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The Use of Non Motorized Treadmills to Facilitate Gait and The Posterior Chain

We’ve recently started playing more with non motorized treadmills at Champion and have been very happy with the results.

Non motorized treadmills have gained popularity in the fitness realm as alternatives to self-powered conditioning machines like bikes and rowers. The Assault Air bikes and Concept 2 rowers have long been popular for their ability to produce amazing workouts.

I am a big fan of conditioning machines that increase their intensity based on the amount of effort exerted. Essentially, the harder you go, the harder they push back!

These have done wonders for high intensity interval training and sprint conditioning work.

Woodway has recently developed the Woodway Curve self-powered manual treadmill. Past non motorized treadmills seemed really cheap to me, but Woodway, who makes some of the best treadmills, has really made an exceptional machine with the Curve. I started using them for sprint work with the Red Sox, but have recently been using it more and more with my rehabilitation clients at Champion.

Because it is nonmotorized, your posterior chain is nicely engaged while walking and running on the Curve. A simple period of ambulation on the Curve does a great job engaging the hamstrings and glutes. I’ve been using these in everyone with diagnoses like patellofemoral pain, low back pain, and even postoperative. We start with a slow walk and slowly build up the speed and eventually get to running.

In the video below I explain more. I’m a big fan of nonmotorized treadmills to facilitate a proper gait form and engage the posterior chain.


Do Tight Hip Flexors Correlate to Glute Weakness?

Lower crossed syndrome, as originally described by Vladimir Janda several decades ago, is commonly sited to describe the muscle imbalances observed with anterior pelvic tilt posture.

Janda Assessment and Treatment of Muscle ImbalanceJanda described lower crossed syndrome to explain how certain muscle groups in the lumbopelvic area get tight, while the antagonists get weak or inhibited.  Or, as Phil Page describes in his book overviewing the Janda Approach, “Weakness from from muscle imbalances results from reciprocal inhibition of the tight antagonist.”  Assessment and Treatment of Muscle Imbalances: The Janda Approach is an excellent book that I recommend if you’re new to the concepts.

When you look at a drawing of this concept, you can see how it starts to make sense.  Tightness in the hip flexors and low back are associated with weakness of abdominals and glutes.

Lower Cross Syndrome

 

I realize this is a very two dimensional approach and probably not completely accurate in it’s presentation, however it not only seems to make biomechanical sense, it also correlates to what I see at Champion nearly daily.

Yet despite the common acceptance of these imbalance patterns, there really isn’t much research out there looking at these correlations.

 

Do Tight Hip Flexors Correlate to Glute Weakness?

Do Tight Hip Flexors Correlate to Glute WeaknessA recent study was publish in the International Journal of Sports Physical Therapy looking at the EMG activity between the two-hand and one-hand kettlebell swing.  While I enjoyed the article and comparision of the two KB swing variations, the authors had one other finding that peaked my interest even more.  And if you just read the title of the paper, you would have never seen it!

In the paper, the authors not only measured glute EMG activity during the kettlebell swing, but they also measure hip flexor mobility using a modified Thomas Test.  The authors found moderate correlations between hip flexor tightness and glute EMG activity.

The tighter your hip flexors, the less EMG was observed in the glutes during the kettlebell swing. [Click to Tweet]

While this has been theorized since Janda first described in the 1980’s, to my knowledge this is the first study that has shown this correlation during an exercise.

 

Implications

It’s often the little findings of study that help add to our body of knowledge.  This simple study showed us that there does appear to be a correlated between your hip flexor mobility and EMG activity of the glutes.  There are a few implications that you can take from this study:

  • Both two-hand and one-hand kettlebell swings are great exercises to strengthen the glutes
  • However, perhaps we need to assure people have adequate hip flexor mobility prior to starting.  I know at Champion we feel this way and spend time assuring people have the right mobility and ability to hip hinge before starting to train the kettlebell swing
  • If trying to strengthen the glutes, it appears that you may also want focus on hip flexor mobility, as is often recommended.  While a common recommendation, I bet many people skip this step.
  • This all makes your strategy to work with people with anterior pelvic tilt even more important.  Here is how I work with anterior pelvic tilt.

So yes, it does appear that hip flexor mobility correlates to glute activity and should be considering when designing programs.

 

A Simple Tweak to Enhance Glute and Reduce TFL Activity

Hip weakness is a common area of focus in both the rehabilitation and fitness fields.  Combine our excessive sitting postures and the majority of activities during the day that occur in the sagittal plane of motion, and hip weakness in the frontal and transverse planes is common.

There are many exercises designed to address glute medius and glute maximus strength in the transverse plane.  But a simple tweak to your posture during one of the most common exercises can have a big impact on glute activity and the balance between your glutes and TFL.

 

The Effect of Body Position on Lateral Band Walking

A recent study in JOSPT analyzed EMG activity of the glute max, glute medius, and TFL muscles during two variations of the lateral band walking exercises.

The subjects performed the lateral band walk in a standing straight up posture and a more flexed squat position.

A Simple Tweak to Enhance Glute and Reduce TFL Activity

I’ve personally used both variations in the past but tend to perform the exercise more often in the slightly flexed position, which we consider a more “athletic posture,” as we don’t really walk laterally with our hips and knees straight very often.

Results showed that EMG of both the glute max and glute medius was enhanced by performing lateral band walks in the partial squat position, and that TFL activity was actually reduced.  Glute activity almost doubled.

 

A Simple Tweak to Enhance Glute and Reduce TFL Activity

The finding of reduced TFL activity is just as important as enhanced glute EMG activity, as the ratio of glute medius to TFL is greatly enhanced by performing the lateral band walk in this athletic position.

Sometimes it’s the simplest studies that make the most impact.

The TFL also acts as a secondary hip flexor and internal rotator of the hip.  In those with glute medius weakness, which is fairly common, the TFL tends to be overactive to produce abduction of the hip.

Considering how our chronic seated posture can cause shortening of the hip flexors and we know many knee issues can arise from too much dynamic hip internal rotation and glute medius weakness, we often try to focus on developing the glute medius ability to become more of the primary muscle involved with abduction, instead of the TFL.

Another interesting finding of the study was that the stance limb, not the moving limb, had higher EMG activity for every muscle in both positions.  This shows the importance of the stance abductors in providing both a closed kinetic chain driving force as well as a lumbopelvic stabilizing force when the moving limb transitions to nonweightbearing.

We focus a lot on abduction based exercises to strengthen the glute medius, but closed kinetic chain exercises in single leg stance may be just as important to train the hip to stabilize the lower extremity.

One thing I would add is that I rarely perform this exercise with the band at the ankles as the authors did.  I much prefer to put the band around the knee and feel it helps develop better hip control.

Based on this study, I’m not sure I see why I would perform a lateral band walk in a tall upright posture.  I’m going to maximize glute activity and reduce TFL activity by doing the exercise in a more flexed athletic position.

 

Anterior Pelvic Tilt Influence on Squat Mechanics

anterior pelvic tilt influences squat mechanicsI feel like we’ve been discussing anterior pelvic tilt lately in several articles and an Inner Circle webinar on my strategies for fixing anterior pelvic tilt.  I wanted to show a video of a great example of how a simple assessment really tells you a lot about how pelvic positioning should influence how we coach exercises such as squats and deadlifts.

If you haven’t had a chance to read my past article on how anterior pelvic tilt influences hip range of motion, you should definitely start there.

In this video, I have a great example of a client that has limited knee to chest mobility and with boney impingement.  However, if we abduct the leg a bit, it clears the rim of the hip and has full mobility with no impingement.

https://www.youtube.com/watch?v=Klh1QOk5vRs

As you can see, because he is in anterior pelvic tilt, he is prepositioned to start the motion in hip flexion, so therefor looks like he has limited mobility.  I have a past article on how anterior pelvic tilt influence hip flexion mobility, which discusses this a little more.

While you are working on their anterior pelvic tilt, you can work around some of their limitations.  I hate when people say there is only one way to squat or deadlift.

Our anatomy is so different for each individual.

Some need a wider stance while others need more narrow.  Some need toes out while some need more neutral.  Do what works best for your body, not what the text book says you are supposed to look like.

 

 

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!

 

 

Updated Strategies for Anterior Pelvic Tilt

The latest Inner Circle webinar recording on the Strategies for Anterior Pelvic Tilt is now available.

Updated Strategies for Anterior Pelvic Tilt

strategies for anterior pelvic tiltThis month’s Inner Circle webinar was on Strategies for Anterior Pelvic Tilt.  This is actually an update on one of my most popular webinars in the past.  I am doing a couple new things and wanted to assure everyone has my newest thoughts.  In this webinar I go through my system of how I integrate manual therapy, self-myofascial release, stretching, and correcting exercises.  To me, it’s all how you put the program together.  My system builds off each step to maximize the effectiveness of your programs.

Hip Rotator Cuff

Hip Rotator CuffThe latest Inner Circle webinar recording on the Hip Rotator Cuff is now available.

Hip Rotator Cuff

This month’s Inner Circle webinar on the rotator cuff of the hip was great.  We discussed how our knowledge of the hip has continued to increase over the last decade and has resulted in a much better understanding of how the hip is involved in the mechanics of the lower body and stabilization in multiple planes of motion.  We then broke down the hip musculature as either prime movers or prime stabilizers, and discussed how different positions and exercises impact both of these different muscles groups.

If this sounds familiar, it is, we use the analogy of the shoulder to show the similarities between the hip and the shoulder.

To access the webinar, please be sure you are logged in and are a member 0f the Inner Circle program.

A Simple Dynamic Stability Exercise for the Leg [Video Demo]

This week’s post is a video demonstration of a simple way to integrate reactive neuromuscular training (RNT) into your programming to enhance dynamic stabilization of the lower extremity.

Reactive Neuromuscular Training for Dynamic Stabilization of the Lower ExtremityIn this video, I show a client that has an ankle sprain.  While going through her rehabilitation, it became clear that she also needed balance training to really work her ankle, knee, and hip to stabilize during functional tasks.

To perform this exercise, you simple need a large resistance band (which are great from many stretching, strengthening, and stability exercises – here are the ones I use).  Loop the band around a rack or other object and step within the loop.  Place the band just above your knee.

I show a few exercise ideas in the video, progressing from simple balance, to unstable surfaces, to incorporating functional movements.  By using the band, you can emphasize training the bodu’s ability to stabilize in the frontal and transverse planes while performing a sagittal plane exercise.  This is essential to optimal function and a big key to my Functional Stability Training program.

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