etc; it probably can’t hold a candle in comparison to the rest of the day (the other 23 hours) and the impact that can have over the course of a week, a month, a year, a decade…you get the idea! In a nutshell, what you do outside your workout or activity of choice is very important and possibly even more important than what you do while exercising or engaging in physical activity!

What Will You do With the Other 23 Hours?

The Seated Work Environment

The most common work position these days is the seated work position. Unfortunately, for those who have to sit often, our bodies were not designed to be so immobile and sedentary for hours on end. The current state of  obesity and painful backs, necks and whatever other body part you want to throw in there can only be worsened by this modern propensity to sit! You could almost say we are “de-evolving’ now as we are becoming “homo electronicus!”

Are We De-evolving?

The Importance of Microbreaks!

Since the amount of sitting we are doing these days isn’t going to stop, it would be wise if we all would at least take frequent “microbreaks”to break the horrendous postures and positions of chronic sitting. Research has shown that even after 20-30 minutes of sitting, negative changes start to take place in the lumbar spine for example that can increase our chance for low-back pain and injury. The forward head posture associated with sitting is also very challenging to the upper back, cervical spine, and shoulder joints with compensatory changes occurring in the jaw (TM joint) the upper arms,forearms, and hands (ever heard of carpal tunnel syndrome?). The bottom line it to change your posture frequently throughout sitting or any activity for that matter.

A helpful mantra to remember is: “the best posture is the one you’re not currently in!”

The following video will go over some easy ideas of how to incorporate the concept of microbreaks into your daily seated positions. The only thing you have to lose is pain and stiffness!

Thanks for reading and watching!

Keats

Creatine: Safe or Dangerous!

I just got this email from the ISSN (International Society of Sports Nutrition) regarding the latest media frenzy over the football players in Oregon who allegedly got rhabdomyolosis from intense pre-season football training while also taking creatine monohydtae, a popular dietary supplement known to safely imprive muscle strength and [...]]]>

Creatine: Safe or Dangerous!

I just got this email from the ISSN (International Society of Sports Nutrition) regarding the latest media frenzy over the football players in Oregon who allegedly got rhabdomyolosis from intense pre-season football training while also taking creatine monohydtae, a popular dietary supplement known to safely imprive muscle strength and power in athletes when taken properly.  Here is the press release exactly from the newsletter email:

“FOR IMMEDIATE RELEASE:
 

Creatine Does Not Promote Dehydration or Rhabdomyolysis in Athletes
Woodland Park, CO, August 25, 2010 – Recent media reports have suggested that ingestion of the dietary supplement creatine monohydrate may have contributed to the hospitalization of several athletes from McMinnville High School in Oregon for rhabdomyolysis (i.e., a rapid breakdown of skeletal muscle due to injury that typically presents with marked elevations in the enzyme creatine kinase [CK] in the blood) and/or anterior compartment syndrome (ACS). It is well known that excessive exercise in hot and humid environments can promote dehydration, muscle breakdown, and result in marked elevations in muscle CK levels.  In severe instances, this may lead to exertional rhabdomyolysis particularly in athletes who have been engaged in intense exercise in hot and humid environments for several days and who become chronically dehydrated.  Additionally, excessive exercise in individuals unaccustomed to heavy training bouts can promote anterior compartment swelling, pain, and pressure.  It is well known that dehydration and/or heat illness can exacerbate this clinical course.

  
According to press reports, the athletes in this case were engaged in a several day “immersion” camp.  The athletes began to complain about swelling in their arms after performing a series of push-up and chair dip exercises in a 30-second alternating bouts of repetitions for over 20 minutes until exhaustion in a hot and humid wrestling room.  Temperatures in the room were reported as high as 115-120°F.  Moreover, the athletes were reported to have to start a repetition scheme over again if all of the athletes did not complete their repetition goals.  Further, the athletes were not allowed to drink water during the training session.  None of the athletes indicated they took creatine (or any other supplement or drug).   Nevertheless, media reports indicated officials are investigating whether creatine may have been linked to this incident.

 
The International Society of Sports Nutrition (ISSN) is the leading professional organization in the field of sports nutrition. In 2007, the Research Committee of the ISSN formed a team of sport nutrition researchers, dietitians, and physicians to extensively review the available scientific literature on creatine supplementation and exercise and to develop a Position Stand for the Society which was published in the Journal of the International Society of Sport Nutrition (see: http://www.jissn.com/content/4/1/6).   After extensive review of the literature, the ISSN adopted the following positions relative to this issue:
1.      Creatine monohydrate is the most effective ergogenic nutritional supplement currently available to athletes in terms of increasing high-intensity exercise capacity and lean body mass during training.
2.      Creatine monohydrate supplementation is not only safe, but possibly beneficial in regard to preventing injury and/or management of select medical conditions when taken within recommended guidelines.
3.      There is no scientific evidence that the short- or long-term use of creatine monohydrate has any detrimental effects on otherwise healthy individuals.
4.      If proper precautions and supervision are provided, supplementation in young athletes is acceptable and may provide a nutritional alternative to potentially dangerous anabolic drugs.
5.      At present, creatine monohydrate is the most extensively studied and clinically effective form of creatine for use in nutritional supplements in terms of muscle uptake and ability to increase high-intensity exercise capacity.

6.      Creatine monohydrate has been reported to have a number of potentially beneficial uses in several clinical populations, and further research is warranted in these areas.
Specific to the alleged association of creatine to development of rhabdomyolysis and ACS; a number of studies have evaluated the effects of creatine supplementation on dehydration, cramping, fluid retention, muscle injury, CK levels, and health status in athletes engaged in intense exercise (including football players engaged in intense training in hot and humid environments).  These studies have consistently indicated that creatine supplementation does not promote cramping, muscle injury, elevations in CK, and/or heat related injuries.  Conversely, studies report that creatine may improve the athlete’s ability to tolerate intense exercise in hot and humid environments and lessen the incidence of injury.  Athletes have been using creatine on a widespread basis as a dietary supplement since the early 1990’s.  No clinically significant side effects have been reported and a number of potentially beneficial medical uses are being studied.   It is the opinion of the ISSN that suggestions that creatine caused this incident is inconsistent with the scientific literature and implausible.  

According to noted sports nutrition scientist Richard Kreider, Ph.D., FACSM, FISSN of Texas A & M University, “Many studies have been done (since the early 1990’s) that show creatine does not cause dehydration, muscle damage, or increase susceptibility to heat-related illness in athletes involved in intense training in hot and humid environments.  If anything, research shows that creatine promotes hyperhydration (i.e., whole body fluid retention) leading to less thermogregulatory stress during intense exercise in the heat.  It is unfortunate that individuals unfamiliar with the creatine literature are speculating that creatine caused this problem when the athletes indicated they did not take creatine and they ignore the obvious precursors: excessive and inappropriate training in a hot and humid environment.” 

About the ISSN:  The International Society of Sports Nutrition is the only non-profit academic society dedicated to promoting the science and application of evidence-based sports nutrition and supplementation. www.theissn.org ”

Well, there you have it folks, it looks like stupidity and not creatione was probably responsible for the health issues these young teens suffered!

Keats

American are not making good food choices!

One of the quicker choices for lunch many Americans reach for is the [...]]]> In today’s fast-paced lifestyle,  planning ahead for things like what to eat for lunch often get ignored. The end result is sub-optimal food choices that are clearly not having a good effect on America’s waistline and health!

American are not making good food choices!

One of the quicker choices for lunch many Americans reach for is the good old Sandwich.  The typical fair might include a sandwich piled high with lunch-meats or cold cuts, cheese, maybe some lettuce or a few veggies, and some mustard, mayo or other sauce to top it off. Usually the choice of bread is some sort of refined wheat-based product that may or may not have any real nutritional value to it other than a quick source of starch/carbohydrates.

                                                                                                               Yummmy…a Ham Sandwich!

So What’s Wrong with this Sandwich?

First off, many lunch-meats are full of sodium nitrates/nitrites which are used as preservatives. These compounds, when eaten in high amounts, have also been linked to stomach and gastric type of caners.  While small amounts of these can be handled just fine in an otherwise healthy diet, routine ingestion of these salty preservatives do seem to have some negative health effects ( including raising blood pressure in some folks).  The typical white bread served on sandwiches also can have negative effects on blood sugar control due to the lack of fiber levels and decreased B-vitamin levels. The protein quality (amino acid levels) of lunch meats is also less than that of whole food sources like chicken breast, steak or fish for example. So you end up needing to eat more lunch meats to get the same protein amount of a similar size of whole protein; and with this you get way too much sodium and preservative’s….not good!

A Better and Healthier Alternative!

The following video shows an example of a chicken breast sandwich served with sprouted grain bread (must be toasted!) that is not hard to make and can really be a better choice long-term for your health and your fitness goals!

Bon Apetit!

Thanks for reading!

Keats

The course will be limited to only 12 participants so sign up early to guarantee your place! The HKC is the first stepping stone in [...]]]> Save the date! October 23, 2010, Mark Reifkind, Master RKC will be teaching another HKC at the  RBF/OSP training facility in Tempe, AZ with assistance from myself and his wife Tracy Reifkind.

The course will be limited to only 12 participants so sign up early to guarantee your place! The HKC is the first stepping stone in learning one of the world’s most exciting and effective methods for using kettlebells, the Russian Kettlebell Challenge certification (RKC)!

Sign up and read more here!

To wet your appetite, here is a video clip from the succesful HKC we held in Tempe in February of this year (2010).

If you are new to KB’s or are a coach or personal trainer who uses them,  I highly encourage you to take this course..it will change the way you work with your clients and hopefully the way you train yourself! If you are not using kettlebells yet, you should be!

Thanks for reading!

Keats

by Keats Snideman & Bret Contreras   Most trainers, massage therapists, and strength coaches do not possess an adequate skill-set when it comes to screening and assessment. This isn’t necessarily their fault as it is poorly taught in most of these profession’s educational curriculum. In fact, so many people get [...]]]> Basic Screening & Assessment: Flexibility/Mobility

by Keats Snideman & Bret Contreras
 
Most trainers, massage therapists, and strength coaches do not possess an adequate skill-set when it comes to screening and assessment. This isn’t necessarily their fault as it is poorly taught in most of these profession’s educational curriculum. In fact, so many people get very nervous and almost paralyzed by the idea of having to do some screening or evaluation that they do choose to do nothing instead. Some people get so carried away with ridiculous assessments that are practically meaningless that its easy to see how one could get a nasty case of “paralysis by analysis!”       

                                              Yikes..not a Goniometer!

 However,  having a basic evaluation system for things like full-body mobility and movement capacity (including stability) will really set you apart from other professionals and allow you to be more effective at your job. The key is to stay within your specific scope of practice and realize that as non-medical professionals, we cannot “diagnose” anything and are simply obtaining information on each client to guide their safety and effectiveness in movement/exercise. It is especially helpful to know when to refer out when you arrive at red flags. Red flags are things like pain or strange or unexplained symptoms that would be better carried out by licensed medical professionals that are trained to look and treat these types of things. 

Here is short list of potential red flags to watch out for:

Red flags for spine fracture

Deep Back/Spine Ache that doesn’t fit usual back ache
Major trauma such as vehicle accident or fall from a height
Minor trauma, or even just strenuous lifting, in people with osteoporosis

Red flags for cancer or infection

Flags from medical history

Age over 50 years and new back pain, or age under 20 years
History of cancer
Constitutional symptoms, e.g. fever, chills, unexplained weight loss
Recent bacterial infection (e.g. urinary tract infection)
Intravenous drug abuse
Immune suppression
Pain that worsens when supine; severe night-time pain; thoracic pain

Flags from physical examination

Structural deformity

Red flags for cauda equina syndrome or rapidly progressing neurological deficit

Flags from medical history

Saddle anesthesia
Recent onset of bladder dysfunction (e.g. urine retention, increased frequency, overflow incontinence)
Recent onset of fecal incontinence

Flags from physical examination

Severe or progressive neurological deficit in the lower extremities
Unexpected laxity of the anal sphincter
Perianal/perineal sensory loss
Major motor weakness: knee extension, ankle plantar eversion, foot dorsiflexion

                                                                                                            Beware of Red Flags!

In this blog Keats Snideman is going to take Bret Contreras through a basic length-tension (mobility/flexibility appraisal) screening system that he uses to evaluate his clients. This screen is used in addition to more dynamic movement screening that includes the FMS (Functional Movement Screen) as well as some basic table assessments. This blog will show videos outlining his table assessments.
 
The Functional Movement Screen (FMS)
 
Before we move onto the table assessments, it is important to have a basic understanding of the FMS. The FMS is a 7 test screen developed by Gray Cook and Lee Burton used to evaluate fundamental movement patterns. The screen will assess risk and can identify situations where the client experiences pain and should be referred to a specialist, situations where a client needs to work on balancing out asymmetries, situations where a client needs to work on increasing mobility, stability, or motor control to improve a particular pattern prior to engaging in various activities. The 7 tests include the deep squat, hurdle step, inline lunge, shoulder mobility, active straight leg raise, trunk stability push up, and rotational stability. The FMS is a very valuable assessment tool that every trainer should incorporate into their arsenal.
 
Basic Table Assessments
 
The table assessments that Keats uses consists of a breathing pattern assessment, a head & neck mobility assessment, a t-spine mobility assessment, a shoulder mobility assessment, and a hip, foot & ankle, and big toe mobility assessment.  These basic tests are assessing what is called ”passive movement testing” (although they can all be done actively as well). Passive movement can be further broken down into what is called “physiologic motion,” which is what we are going to be demonstrating, and “accessory joint motion” (joint play, component movements). Accessory movement testing is beyond the scope of testing for the intended audience of this blog so those tests should be left to licensed professionals trained in orthopedic manual assessment.
 
Breathing Pattern Assessment
 
In this video, Keats takes a look at my breathing patterns. He’s looking for natural diaphragmatic breathing that involves breathing into the belly prior to breathing into the thorax.

 
 
Head and Neck Mobility Assessment
 
In this video, Keats takes a look at Bret’s neck mobility from various directions. Normal ranges include  0-80-90 degrees of cervical flexion,  0-70 degrees of cervical extension, 0-30-45 degrees of cervical lateral flexion, and 0-70-90 degrees of cervical rotation.

 
Thoracic Spine Mobility Assessment
 
In this video, Keats takes a look at Bret’st-spine mobility from various directions. Normal ranges are difficult to isolate since the t-spine is intimately connected with cervical and lumbar spine function. Suffice to say need to be able to at least reverse the normal thoracic kyphosis to straight and be able to rotate at least 45 degrees in each direction from a tall seated position with the hips/pelvis stabilized. The T-spine is truly a huge player in full body movement capacity, breathing, and posture. Its influence on the c-spine (including the jaw/TMJ) and shoulders is often ignored in painful conditions.

 
 
Shoulder Mobility Assessment
 
In this video, Keats takes a look at Bret’s shoulder and scapular mobility from various directions. Normal ranges include 0-180degrees of shoulder flexion, 0-60 degrees of shoulder extension, 0-180 degrees for shoulder abduction, 0-90 degrees of external rotation, and 0-70 degrees of shoulder internal rotation. Also included are basic length tests for pectorilas major, pectoralis minor, latissimus dorsi and teres major which to a large part, determine the mobility in this region.
 

 
Hip, Ankle, and Big Toe Mobility Assessment
 
In this video, Keats takes a look at my hip mobility, ankle mobility, and big toe mobility from various directions. Normal ranges include 0-120 degrees of hip flexion (with bent knee), 0-90 with straight/extended knee,  0-30 degrees of hip extension (from prone position (knee extended), 0-45 degrees of hip abduction,  0-30 degrees of hip adduction,  0-45 degrees of hip external rotation, 0-40 degrees of hip internal rotation, 0-20 degrees of ankle dorsiflexion, 0-50 degrees of plantar flexion, 0-35 degrees of inversion, 0-15 degrees of eversion,  and 0-65 degrees of big toe extension (although only 45 degrees are needed for gait).  Also included is the thomas test for hip-flexor length. Not shown but extremely important is the “obers test” for hip-abduction contracture/tightness.

 
What do I do if Clients Don’t Possess Normal Ranges of Motion in Various Joints?
 
There are three basic scenarios that can occur with your assessments:

1) the individual will possess adequate ROM that doesn’t require any remedial stretching or mobilizations. For these people, a quality training/conditionig program will serve to maintain the range they already have.  Semi-frequent re-testing is needed to make sure this range of motion isn’t lost however.

2) the individual has excessive ROM which may or may not be a problem depending the strength and motor control capacities of the person. Too much ROM (hypermobility) can be as bad in some situations as too little ROM! For specifically assessing if someone has too much ligamentous laxity/hypermobility all over there body, the Beighton Score is an easy testing protocol to administer.

3) the individual will possess decreased ROM/hypomobility in a given joint motion which could signify that either a musculo-tendinous/fascial or “extra-articular” (outside the joint) problem exists. Or, there could be a problem within the joint (intra-articular) that would required more attention to the joint capsule and other structures that would be best performed by a licensed professional trained to administer joint mobilitzation (Osteopath, physical/physio-therapist, chiropractor). This is a good reason for personal trainers and bodyworkersto have a good network of other professionals who can perform any specific joint work that might be needed. The basic goal with these people is to improve the range of motion of the truly short, or stiff tissues. Utilizing the corrective strategies concept as promoted by the FMS, once lost ROM is regained, it must be backed up with some stability training (static, then dynamic stability) in order for it to stick. Stretching in and of itself is often not enought to change movement in any meaningful way!

A Hypothetical Scenario – Tight Hamstrings

Corrective exercise for a mobility restriction or stability problem is an art unto itself and would require an entire book (just read Gray Cook’s new book which should be available soon) to list all the various protocols. To give one example of a corrective sequence, let’s say that an individual has poor hamstring flexibility. Perhaps they are overworked from synergistic dominance due to weak glutes and tight hip-flexors on the other side. You would want to incorporate self-myofascial release for the hip flexors and activation work for the glutes in order to “release the brakes” on the hamstrings and decrease hypertonicity.

You would also want to incorporate various types of stretches and mobility drills for the hamstrings. Finally, you may want to start the client off with rack pulls and work on gradually increasing the range of motion until a full range deadlift can be perform while maintaining a neutral spine. Knowing various drills and progressions is critical in improving motor patterns and eliminating dysfunction. Assessments & Screens provide you with great information but you also need to know what to do with that information in terms of exercise selection and program design.

At any rate, we hope you enjoyed the videos. Over time, we will try to post more blogs that provide more information on screening and corrective exercise. Thanks for reading and watching!

-Keats Snideman and Bret Contreras

By Keats Snideman RKC, CSCS, LMT, CNMT

 Have you ever stubbed one of your toes really hard?  Hurts a lot doesn’t it? In fact, more four letter words have probably been uttered in the agonizing seconds immediately following the dreaded event than almost any other accidental (yet non-serious) injury. Fortunately, unless you [...]]]>

By Keats Snideman RKC, CSCS, LMT, CNMT

 Have you ever stubbed one of your toes really hard?  Hurts a lot doesn’t it? In fact, more four letter words have probably been uttered in the agonizing seconds immediately following the dreaded event than almost any other accidental (yet non-serious) injury. Fortunately, unless you break the darn thing, the stubbed toe probably stays sore for a couple of days and then fades away with no recurring or lingering pain or alterations in function.

Such is not always the case with athletic injuries to the toes and specifically the big toe. One of the most common injuries to this toe (also called the “hallux),” is the ubiquitous “turf toe” injury, which is essentially a hyper-extension injury (or more accurately a hyper-dorsiflexion injury).

 The Dreaded Turf Toe Injury!

 This is a common injury among speed and power athletes and is commonly seen with too much play on artificial turf and hard surfaces like basketball courts. While seemingly trivial, this initial insult to the big toe often sets the stage for future degenerative changes that over time, can severely limit range of motion and cause other dysfunctions up the kinetic chain which will be discussed below.

This injury is no stranger to the author as I suffered the injury during high school playing field hockey (field hockey…yeah yeah, I know what you’re thinking..and no, I did not wear a skirt!).

Me playing Field Hockey in High School; gotta love the short shorts!

 Thus, the remainder of this article will dive into the many body-wide ramifications that can occur when adequate range of motion (primarily in 1^stMPJ dorsiflexion) does not exist. Finally, I will also give some practical treatment advice in the form of some videos I filmed with my twin brother Franz Snideman and my friend and colleague Patrick Ward. Hopefully, by the end of this article, you will never look at the big toe the same again!

 With a Stiff Big Toe, it’s Hard to Go!

 The primary dysfunction we’re going to discuss here is called Hallux Limutus/Rigidus, which is a combination of degenerative changes and restricted range of motion in dorsiflexion of the 1^st MPJ. There is another condition called functional hallux limitus (FHL)that is similar to hallux rigidus except that degenerative changes are not seen on an x-ray. The main finding with FHL is that normal ROM is found during non-weight bearing of this joint which subsequently is significantly reduced during weight bearing gait (walking and running). The usual sequence of events that occur in response to an injury like turf toe is to first develop FHL, followed by hallux limitus, and then finally as the arthritic changes worsen, hallux rigidus sets in. Hallux Rigidus Sucks!

Before we continue, here is a video doing some basic anatomy of the bony structures of the foot:

Here is a video off Youtube that explains more about Hallux Limitus and Rigidus:

 Before we go any further it might be helpful to go over the expected normal ROM for this joint. Typically, the theoretical model that has been taught in schools of Podiatric and Orthopedic Medicine respectively has been to look for 65-75 degrees of dorsiflexion. There is some confusion however with these numbers since not every clinician or researcher was being clear as to how the measurement was being taken, weight-bearing or non-weight bearing? The real key is what happens in this joint during walking and running (i.e. weight bearing), the more practical/functional way we use the 1^st MPJ. And until recently, there has been very little data and no definitive accurate methodology to measure the ROM during gait.

                 Like Former President Bush, the Research Can Be Confusing!

In 1999 however, a study was published by Nawoczenski, et al, which looked at the motion of the 1^stMPJ in 10 healthy people during gait. To measure the motion of the hallux relative to the first metatarsal bone, they used an electromagnetic tracking device. What they found was that the average dorsiflexion ROM during gait was around 42 degrees. The average ROM tested during non-weight bearing of this same group was 57 degrees. Therefore, there are some researchers who now recommend that the gold standard “normal” ROM for this joint during weight-bearing should be 45 degrees. But this was during walking, what about running?

There is no published data that I could find on this but in an article in Podiatry Today (How to Treat Halux Rigidus in Runners, by Doug Richie Jr., DPM, April 2009), unpublished research by Mari Adad, DPM, showed that the average ROM of dorsiflexion during running was found to be only 26 degrees! This is considerably lower than the 42 degrees found in the research by Nawoczenski as mentioned above. This may account why several runners with hallux rigidus/limitus may feel worse when walking as compared to running. I could not find any data on the ROM during sprinting, which is my recreational sport so if anyone knows of any, please send it my way! (ksnideman@gmail.com)

There’s a Lack of Scientific Data on Sprinting and the Big Toe!

 Regardless of what the research says about the exact requirements of dorsiflexion at the hallux, a lack of ROM can cause the following disruptions/compensations up the kinetic chain (Chaitow & DeLany 2002):

•  Closer to the foot, the lack of 1^stMPJ dorsiflexion will cause limited plantar flexion at the ankle joint (talo-crural joint) which will strain the Achilles/gastroc-soleus musculo-tendinous complex. This can lead to pain and subsequent tendonosis of the Achilles region and plantar fascia problems. Excessive pronation of the foot will often be seen as well even though the weight will often be shifted to the outside of the foot to avoid stressing the big toe.

•  The lack of plantar flexion leads to early knee flexion which disrupts the entire gait cycle and limits normal hip-extension.

• With limited hip-extension, trunk flexion will often occur to compensate which over time, can be stressful to the intervertebral discs.

•  Because of limited hip-extension, the hip-flexors are not lengthened properly (lack of pre-stretch) which makes them have to work that much harder to advance the leg on the “swing’ cycle of gait. This can lead to chronic shortening and trigger point activity in the ilopsaos, rectus femoris, TFL, Sartorius, and possibly even the short adductor muscles. I know this chronic hip-flexor pattern all too well since I’ve had it as long as I can remember since high school.

• There will also be a contralateral side-bend away from the restricted side that will be coupled with a rotational force which is challenging to the facet joints and lumbar discs. Chronic quadratus lumborum (QL) and even abdominal oblique tightness and trigger point activity will usually result. The opposite S-I joint can be overly stressed as well leading to chronic shortening of the piriformis muscle in efforts to stabilize the joint.

Chronic Trigger Points in Quadratus Lumborum (QL)

• If you follow the compensations up higher, there will even be changes to the thoracic spine (increased flexion often) with subsequent righting mechanisms of connections are mostly mechanical however which in turn lead to changes in the myo-fascial tissues, joint/connective tissues, and to nervous and vascular systems. It’s hard to effect one system without affecting them all!

 Abnormal Biomechanics Due to Hypomobile Big Toe!

 So here’s what the gait patterns look like between a normal 1^stMPJ dorsiflexion range and a limited one:

                                                                                    Normal ROM                                                                                              

Limited ROM!

 And here is a potential gaiting pattern dysfunction of the entire body when viewed from the side:

                NOT GOOD…This could be me and my twin brother in 30-40 years!!

 Treatment Options

 There are many treatment options available for those suffering from Hallux Limitus/Rigidus/FHL including conservative therapies/care like orthotics, pain killers and anti-inflammatroy drugs, and finally surgery. My focus in on the conservative options, assuming that someone is not so far degenerated in the 1^stMPJ that they can’t regain any lost ROM. There is a point of no return unfortunately in any joint where conservative treatment options will not be of any real value. For such individuals, this is a time for considering surgical options and very specific orthotic devices. Surgery is obviously not my area of expertise so I won’t be discussing those options and consultation with an appropriate podiatrist or orthopedic surgical specialist would be warranted.

  One thing medically I did pick up in my research for this article is that neither anti-inflammatory drugs nor cortisone injections seem to be that effective for long-term improvements. This makes sense since masking the pain and putting out fires (inflammation) temporarily does very little to alter the behavior or mechanical faults that lead to the condition in the first place!

 Anti-Inflammatory Drugs         

 Cortisone Shots

The primary conservative options I’m going to discuss include soft-tissue and joint mobilization, alteration of footwear, as well as daily mobility exercises and stretches.

 Footwear

 There are two schools of thought when it comes to treating this condition with regards to footwear:

 1)      Everyone needs supportive shoes and/or orthotic foot inserts.

2)      Try to get the ankle/foot complex to function well on its own (a la going “barefoot”).

 Orthotics for Everyone?

In reality, there are some cases where people should be wearing orthotics due to their specific condition or dysfunction while others would be better served trying to take the minimalist shoe approach and wear shoes that permit a more natural, barefoot-like gait pattern. Which route to choose must be made after careful assessment of an individual’s unique case history?

 I am personally biased towards trying to regain as much functional mobility and capacity first, before trying orthotic devices but again, this must be made on a case-by-case basis. Since not everyone gets the miracle cure from going barefoot, a shoe is often needed with some support. I recommend however that the shoe be as minimalist as possible and does not “over-support” your foot.Vibram 5-Fingers are Getting Very Popular!

 The Kigo Shoe, another Barefoot Option

                                                                                                                The Ultimate Barefoot Shoe!

 Below is a video clip of my thoughts and opinions on the barefoot versus orthotic controversy:

Self-Mobility Exercises and Stretches

 There are several stretches and self-mobilizations that can be performed daily or even several times per day to encourage better mobility at stiff/restricted segments of the ankle and foot. To recap all the possible options would be impossible but below are two videos of some self-mobilizations that I filmed with my twin brother Franz Snideman during a recent visit to Arizona.

Soft-tissue Mobilization

A great place to start here is with releasing the stiff and shortened tissues that are either directly or indirectly affecting the 1^stRay/MPJ. We could probably start at the pelvis and lumbar spine and look at lumbar erector spinae, QL muscles, the hip-flexors (psoas, iliacus, TFL, Sartorius), quads (primarily rectus femoris) and groin; all the muscles indicated to be potentially shortened in a lower Cross Syndrome. Increased tone in these muscles can cause anterior rotation and a forward displacement of the pelvis in the saggital plane which can shit the weight of the body more anterior on to the toes and balls of the feet; the typical resting position for a power/speed athlete. Many endurance athletes may fit this criterion as well.

Lower Crossed Syndrome (Vladimir Janda)

From here, the lower leg should be treated in its entirety which can be conveniently broken down into 3 compartments:

 The Anterior Compartment: which consists of the anterior tibialis, extensor hallucis longus, extensor digitorum longus, and the peroneus tertius (if present).

The Lateral Compartment: which consists of the peroneus longus and brevis.

The Posterior Compartment: which consists of a superficial layer which houses the gastrocnemius, soleus, and plantaris mucles; and a deep layer which contains the tibialis posterior, flexor hallucis longus, and the flexor digitorum longus muscle.

Moving to the foot, the dorsal (top) and plantar (bottom) surfaces would then be examined with specific attention paid to the muscles attaching to the first ray including the two sesamoid bones that sit under the distal end of the 1^st metatarsal bone.

The Sesamoid Bones are Very Important!

Here is a video of my friend and colleague Patrick Ward talking more about treatment options for big toe dysfunctions.

Joint Mobilizations

 To perform specific joint mobilizations requires the proper license so many of these techniques are out of the scope of a typical personal trainer or strength and conditioning coach. With that said, it still important for the fitness or even massage professional to understand the basics of joint mobilization and realize when a referral might be needed to a competent rehabilitation professional trained and skilled in joint mobilization techniques. The techniques I will summarize come from the greats in the field of manual medicine such as Geoffery Maitland, James Cyriax, Freddie Kaltenborn, and Brian Mulligan.

There are several different types of joint mobilization techniques and the proper one to use is based on several key issues:

1)  The current state of pain of the joint in question

2) The level of degenerative changes present in the joint to be mobilized.

In the case of the big toe (1st MPJ), what is often needed is not only a regaining of basic physiological motion(i.e. flexion, extension, etc..);  but also to re-esatablish the proper accessory motionswhich must accompany the phsyiological ones. The accessory joint motions are classified as:  compression, distraction, slide, roll, and spin. These are more specifically known as joint-play motion  and they cannot be made actively or consciously; they occur (or should occur) as a result of normal joint motion. So in the case of walking for example, when toeing off the ground, the normal dosri-flexion that must occur at the 1st MPJ must be accomanied by a dorsal glide and so a combination of traction of anterior to posterior glides might be helpful to try and restore the normal joint play. Again, these mobilizations are much more complex than simple massage/soft-tissue techniques and must be performed by a licnesed health care provider trained in such techniques.

Other Problems of the First Toe/Differential Diagnosis

Many other conditions can disrupt the healthy functioning of the big toes including Hallux Valgus (often seen with bunions and often involved with Hallux limitus/FHL), Hallux Varus, hammer Toes, claw toes, gout, neuropathy, infection, cancer, tumors and many other rare, systemic conditions that are  beyond scope of this article. If you have big toe pain or dysfunction (and the compensatory pain it often cause up the kinetic chain), it always best to get medically evaluated first before trying any self-treatment options so you know what you are really dealing with.

Hallux Valgus!    

Bunion 

 Conclusion/Putting it All Together

I hope that this has been a helpful and possibly eye-opening article and that some of you reading will come away with some strategies and ideas for dealing with limitations of movement in the 1^st MPJ. If you have no big toe issues yourself, you probably might know someone who does, so please pass this on to them. Also, please send comments or feedback to ksnideman@gmail.com. Thanks for reading!

Keats

Resources

1). Clinical Applications of Neuromuscular Techniques, Volume 2: The Lower Bodyby Leon Chaitow and Judith Walker Delany. 2002 Elsevier Science Limited.

2) Evaluation, Treatment and Prevention of Musculoskeletal Disorders, Volume 2: Extremities (3rd Edition) by John P. Tomberlin and H. Duane Saunders. 1994 The Saunders Group.

3) How To Treat Hallux Rigidus in Runners, by Doug Richie Jr., DPM. Podiatry Today (www.podiatrytoday.com) April 2009 (pgs. 46-56).

4) Nawocenski DA, Baumhauer JF, Umberger BR. Relationship between clinical measurements and motion of of first metatarso-phalangeal joint during Gait. J of Bone Joint Surgery, 81(3): 370-6, 1999.

5) Contributions from Franz Snideman, RKC-TL, CK-FMS and Patrick Ward, CSCS, LMT, CNMT

Review of the Functional Movement Screen Workshop!

Two weekends ago (May 7-8) [...]]]> This blog-post is about two weeks late since I’ve been dealing with some issues getting my website switched over to a new server. All is done with the transfer, so now I can begin blogging away since I have a lot of ideas to write about!

Review of the Functional Movement Screen Workshop!

Two weekends ago (May 7-8) I was fortunate enough to take the Functional Movement Screen workshop & certification put on by Perform Better with Gray Cook and Lee Burton of Functional Movement Systems.

Gray Cook      Lee Burton

For those who aren’t familiar with the Functional Movement Screen (FMS for short), it a series of 7 tests/screens which evaluate and rank movement quality in fundamental movement patterns that most able-bodied humans should be able to perform. The movements are all ranked on a 3 point testing scale with a score of zero given for pain. Therefore, the maximum score anyone could achieve is a 21. Statistically, a score of 14 and below appears to be the cutoff point for increased risk of injury. Since many of the test also test the left and right side of the body independently, the screen is also looking for asymmetries since they are implicated with increased risk of injury as well. The 7 fundamental tests are as follows:

1) Deep Squat

2) Hurdle Step

3)In-line Lunge

4) Shoulder Mobility

5) Active Straight-leg Raise

6) Trunk Stability Push-up

7) Rotary Stability

In addition to these 7 patterns, are 3 clearing tests which include an impingement test for the shoulder and a flexion and extension clearing test for the lumbar spine. The shoulder and lumbar areas are amongst the most commonly injured due to the inherent lack of stability often found in these joints. Any pain on these clearing tests would make the preceding movement screen score an automatic zero with an appropriate referral to a competent medical professional if needed.

You can read more about all the tests and see photos and descriptions here.

The major goal of the screen is to identify those individual (young or old) who are at increased risk for injury (specifically non-contact type of injuries). The screen is the only kind in existence that is being used on a large scale right now with professional, collegiate, even high school athletics as a way to statistically demonstrate and correlate risk in certain individuals who fall below a minimum level of movement competency.

Wisdom and Knowledge from Gray Cook and Lee Burton

The following are some of the notes I jotted down during the seminar that struck me as revelatory or important:

About the FMS in General

*We build systems to protect us from our own subjectivity… the FMS is that system for movement evaluation. FMS is about capturing movement patterns from a behavioral standpoint to asses injury risk.

*FMS is a system, not a program.

*Systems= if this, than that..if this than that= more options!

*Programs= no matter what…do this= less options!

*FMS is a “screen,” which doesn’t tell us what is wrong..only that something is not functioning properly..to find out more you then need to assess and evaluate with different more “specific’ testing.

* FMS really tells us 2 things:

1)If there is pain or dysfunction

2) If a client/athlete can move..

*Quality movement is the is foundation of all good skill and performance so needs to come first!

*Fitness on top of good movement= insurance policy.

*Fitness on top of poor movement= increase risk for injury and jeopardized performance.

*FMS is not a sensitive enough test for people currently in pain, that’s not what its designed for. Refer out to someone who can do the SFMA (Selective Functional Movement Assessment) instead.

*FMS with kids and elderly can still be done. Don’t omit a test; if it can’t be done then just give a zero score and list why. Do as many tests as can be performed to capture movement capacity of the individual.

*Unless you can document that a movement pattern is whole, its not..its not authentic yet.

*Table tests only give you a brief “snapshot” of a great big movie. They don’t tell you how a given individual can put movement patterns together,etc..

*Strength and ROM on a table can be the same in 2 different individuals, yet functional performance is vastly different!

*Quality (i.e. “authentic”) movement is the key..if that’s out, nothing else matters! Programming is secondary to a quality a baseline of movement competency.

*Movement and Metabolics is how we get quality performance!

Central Nervous System stuff and more…

*The CNS is key! Kinesiology 101 is a map..a map of movement and a map of anatomy are NOT the same thing! In other words…the map is not the terrain!

*Muscle function is movement-pattern specific; isolation does not necessarily improve integrated movement.

*In a stressful (i.e. survival or threatened) environment/situation, the body will always sacrifice movement quality for movement quantity (i.e. run away from saber-tooth tiger in pre-historic man).

*The brain many times, will create a mobility problem, cause its the only option left.

*Developmental Kinesiology- the eyes start the process of “reflex” learning of primitive movements which eventually lead to movement patterns. You must challenge perception to increase awareness in clients..they must make mistakes to learn. This is organic and authentic learning.

*We’ve damn-near made exercise “idiot-proof” with machines and professional rep-counters in big-box gyms. You need to be mentally engaged for exercise to have a positive effect!

Core Issues, Motor Control and more..

Two different core functions:

1) Hard-core/high-threshold strategy- this would be more of the global “outer’ muscles that are more responsible for torque production/reduction (Rectus abdominus, obliques, erector spinae). The movement screen test that really tests this is the TSPU (Trunk stability push-up).

2) Soft-core/Reactive Core (RC)/low-threshold strategy- this involves the deeper “stabilizer” muscles (aka “Inner Unit) including TVA, Diaphragm, pelvic floor, multifidus. These muscles are more responsible for stability, timing, adjustment, or what Gray called “tapping the breaks.” The key is that these muscles have to contract first, before the bigger, prime-mover muscles. The movement screen that tests this specifically is the Rotary Stability test (RS).

*You can’t strengthen a “stabilizer” muscle in an isolated way and expect it to function well dynamically.

*The Reactive Core (RC) needs faster, quicker contractions; they need to be finely tuned to control proper movement path in the joints involved in a particular movement. Use of quick hands, push-ups with claps, etc.. can train this function.

*Best way to re-set core is to remove or improve biggest restriction/obstacle that is impeding healthy movement; in other words..work on the worst of the 7 scores. For many people it means improving their straight leg raise or shoulder mobility scores.

*If you want to see your abs, eat better! If you want better functioning abs…move better!

*Motor Control is key! The timing of the stabilizers with the mover muscles is the key to healthy movement quality.

On Correcting Movment Problems, Programming, etc..

*Best place to start with most people is on correcting their ASLR and SM. These are more related to “primitive patterns” and cleaning these up first will often correct more “functional” standing patterns like the DS, HS, and ILL.

*Poor SM scores are often T-spine problems. Correcting breathing patterns, massage/stick work, and improving thoracic mobility (often in extension and rotation) are keys to a healthy gleno-humeral joint.

*Don’t micro-manage specific muscles, fix the pattern!

*Pain requires immediate attention first. Asymmetries are next in importance to fix. Then address primitive patterns (i.e. rolling patterns) to re-set reflexive core activity.

*Inconsistencies in screening are often stability problems where recurring restrictions are most likely mobility issues.

*Think “get people back to the crib!” Many people need to practice basic crawling and rolling patterns to re-learn how to engage core muscles properly. See “Secrets Of Primitive Patterns” for more on this!

*After screening the key is to first restore any lost mobility that the person might need. Without adequate mobility is will be impossible to achieve true, or “authentic” stability elsewhere. Decreased mobility leads to less proprioception and awareness of any given area.

*Tightness oftnes replace authentic stability.

*You can’t fix it and if you can’t feel it!

*Exercises like the Turkish Get-Up and Indian Clubs done well, are great for improving stability and mobility problems simultaneously. Gray Cook, Brett Jones, and Dr. Mark Cheng did a great DVD on the intricacies of the Get-Up call Kalo Thenos, Kettlebells from the Ground Up. Get the DVD!

*Its important to keep client relaxed when fixing a movement patter. You don’t want to engage a high-threshold strategy. Look for loose traps and face. If face is grimacing chances are breathing has altered as well and has become upper chest than diaphragmatic. Keep shoulders down!

Conclusion

Well, that’s enough for now since the post is becoming way too long; I could keep writing since I have several more pages of notes. But this is a pretty good start! 

If you are a fitness professional and have not taken the FMS workshops (either through Perform Better or Dragon Door), I would highly recommend them! If you are not a fitness professional but just an active person or someone who is considering becoming more active, I highly recommend seeking out an FMS certified individual who can take you through the screen.  The FMS is a fantastic system for ranking movement and should be utilized a lot more throughout and athletic and general population. What is your FMS score?

If you live in AZ and would like to be screened please do give a ring and make an appointment to come in to my facility for a screen. Otherwise, you can look on the FMS directory page, or on Dragon Door to find someone who is trained in the very exciting CK-FMS certification which combines the best corrective strategies already inherent to the RKC system of teaching kettlebells with the strategies as taught by Gray Cook of Functional Movement Systems. Kettlebells and the FMS, a winning combination.

Thanks for reading!

Keats