Does Periodization of a Program Help Improve Strength?

When designing programs to enhance strength, there are many variables that you can (and should) manipulate to facilitate improvement.  These can obviously include the sets and reps (volume), loads (intensity), frequency, and rest time (density).  However, how we periodize these variables is also very important.  Periodization is the systematic structuring of how you plan on manipulating these variables over time.

You probably know me well enough by now to know that I value systems and planning.  One of our fundamental principles in program design at Champion is to “begin with the end in mind.”  It drives me crazy to see programs written month-to-month without a goal in mind.

So it makes sense to develop a system of how you plan on periodizing your strength training, wether in the personal training, sports performance, or even rehabilitation setting.

While the strength and conditioning world has really embraced the concept of periodization, physical therapists are notorious for a complete lack of periodization.  It’s not uncommon to perform “3 sets of 10″ in the rehabilitation setting forever.

Perform a Google search for strength training periodization and you’ll find a sea of conflicting terminology that is likely to make you dizzy.  Linear periodization, reverse linear periodization, non-linear periodization, undulated periodization, conjugated periodization, concurrent periodization, and block periodization are some of the many types of periodization programs that you can find.

Unfortunately there is little consensus on terminology or definition, feeding the confusion for people looking to learn about periodization even more.  Add to that the ability to essentially say anything you want on the internet without needing any scientific validity and you’ll find a dozen different “best” ways to get strong.

But the real question still remains – does strength training periodization even matter?  And if so, what type of periodization is best?

 

Effect of Periodized Versus Non-periodized Programs on Strength

Since the rehabilitation setting does such as poor job at implementing periodization into programs when returning from injury, we should start by establishing the need for periodization.

Anytime I have a research question in regard to Strength and Conditioning, I head over to Chris Beardsley and Bret Contreras’ website Strength and Conditioning Research.  Chris has an excellent article on our current scientific understanding on strength training.

The article reviewed 7 studies comparing periodized and non-periodized programs on strength in untrained individuals.  Of these studies, 4 reported significant benefits of periodization over no periodization.

Similarly, there were 7 studies comparing periodized and non-periodized program on strength in trained individuals.  Of these 7 studies, 4 reported significant benefits of periodization and the remainder reported no differences. Using periodization may therefore have a beneficial effect on strength gains in both the trained and untrained population.

I wouldn’t say the research is overwhelming, but leans towards at least some form of periodization being more effective than using no periodization at all.  I think we would all anecdotally agree with this as well.

 

Effect of Linear Versus Non-Linear Periodization

Now that we have established we should use some form of periodization, the focus now shifts on determining what the best form of periodization may be to improve strength.

Lets simplify, and perhaps oversimplify, the forms of periodization for this conversation as either linear periodization or non-linear periodization.

Linear periodization refers to the slow decrease in reps and increase in load.  For example a 4-phase program may look like this:

  • Program 1 – 3 x 12 with a light load
  • Program 2 – 3 x 8 with a moderate load
  • Program 3 – 4 x 5 with a moderate to heavy load
  • Program 4 – 5 x 3 with a heavy load

Linear Periodization

As the reps go down, the weight goes up.  This has been the most classic form of periodization used for the last several decades.

Antagonists to the linear periodization model often point out that the benefits seen early in the program in regard to strength and hypertrophy are not maintained throughout the program as the focus continuously shifts from program to program.

This has lead to several variations of non-linear periodization, including one of the most common, undulated periodization.  Undulated periodization involves continuously shift the focus of the program on either a daily or weekly cycle.

A weekly undulated periodization program may look like this:

  • Week 1 – 2×15
  • Week 2 – 3×8
  • Week 3 – 5×5

While a daily undulated periodization program may look like this:

  • Monday – 2×15
  • Wednesday 3×8
  • Friday 5×5

Undulated Periodization

While many have stated that undulated periodization is more beneficial at eliciting strength gains, does the research agree?

A recent meta-analysis was publish in the Journal of Strength and Conditioning Research.  They reviewed hundreds of articles and ultimately select 17 that met all their strict criteria for analysis.

Of these 17 articles, here are a few bits of information:

  • 12 compared linear periodization to daily undulating periodization.  3 compared linear to weekly undulating.  1 study compared all 3.
  • 7 studies were on untrained people (<1 year experience), 10 on trained (> 1 year), and no studies included advanced trainees (>5 years).
  • 16 out of 17 studies reported significant increase in strength in both linear and undulated periodization.  12 studies found no difference between the two periodization models.  3 found undulating better than linear and 2 found the opposite.

The overall meta-analysis also agree and the article concluded that there is no difference in strength gains between linear and undulated periodization.

However, when analyzing trained individuals, people that had previous experience with linear periodization had an improvement in strength when switching to undulated periodization.  There was no difference between the linear or undulated periodization in untrained individuals.

Based on this it appears that as your training age increases, you may need to change your training stimulus to maximize your gains.  However, linear periodization will work fine in new trainees.

Realize that the majority of articles you read on the internet are geared towards the very small percentage of people that fit into the advanced trainee grouping, when in reality, this is not what 95% of us see on a regular basis, especially in the rehabilitation and general population personal training worlds.  Sure, advanced periodization programs are needed to get from 500 lbs to 600 lbs on a lift, but probably not as much from getting from 100 lbs to 200 lbs.

Linear periodization offers a great way to introduce and teach movement patterns with a lower load and higher rep scheme, then as the movement skill is perfected, the load can safely increase.

 

Periodization for Strength Training and Rehabilitation

Because the topic of periodization is so large, important, and so often neglected in the rehab and personal training setting, this month’s Inner Circle Webinar is going to be on Periodization for Strength Training and Rehabilitation.  In this webinar, I am going to discuss the above concepts in much more detail and show you how we periodize some of our programs for healthy people and those coming back from injury in the physical therapy setting.

The webinar is Monday May 18th at 8:00 PM EST and will be recorded for Inner Circle members.

 

 

 

 

How to Improve Overhead Shoulder Mobility

The latest Inner Circle webinar recording on my How to Improve Overhead Shoulder Mobility is now available.

 

How to Improve Overhead Shoulder Mobility

Improving Overhead Shoulder MobilityThis month’s Inner Circle webinar is on how to improve overhead shoulder mobility.  In this webinar I’ll discuss:

  • We we are losing overhead shoulder mobility
  • Why it matters
  • The 4 main reasons why we lose overhead mobility
  • How the body compensates when we lose overhead mobility
  • How to assess for a loss of overhead shoulder mobility
  • What you MUST stop doing immediately with people that have lost overhead mobility – you are making them worse!
  • Corrective exercises to enhance overhead position
  • Manual therapy techniques to improve mobility

 

To access this webinar:

4 Ways to Improve Overhead Shoulder Mobility

4 Ways to Improve Overhead Shoulder MobilityOne of the most common areas we attempt to improve in clients at Champion PT and Performance is overhead shoulder mobility.  If you really think about it, we don’t need full overhead shoulder mobility much during our daily lives.  So our bodies adapt and this seems to be an movement that is lost in many people over time if not nourished.

I’m often amazed at how many people have a significant loss of overhead mobility and really had no idea!

That’s not really the issue.  The problem occurs when we start to use overhead mobility again, especially when doing it during our workouts and training.  Exercises like a press, thruster, snatch, overhead squat, kipping pull up, toes to bar, handstand push up, wall ball, and many more all use the shoulder at end range of movement.  But here are the real issues:

  • Add using the shoulder to max end range of overhead mobility and we can run into trouble
  • Add loading during a resisted exercise and we can run into trouble
  • Add repetitions of this at end range and we can run into trouble
  • Add speed (and thus force) to the exercise and we can run into trouble

 

4 Ways to Improve Overhead Shoulder Mobility

In this video I explain the 4 most common reasons why you lose overhead shoulder mobility and can work on to improve this movement:

  1. The shoulder
  2. The scapula
  3. The thoracic spine
  4. The lumbopelvic area

The first three are commonly address, but not so for the lumbopelvic area, which is often neglected.  I’m going to expand on this even more in this month’s Inner Circle webinar.  More info is below the video:

 

Improving Overhead Shoulder Mobility

This month’s Inner Circle webinar is going to expand on this topic and discuss how and why you want to improve overhead shoulder mobility.  In this webinar I’ll discuss the importance of overhead mobility, how to assess the 4 most common causes of loss of mobility we discussed above, what corrective exercises to perform, and tips for manual therapy.  The live webinar will be on Monday April 20th at 8:00 PM EST, however will be recorded for those that can not attend live.

 

 

 

6 Things You Do That Your Clients Hate

6 thing you do that your clients hateIt’s funny, over the years you start to accumulate several thoughts on a subject that one can only do through experience.  The old saying “if only I knew then what I knew now” is certainly true.  I often laugh at some of the things I did and say to my clients when I was less experienced.  We were having this discussion with our students at Champion the other day, and I consider this a normal part of your career advancement.

In addition to reflecting on your own personal practice, I think there is also a lot to learn about from your clients when they tell you their past experiences with other professionals.

I tend to see a lot of clients that have tried other health care and fitness professionals and for whatever reason find themselves with me after not achieved the results that they wanted.  In my experience, this is often due to a few reasons:

  1. They didn’t listen
  2. They didn’t connect
  3. They didn’t put in the time

 

Notice how none of these things are “clinical” in nature.  Sure, I see my fair share of clients that were not diagnosed well or treated properly, but in all reality, I’m not perfect either.  But I listen, connect, and put in the time.  This allows my the luxury of being able to call an audible with my clients when I feel we may have started down the wrong path.  They trust me.  If they didn’t trust me, they’d move on to the next clinician.

How about these two comments I received recently from clients about their past experiences with other professionals.

  • “All my therapist did was tell me what I was doing wrong.  I know what I am doing wrong, that’s why I went to therapy.”
  • “I left my last therapist and always felt bad about myself.  They made me feel bad about myself.”

 

For the young clinicians (and I guess the more experienced one’s too!), I want to share some of the things I have picked up over the years that clients hate.  Remember, you need to connect in order to do you best with your clients.  Learn from my mistakes and errors and avoid these 6 things you do that your clients hate!

 

Stare at Your Device

I can’t think of a worse way to start off your experience with a healthcare professional than having them stare at their computer and typing while asking you a series of questions.  Not a great way to connect and help your client feel like your are compassionate about them, rather than just trying to finish your “task” of their evaluation.  I still take notes briefly when pencil and paper and do my documentation afterwards.  Sure, it takes more time out of my day, but it’s the right thing to do.

This also goes for staring at your phone their whole session.  You could be responding to a highly urgent and work-related email, but realize your clients will just assume your are posting pics of your kittens on Facebook.  Excuse yourself and respond to an urgent message if you must, but don’t do it right in front of your client.  This looks like they are not important to you at the moment.  Otherwise, keep your phone in your pocket.

I’m not sure if the Apple Watch is going to help us here or hurt us, we’ll see!

Your client needs to feel like they are the most important person in the world to you during their session.

 

Don’t Listen to Them

Your first interaction with someone is really important for several reasons.  Obviously you need to determine where to start with your client, but it’s also the most critical interaction to development a connection.

This starts with letting them talk.  You want to hear their story.  Some will want to get right to the point, while others will want to elaborate.  Let this happen.  Don’t interrupt if you can, and let them lead the discussion.

As I get more experience, the subjective portion of my exam could really only last 30 seconds for me to have enough information to start looking at the client.  However, I have learned that a big part of connecting with your clients is listening to your client.  You need to provide the platform for them to share what they want with you.

 

Force Feed What You Want Instead of What They Want

It’s not about you.  Starting with this simple concept is a great start.

As an example, perhaps a client comes to you and says “kinesiology tape really makes me feel better.”  How do you think they’ll respond when you say, “Your shoulder pain is coming from signals in your brain, kinesiology tape won’t help that and doesn’t really do anything.”  Ummm, probably poorly.

You said that kinesiology tape “doesn’t do anything” and they said it “really helps.”  That sounds like conflict, not connecting, to me.

In all honesty, we don’t know as much as we think we do about the human body.  I have no problem providing a treatment, such as kinesiology tape, if there will be no harm, no long term consequence, and there is no definitive research saying it is ineffective.  Obviously, if scientific evidence is available to completely say something is ineffective that changes the topic.

Don’t get me wrong, I will do what I want to do with that client, but may also try some kinesiology tape as well.  Perhaps that makes my treatments even more effective.

Another great example in the fitness world is the focus on movement and corrective exercises.  I think this is great, but don’t lose focus.  If someone comes to you for fat loss and all you talk about is how poor they move and how you want to fix their asymmetrical 1 on the FMS straight leg raise, you are forcing what you want on the client, and not focusing on what they want.  They don’t give care at all about what their straight leg raise looks like.

Again, I think you should work on that movement pattern.  But that can’t be the focus of the program.  It has to meet their goals first.  Sure, we sneak our goals into our programs too, but be careful here.

 

Tell Them Everything That is Wrong with Them and Nothing That is Right

I think we all get carried away sometimes with finding “deficits” during our assessments and evaluations.  That is normal.  But we need to be careful with how we present this to our clients.

Some people will focus too much on the little things, while others will seem just feel bad about themselves.

Every client should leave your facility feeling better, more optimistic, and in a good mood.  You want to be one of the best parts of your clients’ days.

I’ve actually talked about this in the past in an article on The Dale Carnegie Approach to Assessments.

 

Talk Over Their Head

As you can see, communication and people skills are pretty valuable in our professions.  Another area that I often see as being an issues is not bringing the discussion to your client’s level.

Just like you should be trying to match your clients’ energy levels, I also try to bring my discussion to their level as well.

Students and young clinicians are often guilty of this for a few of reasons:

  1. They are used to talked scientifically to justify what they are doing to their professors
  2. They haven’t accumulated that database of analogies we all use on our heads
  3. Unfortunately, they are a little too egotistical and trying to impress the person with how much they know

Confusing someone and talking over their head is not going to impress someone.  Some people like to hear all the detailed scientific things, while others just shut you out.  You need to feel this out and adjust.  However, your ability to convey your points and messages in a manner that connects with each person will impress them.

I use several different tools to accomplish this based on how I feel the conversation is going, but my go-to methods are:

  1. Using pictures and videos during my evaluation
  2. Using analogies to compare a complicated point to one they understand.  Car analogies work well!  Things like, “it’s like driving with your wheels out of alignment, eventually your tires are going to wear down unevenly.”
  3. Using a whiteboard to express thoughts.  This doesn’t always just mean drawing a picture.  I also often write and make lists.  Some people are more visual learners.  You can usually tell when they whip out their phone to take a pic of the whiteboard when you are done!

They key is to give them the science but don’t stop there, back it up with something they can understand.

 

Criticize Their Other Healthcare Professionals and Past Experience

I’m surprised at how common this point is in our professions.  I have many clients that have commented on how other professionals they have worked with in the past just criticize everyone else they have and had worked with in the past.  Like a personal training putting down their physical therapist or their physical therapist putting down their chiropractor, as a couple of examples.  Realize that your client has probably built up a lot of trust and respect over the years for the other people they are working with, which have not currently built up.

Not only does this make the person feel bad about their past choices (see above), but it’s also very transparent that you are just slamming someone else to try to make yourself look good.

I have a general rule of thumb that I developed over the years after seeing many “prestigious” people commit this error – Don’t make others look bad to make yourself look better.  It may work in the short term, but always catches up to you.

Yes, you are a genius when you have the power of hindsight.  Everything is clearer in retrospect.  Be respectful of their other people your client is seeing and has seen, you aren’t always right.

 

In reality, I probably could have listed another dozen, but these are a great start.  Avoid these 6 things that you do that your clients hate and focus on connecting, listening, and putting in the time to maximize your own effectiveness in helping people achieve their goals.

 

 

 

How to Enhance Recovery Beyond Nutrition

Today’s guest post comes from Kamal Patel and the team at Examine.com.  If you haven’t heard of Examine.com just yet, you’ve been missing out!  Examine.com is the web’s best resource for evidence-based information on nutrition and supplementation.  They are completely unbiased and only report on scientific fact, not speculation.  The nutrition and supplement fields are filled with anecdotal information, false beliefs, and downright inaccurate claims about efficacy.  Examine.com helps us sort through what is fact and fiction.  Be sure to check out the special offer from Examine.com at the end of this article.

 

How to Enhance Recovery Beyond Nutrition

Training sounds pretty simple on paper. Just eat right, sleep well, and lift a little bit more weight every workout. But every workout takes place in real life, and real life can make training pretty hard.

To improve at the rate that you read about on internet forums – hitting a 315 pound squat or 225 pound bench press after a year of training – you need to train like an athlete. That doesn’t just mean going to the gym three times a week and downing a protein shake afterward. Optimal training only occurs when daily life doesn’t get in the way.

Training like an athlete while working a full time job or going to school is not easy, but fixing weak points in your habits and lifestyle can help avoid training setbacks and plateaus.

Alleviating Soreness and Joint Pain

Exercise causes muscle and joint pain. The severity of the soreness and how long it takes to recover depends on diet and lifestyle, as well as the kind of exercise performed.

The basics

A high-carbohydrate diet is the first step to alleviating post-workout joint pain. A low-carbohydrate diet, while potentially useful for fat loss, is not ideal for resistance training.

People on a low-carb diet should eat the majority of their carbohydrates in the post-workout period. Going into a workout with low glycogen is not ideal for strength training, but if joint pain is interfering with exercise, fixing the problem should be a priority.

Magnesium deficiencies can also exacerbate joint pain and cause muscle cramping in athletes. The lack of other electrolytes, like potassium, can contribute to pain. Potassium deficiencies must be alleviated through dietary changes, since too much potassium on an empty stomach can cause potentially fatal cardiac arrhythmia.

 

Troubleshooting Joint Pain

If dietary changes don’t alleviate persistent joint pain, anti-inflammatory supplements may be able to help.

Anti-inflammatory supplements are not as potent as pharmaceuticals like aspirin, acetaminophen, and aleve. However, curcumin and fish oil are both used to alleviate joint pain in athletes. Though the research on these two supplements is done in the context of arthritis, the benefits should theoretically extend to athletes as well. More research is needed to confirm this effect.

Cissus quadrangularis can alleviate the joint pain that results from specific injuries. If your post-exercise joint pain has persisted for years, you may want to consider consulting with a physiotherapist.

Do not supplement high amounts of anti-inflammatory supplements to dull injury pain. Continuing to work out after an injury can exacerbate tissue damage and increased recovery time, leading to overuse of pain-reducing supplements and permanent damage.

 

Alleviating Fatigue and Lethargy

There’s nothing like proper rest and nutrition to facilitate training, but sometimes you can’t avoid staying up late to finish a paper or getting up extra-early to beat the boss to the office.

 

The basics

Running a caloric deficit is great for weight loss, but not as great for energy levels. Though some people can go for long periods of time on reduced calories, a crash is inevitable. If your diet is interfering with your daily energy, consider a less drastic deficit.

The occasional all-nighter won’t have a long-term effect on gym performance, but consistently poor sleep will. Aim for six to 10 hours of sleep every night, and make sure your sleep environment doesn’t affect your recovery.

A healthy sleep environment is:

  • A slightly cool room tends to facilitate sleep, while a puddle of sweat is awful to wake up in.
  • Smart phones and tablets just before bed will disrupt melatonin secretion, leading to a more difficult time falling asleep.
  • Ears don’t close like eyes do. Even if you sleep through the night, loud noises can still impair sleep quality.
  • Caffeine-free. Any compounds that impair sleep will lower sleep quality, even for veteran coffee drinkers that can drink a pot of coffee at 8:00 p.m.
  • Where you sleep and how long you sleep for should be the same from night to night.

A good sleep environment actually makes it easier to get out of bed in the morning, since improved sleep quality leaves you feeling more rested.

 

Troubleshooting sleep quality

Some sleep issues can be alleviated through supplementation. People that have issues with sleep latency, meaning they have trouble falling asleep, can supplement melatonin or lemon balm.

Melatonin is a hormone that regulates sleep, but people with no difficulty falling asleep will not experience any further sleep benefits.

Lemon balm is a light sedative used to alleviate intrusive thoughts that can interfere with sleep.

Supplements that improve sleep quality, as opposed to sleep latency, include glycine and lavender.

About three grams of glycine taken thirty minutes before bed will improve sleep quality, but the supplement becomes less effective after prolonged use. To use glycine in the long term, avoid taking it daily.

Lavender, used in aromatherapy, is associated with improved sleep. Rubbing lavender oil on a pillow before bed can also improve sleep, but some people may experience skin irritation due to long-term exposure of skin to oil.

If stress is causing reduced sleep quality or poor sleep latency, supplements called adaptogens can help the body adapt to stress, resulting in fewer stress-related side effects, like fatigue and anxiety.

The most popular adaptogens are ashwagandha, Rhodiola rosea, and Panax ginseng. Ashwagandha is sometimes supplemented by athletes because it may improve cardiovascular performance and muscular strength. Siberian ginseng is another adaptogen option for people that get sick often, though it has very little effect on physical performance.

Breaking through plateaus

There’s a lot of factors to keep track of during long term training. Hitting a plateau can be frustrating because it takes time to isolate the factor responsible.

 

The basics

Daily caloric intake is the biggest influence on physical performance. Carbohydrates are more effective for strength training than fatty acids, but both are necessary for busting through plateaus.

Addressing general energy levels, fatigue, and joint pain is also a vital aspect of breaking through a plateau.

 

Troubleshooting plateaus

Supplements that improve physical performance can be useful for breaking through training plateaus. Creatine is the go-to recommendation, while caffeine (400mg) can be used once or twice a week as a pre-workout supplement.  Please note that although 400 mg is listed as a low dose in some studies, this would be a relatively high dose for someone who is caffeine naive.

There is preliminary evidence that suggests cholinergics like CDP-choline and Alpha-GPC may improve physical performance in a non-stimulatory way, but more research is needed to confirm this effect.

 

Identifying Lifestyle Weaknesses

To facilitate effective training, learn to isolate the weak points in your habits and work to improve them. Start with obvious factors, like staying up too late, and address others as they arise, whether in training, at work, or in life.

 

Examine comKamal Patel is a nutrition researcher with an MPH and MBA from Johns Hopkins University, and is on hiatus from a PhD in nutrition in which he researched the link between diet and chronic pain. He has published peer-reviewed articles on vitamin D and calcium as well as a variety of clinical research topics. Kamal has also been involved in research on fructose and liver health, mindfulness meditation, and nutrition in low income areas.

Special Offer for Inner Circle Members

Examine.com was kind enough to extend two special discounts for my Inner Circle members:

  • Examine Supplement Goals Refernce GuideExamine.com Supplement Goals Reference Guide – This is the ultimate resource on supplements, and what they call “the cheat sheet” to better health, a better body, and a better life.  They’ve done all the work and analyzed over 33,000 research studies to discuss over 300 supplements and 180 health goals.  Within seconds you’ll be browsing around, identifying health goals you want to improve, and finding supplements that will help you get there.  Best of all, this is a lifetime eBook.  Every morning the guide is updated based on the latest scientific evidence!  It’s really unbelievable.  This is normal $49 but they have a special offer for Inner Circle members of $39.99.
  • Examine.com Monthly Research Digest – For this looking for even more, Examine.com has a monthly research digest that reviews all the latest nutrition and supplement articles for you to stay on top of the evidence.  Inner Circle members get $5 off the monthly price or $50 off the yearly price.

How to access the special offers:

 

 

Scalene Hypertrophy

I recently evaluated yet another Major League baseball player with the “yips,” or what I like to call thoracic outlet syndrome.  I really don’t believe in the yips at all and feel that thoracic outlet syndrome is almost always to blame.  Telling a professional athlete it’s all in their head or some mysterious mechanical flaw is just insulting.

One of the major reasons that thoracic outlet syndrome occurs in baseball pitchers is from hypertrophy of the scalene muscles (and sternocleidomastoid).  Throwing a baseball causes many adaptations to the body, including this increase in scalene size.

Here is a video of the athlete inhaling with his head turned to each side.  Notice the significantly larger scalene and sternocleidomastoid on his right side.

scalene hypertrophy

I wish I had a magic trick to help in this situation.  I will perform manual therapy on the scalene muscles, surround musculature, 1st rib, and thoracic cage, however, it’s hard to combat the hypertrophy associated with throwing.

Understanding what to look for is the first step, though.  Scalene hypertrophy is a subtle finding to detect on examination.

 

 

Should We Stop Blaming the Glutes for Everything?

Today’s guest post comes from John Snyder, PT, DPT, CSCS.  John, who is a physical therapist in Pittsburgh, has a blog that has been honored as the “Best Student Blog” by Therapydia the past two years.  He’s a good writer and has many great thoughts on his website.  John discusses some of our common beliefs in regard to the role of the proximal hip on knee pain.  I’ll add some comments at the end as well, so be sure to read the whole article and my notes at the end.  Thanks John!

 

Should We Stop Blaming the Glutes for Everything?

should we stop blaming the glutes

Anterior cruciate ligament (ACL) rupture1,2 and patellofemoral pain syndrome (PFPS)3,4,5 are two of the most common lower extremity complaints that physicians or physical therapists will encounter. In addition to the high incidence of these pathologies, with regards to ACL injury, very high ipsilateral re-injury and contralateral injury have also been reported6,7,8.

With the importance of treating and/or preventing these injuries, several researchers have taken it upon themselves to determine what movement patterns predispose athletes to developing these conditions. This research indicates that greater knee abduction moments9,10, peak hip internal rotation11, and hip adduction motion12 are risk factors for PFPS development. Whereas, for ACL injury, Hewett and colleagues13 conducted a prospective cohort study identifying increased knee abduction angle at landing as predictive of injury status with 73% specificity and 78% sensitivity. Furthermore, as the risk factors for developing both disorders are eerily similar, Myer et al performed a similar prospective cohort study finding that athletes demonstrating >25 Nm of knee abduction load during landing are at increased risk for both PFPS and ACL injury14.

 

Does Weak Hip Strength Correlate to Knee Pain?

With a fairly robust amount of research supporting a hip etiology in the development of these injuries, it would make sense that weakness of the hip musculature would also be a risk factor, right?

A recent systematic review found very conflicting findings on the topic. With regards to cross-sectional research, the findings were very favorable with moderate level evidence indicating lower isometric hip abduction strength with a small and lower hip extension strength with a small effect size (ES)15. Additionally, there was a trend toward lower isometric hip external rotation and moderate evidence indicates lower eccentric hip external rotation strength with a medium ES in individuals with PFPS15. Unfortunately, the often more influential prospective evidence told a different story. Moderate-to-strong evidence from three high quality studies found no association between lower isometric strength of the hip abductors, extensors, external rotators, or internal rotators and the risk of developing PFPS15. The findings of this systematic review indicated hip weakness might be a potential consequence of PFPS, rather than the cause. This may be due to disuse or fear avoidance behaviors secondary to the presence of anterior knee pain.

 

Does Hip Strengthening Improve Hip Biomechanics?

Regardless of its place as a cause or consequence, hip strengthening has proved beneficial in patients with both PFPS16,17,18 and following ACL Reconstruction19, but does it actually help to change the faulty movement patterns?

Gluteal strengthening can cause several favorable outcomes, from improved quality of life to decreased pain, unfortunately however marked changes in biomechanics is not one of the benefits. Ferber and colleagues20 performed a cohort study analyzing the impact of proximal muscle strengthening on lower extremity biomechanics and found no significant effect on two dimensional peak knee abduction angle. In slight contrast however, Earl and Hoch21 found a reduction in peak internal knee abduction moment following a rehabilitation program including proximal strengthening, but no significant change in knee abduction range of motion was found. It should be noted that this study included strengthening of all proximal musculature and balance training, so it is hard to conclude that the results were due to the strengthening program and not the other components.

 

Does Glute Endurance Influence Hip Biomechanics?

All this being said, it is possible that gluteal endurance may be more influential than strength itself, so it would make sense that following isolated fatigue of this musculature, lower extremity movement patterns would deteriorate.

Once again, this belief is in contrast to the available evidence. While fatigue itself most definitely has an impact on lower extremity quality of movement, isolated fatigue of the gluteal musculature tells a different story. Following a hip abductor fatigue protocol, patients only demonstrated less than a one degree increase in hip-abduction angle at initial contact and knee-abduction angle at 60 milliseconds after contact during single-leg landings22. In agreement with these findings, Geiser and colleagues performed a similar hip abductor fatigue protocol and found very small alterations in frontal plane knee mechanics, which would likely have very little impact on injury risk23.

 

Can We Really Blame the Glutes?

The biomechanical explanation for why weakness or motor control deficits in the gluteal musculature SHOULD cause diminished movement quality makes complete sense, but unfortunately, the evidence at this time does not agree.

While the evidence itself does not allow the gluteal musculature to shoulder all of the blame, this does not mean we should abandon addressing these deficits in our patients. As previously stated, posterolateral hip strengthening has multiple benefits, but it is not the end-all-be-all for rehabilitation or injury prevention of lower extremity conditions. Proximal strength deficits should be assessed through validated functional testing in order to see its actual impact on lower extremity biomechanics on a patient-by-patient basis. Following this assessment, interventions should be focused on improving proximal stability, movement re-education, proprioception, fear avoidance beliefs, graded exposure, and the patient’s own values, beliefs, and expectations.

 

John SnyderJohn Snyder, PT, DPT, CSCS received his Doctor of Physical Therapy degree from the University of Pittsburgh in 2014. He created and frequently contributes to SnyderPhysicalTherapy.com (Formerly OrthopedicManualPT.com), which is a blog devoted to evidence-based management of orthopedic conditions.  

 

Mike’s Thoughts

John provides an excellent review of many common beliefs in regard to the influence of the hip on knee pain.  While it is easy to draw immediate conclusions from the result of one study or meta-analysis, one must be careful with how they interpret date.

I think “anterior knee pain,” or even PFPS, is just too broad of a term to design accurate research studies.  It’s going to be hard to find prospective correlations with such vague terminology.  Think of it as watering down the results.  Including a large sample of people, including men, women, and adolescents and attempting to correlate findings to “anterior knee pain” is a daunting task.

Imagine if we followed a group of adolescents from one school system for several years.  Variations in gender, sport participation, recreational activity, sedentary level, and many more factors would all have to be considered.  Imagine comparing the development of knee pain in a 13 year old sedentary female that decided she wanted to run cross country for the first time with an 18 year old male basketball player that is playing in 3 leagues simultaneously.  Two different types of subjects with different activities and injury mechanisms.  But, these two would be grouped together with “anterior knee pain.”

What do we currently know?  We know hip weakness is present in people with PFPS and strengthening the hips reduces symptoms.  As rehabilitation specialists, that is great, we have a plan.  I’m not sure we can definitely say that hip weakness will cause knee pain, but I’m also not sure we can say it won’t.  Designing a prospective study to determine may never happen, there are just too many variables to control.

John does a great job presenting studies that require us to keep an open mind.  I’m not sure we can make definitive statements from these results, but realize that there are likely many more variables involved with the development of knee pain.  Hip strength and biomechanics may just be some of them.  Thanks for sharing John and helping us to remember that it’s not always the glutes to blame!

 

 

Are We Missing the Boat on Core Training?

A lot of attention has been placed on core training over the last several years, both in the rehab and fitness industry.  I recently watched my friend Nick Tumminello’s latest product Core Training: Facts, Fallacies, and Top Techniques and it made me think (more on Nick’s product, which is on sale this week, below).

We’ve made exceptional progress in our understanding of the core and have shifted away from isolated ab training to integrated core training.  My DVD with Eric Cressey on Functional Stability Training for the Core discussed this at length and showed a nice system to effectively train every aspect of the core.

However, the more I read on the internet the more I wonder if we are still missing the boat a little bit.  I’ll chalk this up as a another pendulum swing, but while we have progressed away from isolated abdominal exercises like sit ups, I wonder if we have swung too far to an extreme and started to focus only on isometric anti-movement exercises for the core.

 

Anti-Movement Core Exercises

Realistically the core helps stabilize the body and allow a transfer of energy.

Anti-movement exercises, such as planks for anti-extension, should be the foundation of the basic levels of core training.

Plank - core training

Once your baseline ability to maintain an isometric posture with the core is obtained, the next progression is to control limb movement with a stable core.  This involves combining upper body and lower body movements while maintain a stable core.  An example of this would be an anti-extension drill with TRX Rip Trainer.

However, the core does need to “move” during normal function.  It rotates, bends, flexes, extends, and all of these at once!  Should we train this?

 

Don’t Forget the Trunk is Designed to Move

I would say we should.  I think the difference here is to train these movements within a stable range of motion.  We should be training the body to work within it’s normal mobility, but to stabilize at end range of motion.

We get into problems with core movements, like rotation, when we depend on our static stabilizers, like the joints and ligaments, to control end range instead of our muscular dynamic stabilizers.

Perhaps the goals should be to train to control the core at end range of motion.

 

End Range Core Stability

These types of drills would include chops, lifts, push-pull movements on a cable or Keiser system, and medicine ball drills.  You are probably doing these already, right?

They all involve a transfer of energy from the limbs through the core.  The core needs to move during these exercises, but you are working in the mid ranges of motion and controlling end range.  These should also progress to include functional movements patterns like swings, throws, and kicks.

In the video above, I combine the act of throwing and decelerating in the half kneel position.  This takes the lower half out of it and requires the core to stabilize.

I guess the point is that we shouldn’t be afraid to move the core.  That is not beneficial to teach our patients, clients, and athletes.  Rather, train the core to move and stabilize at end range of motion to take stress off the structures of the spine.

 

Core Training: Facts, Fallacies, and Top Techniques

If you want to learn more about training the core, Nick’s program Core Training: Facts, Fallacies, and Top Techniques is on sale this week.  I watched Nick’s presentation last week and enjoyed it.  Nick does a great job discussing some of these concepts.  Click below for details: