Intelligent Training Systems

Cross Trainers are a great alternative cardiovascular workout.  We do get a number of PTs however who say that some of their clients get numb feet towards the end of a longer workout and nothing they seem to do helps.

There are 2 categories of causes for this; extrinsic and intrinsic.  Extrinsic causes are things like inappropriate shoes and poor technique.  If the shoe profile doesn’t fit the client’s type of foot or its ill-fitting, then this can compromise circulation to the feet and importantly to their nerve supply, causing the numbness.  Technically if the heels are kept on the cross trainer foot plates then this prolonged pressure can cause the numbness too.  It is important to encourage your clients to let their heels lift as they would in normal gait to alleviate the pressure on their feet.  Working at different speeds and intensities during their workout can also help.

Intrinsic causes should also be considered.  From a musculo-skeletal perspective, numbness is usually due to nerve and/or circulatory issues, so its important to check your client’s sciatic nerve mobility.  If the nerve is tethered or tight then this can have the effect of sending the feet numb during cross training.  Try the SLR test to see if this could be a problem for your clients. Lay your client supine and slowly lift their leg until they feel tension, tingling, discomfort or a stretch in their leg.  At this point establish where they feel that sensation.  If its in their hamstring, we are not sure at this point whether its their hamstring or their sciatic nerve that is tight.  Slowly adduct the leg across the mid-line (without letting their leg lower) until the inside of their foot reaches the outside of their opposite leg.  If the tension they previously felt changes in any way (increases, decreases or changes position) then the problem is a tight sciatic nerve and not hamstring.  If when you lift their leg they feel the tension or discomfort outside of the hamstring area, i.e. in their calf or foot, then the test is immediately positive for sciatic nerve tension.

So if your client does have positive nerve tension signs for sciatic nerve then try mobilising it as part of their warm up to prepare them for the cross trainer workout, it may well give them the capacity to perform the exercise with less numbness.  If it doesn’t change their symptoms, then its clearly something else, work through the list of possible causes and work it out by a process of elimination.

One thing also to note about the Cross Trainer is that if your clients have a dysfunctional pelvis or rotated pelvis, then the cross trainer will probably aggravate it.  This is usually due to the feet being in a fixed position and reducing the legs ability to compensate for the abnormal pelvic mechanics.  Pay particular attention to female clients who have recently had a baby, if it was more than 8lbs then they are very likely to have rotated or dysfunctional pelvis, so be aware of putting them on the cross trainer.

The performance of the human body can be likened to a motor car.  It would not however be a model T-ford, where the brakes work independently of the engine or the steering.  It would instead be like a formula 1 car, in which each system (brakes, steering and engine) all rely on each other and feedback information to each other and the engine management chip.  In humans this is the equivalent of the nervous system.  Engine output is altered by braking as the two systems work in harmony.  It is however worth bearing in mind that there is a price to pay for this synergy which improves performance – that is the formula 1 car’s engine usually only lasts for a single race before needing replacement.  Likewise human beings cannot make the transition to high performance without similar regular monitoring and repairing.

Understanding nerves

To be able to understand this more thoroughly we have to understand about ‘nerve tension’ and ‘Adverse Neural Tension’.  These concepts have been recognised for over 100 years in terms of treating patients clinically, but their full potential has never been understood until now. An analogy with the invention of the wheel is an interesting one.  The discovery of nerve tension and it being used for the treatment of injuries is like the wheel being invented and placing it on its side, putting 4 legs around the underside and using it as a table.  It makes a great table, but the idea to use it as a wheel was ground breaking.  The same applies to nerve tension and its application to athletic performance. 

To help you understand.  The entire nervous system, is a single continuous tract, so it follows that if any part of this continuous tract is trapped or tethered (as with an injury) then it also follows that there will be some restriction of the mobility of other parts of the nerve system.  So a problem with one part of the nerve can cause pain in another – this is the clinical application.  However, we have discovered that this is not always represented by pain but by a reduction of joint range of movement, altered joint biomechanics which affects a whole host of problems that can cause restricted performance and may ultimately lead to injury.  Moreover, with the increased muscle spasm and associated factors, local fatigue increases and so understanding these principles can lead to benefits not only in human performance but also fatigue.

Research

We know this happens from research performed at Liverpool Hope University College (Barrow 2002) and studies there demonstrate astonishing results.  One experiment showed that a muscle can increase its force output by 14% after a brief preliminary warm-up (just one 15 second workout using this concept).  Another experiment showed that by following the same concept a 2 minute programme performed daily for 10 days increases muscle output by over 50%.  By understanding the importance of the interaction of individual body systems with each other, we have established the world’s largest database of its kind and have therefore been able to develop a series of courses that help you understand the relationship.  These courses show you how you can test your ‘nerve tension’ and prescribe movement patterns to enhance the coordinated output of your body’s systems.  These studies have been validated at the highest level.  A paper was submitted at the 6^Th Asian Biomechanics Congress (one of the world’s most credited) by Nicholas Barrow and was enthusiastically received.  In a practical sense the programmes have been rigorously tested by people such as Olympic athletes through to workers on a product line and hospital health trusts.

Remember in most cases we are not even aware we have a problem, but even so you can still achieve these remarkable results. Just imagine what these figures could do you for your performance in your sport.

Terminology

So when it comes to exercise programming our holistic approach, which is commonly described but rarely understood and demonstrated, takes into consideration all of the body’s systems, and it has a deep understanding of how they interact and are guided by our nervous system.  Description terms such as strength and power in this model are inadequate, so when we talk about exercises in these terms, we should be talking in terms of  movement patterns, which are used to enhance a given set of functional movements, not stretches or strengthening exercises, as the latter do not give credit for the full implications of the programming. 

Example

Lets take a hamstring stretch as an example, we are not trying to stretch the hamstrings when we extend the leg out in front of us, we are trying to improve the range of hip flexion and knee extension by stretching the structures on the back of the leg and back.  This brings in more than just the hamstrings, it can also be limited by a tight sciatic nerve, a rotated sacro-iliac joint in the lower back, tight gastrocnemius, tight spinal cord and indeed almost any nerve in the chain given the continuum concept described earlier.  How many times have you stretched your hamstrings using the generally accepted methods only to find that their flexibility continues to be stubborn and often returns to their standard length very soon?  Many people experience this phenomenon.  The reason is often due to them stretching only one of the structures that limit the movement, i.e. the hamstrings.  If they do not stretch the other structures as well, of course they will not be affected and so the limited range will usually return.  So we are trying to acquire a pattern of movement, not just stretching the hamstrings. 

So, does stretching get on your nerves?  Hopefully now you understand a little more about how are systems work together, stretching and any other type of exercise you do, won’t be quite so ‘nerve wrecking’.  To find out more become a biomechanics coach.

The skills of the personal trainer have increased dramatically over recent years.  The demand of their clients has driven their development down paths that hadn’t previously been considered.  Clients generally go to personal trainers to get fitter or lose weight, but as consumers have become more intelligent, sophisticated and more demanding, so their needs have evolved.  Now clients will commonly expect you to provide ‘some exercises for my back, as it’s a bit sore today’.  Also you will hear them ask for advice and exercises for a knee problem they felt while training for example.

 This evolving role will likely increase further as the credit crunch escalates.  This will likely result in people being even less likely to want to spend extra money on seeing a health professional for what they perceive to be a ‘niggle’ and not want to go to the expense or hassle of seeing anyone else.  As personal training qualifications develop, we must be careful here that we don’t train ‘jack-of-all-trades’ who know only enough to be dangerous, but with the new methods of screening coming up like functional and biomechanical screening, there is much personal trainers can do to help in a very real way while retaining their professional integrity and not becoming ‘pseudo-physios’.

The body is an integrated system, each of its component parts links together to provide coordinated movement as we move in our daily lives.  Functional training helps us prepare each unit for these tasks and engrains the correct movement patterns that our brains are used to rather than by training ‘muscles’ as we used to a few years ago.

Functional training has its origins in rehabilitation and has been around for 40 years or more. In this time we have established that it can help your client’s performance and preparation for their common tasks, and possibly also reduce their risk of injury.   

Over the time that functional training has been around in rehabilitation, we have found that biomechanical screening is a critical precursor to functional screening and functional training, otherwise the foundations for the movement patterns can be flawed and although they may cosmetically look OK, intrinsically the body can be working hard to compensate for flaws in the system that functional screening doesn’t pick up.

As the functional concepts start to become more widely accepted in fitness and conditioning, it is important to recognize that the biomechanical screening has not yet followed into these arenas.  Functional and biomechanical screening and training are very important aspects of an overall conditioning programme for any sport or activity and are complimentary in every way. For example, there are many people who pass a functional screen, yet fail a biomechanical screen.  They detect different factors, both of which are important to the trainer.

Specifically we need to develop our understanding into nerve biomechanics and the biomechanics of specific joints, like the pelvis, spine, shoulder and knee.  Once we understand these principles and how to screen our clients with them in mind, we can prescribe very precise exercises that relate specifically to their problems and goals.  Once these biomechanical issues have been resolved then functional training or any other form of training you may wish to do has more chance of being successful and there is less risk of your client becoming injured.

The Intelligent Training Systems™ Biomechanics Screening Courses for Personal trainers and Coaches have been designed by experts to help your cyclists improve their cycling performance and help them improve their power from Top Dead Centre (TDC), reduce unwanted movement in the saddle and reduce the risk of injury.  The programme achieves this by using advanced screening and training techniques to help improve their flexibility, muscle performance and joint stability. Make no mistake, although these principles are used to help elite cyclists, these courses take a very simple form and is easy to follow. 

Have you ever wondered how the elite cyclists can ride so smoothly and effortlessly, while still generating the power to cover the ground very quickly? 

Clearly their technique is better than amateurs and we know that it’s important that they see a qualified coach to ensure that they’re working on the right technique for their personal cycling peculiarities.  Often though their technique is compromised by poor biomechanics, which includes lack of flexibility and poor strength, often from inadequacies that they don’t know that they have.  Cyclists are often left thinking: “I understand what I’m being told to do, but my body just won’t do it”.  

For example, one top coach talked to us about an Olympic cyclist who had an abnormal knee rotation pattern just after TDC.  Not only was this causing knee pain, but also it was very inefficient when turning on the power.  He had tried to coach the problem out of the cyclist with little success.  Once his biomechanics had been checked, it became apparent that the leg was 1cm longer. This caused the body to want to compensate and shorten the leg, which is the body’s natural tendency to take the load off the pelvis and spine.  Unfortunately because the distance between the hip and ankle are fixed within the confines of the crank shaft length while cycling, the only way of compensating for this is at the knee and by laterally moving the hip.  This is what was causing the abnormal knee movement.  The biomechanical screening established that this leg length discrepancy was due to a pelvic rotation and that certain exercises would help eradicate the problem.  Three weeks later the length discrepancy was no longer apparent and the knee pain was reducing as well as the coach being happier with the look of the knee drive from TDC. 

The mechanical problems that can interfere with the mechanics of the cycling technique include – one leg being longer than the other, tight nerves in your legs, poor ‘core’ (trunk) muscle control, poor flexibility, inflexible pelvis and incorrect positioning of the pelvis.  These mechanical issues can not only compromise the way your cyclists ride, as they have to compensate for them, they can also set them up for injuries in the structures that are compensating.

So although technique is important, they have to have the right tools to ensure they can perform the tasks their coaches are recommending.  In sports so far it has been left more to luck than judgment, but as technology improves, so we can offer cyclists more information than ever before to improve their technique by providing their body’s with the building blocks for the correct movements.

In addition to improving their ability to perform the correct mechanics to cycle, improving their mechanics will help prevent (and in some cases cure) injury. The very mechanical problems that they can have with their pelvis and spine which compromise the way they ride, will also cause problems with the joints and muscles that compensate.  Cyclists often say, “Why can I ride smoothly and without ‘niggles’ or stiffness one day and the very next day, I can’t?”  The reason invariably is because you have a series of compensations for mechanical issues that exist, and your body and brain adapts to those compensations – in other words it learns how to move with them.  Then something happens to change either the problem, or the compensation, and the body and brain then have to learn a completely different way of moving to deal with the change, and that takes time to learn. 

For example, if one group of joints in your spine are stiff and tight, you typically get compensations in the opposite side of your pelvis and the opposite shoulder.  Then you cycle with your body having adapted to these set of conditions.  Overnight you may sleep awkwardly, perhaps your pillow is not positioned correctly, and you can wake up with a different set of conditions for your body to compensate for.  Sometimes you can be aware of some more extreme stiffness in the mornings, but more often they are imperceptible and your body adjusts without you even knowing.  But although this adjustment is immediate, it usually takes the body and brain some time to adapt. If you ride before you’ve fully adapted, then the easy, ‘niggle-free’ ride that applied yesterday, will no longer apply today.

The Biomechanics Coaching Courses that we have developed for personal trainers, coaches and strength and conditioning coaches can be applied to screening cyclists, which helps them identify any biomechanical weaknesses.  Moreover, coaches re then taught the best exercises to ensure these issues are dealt with in the quickest and most efficient way possible.

I saw an article in a fitness promotion recently which talked about the single leg squat being the best exercises for gluteus maximus.  It justified this statement by saying that this exercise uses about 60% of a maximum isometric contraction of gluteus maximus.  What a ridiculous statement, the guys really do not understand whats going on here.  Firstly the exercise is an isotonic contraction not isometric (unless you hold the position at any point).  Secondly if it only uses 60% of the maximum voluntary contraction (which I can only assume is what they’re talking about), then why not use something where you use more than 60%?  Don’t believe everything you read, just because its in a posh leaflet and by someone who should know what they’re talking about, doesn’t make it so – challenge everything!!!

It is not overly common thankfully, but a biceps rupture is very debilitating.  One of our  Programme Directors’ partner has had a ruptured his biceps and has recently had surgery on it.  He is progressing very well and is now in the gym and building up his training.  We thought it would help anyone else who has had this injury to understand a bit more about it.

The Long Head of Biceps (LHB) is the tendon that arises from the top of your biceps muscle in the front of the arm, then it runs up to your shoulder to fix your biceps at the top of your arm. Your biceps will bend your arm as if you were doing a biceps curl in the gym or lifting a drink to your mouth. A rupture of the LHB means a rupture of this tendon, usually just under the front of the tip of your shoulder.

Most people feel a sharp pain in the upper arm sometimes associated with a tearing sensation, which is sometimes accompanied by an audible ‘snap’.  Afterwards there is usually pain and bruising, and a lump appears on the front of your arm, but much lower than your normal bicep mass.  It can look like your biceps has slipped downwards, whereas in fact the natural tension in the muscle pulls it down as it no longer has an anchor near the shoulder. Some people however can have a ruptured biceps tendon and not even notice it and they only realize that something is wrong when they see the lump.  Often you will feel a weakness in the arm when you try and bend your elbow and when turning your palm upwards, as if you were using a screw driver.

Typically it happens to those between 40 – 60 years old, but it can happen to younger people (Darren wont thank me for that one!!). A history of prolonged inflammation of the tendon from wear and tear can lead to the tendon fraying, leaving it vulnerable and weak.  This can mean that a very minor trauma can lead to a rupture. Conversely the tendon can rupture due a high velocity contraction during weight training or playing sport without necessarily having prior injury.  Often this gradual weakening can follow a history of rotator cuff injuries, which are the stabilising muscles of the shoulder.  So then when over head exercises are performed, which need strong engagement of the rotator cuff to control the shoulder, their weakness can increase the pressure on the LHB and cause injury.

If you are over 40 then conservative measures are often enough to allow a return to your daily life.  That consists of immediate ice to minimise the swelling and at some point anti-inflammatories can be useful. It is advisable to rest the muscle and limit its movement when there is pain, and you will usually find heavy arm exercise is not possible for 3 – 4 weeks or more.  Mobility exercises and strengthening exercises to keep the shoulder and arm active helps with the healing and making sure the shoulder does not cease up.

However if you are younger than 40 years old and/or do heavy lifting or compete in a sport that loads your shoulder (like Darren), then surgery is more likely.  Surgery is also a more likely option if you cannot live cosmetically with the unusual lump on the front of your arm.  Surgery is usually followed by a period of time in a sling and then progressive mobility and strengthening exercises follow.  Heavy lifting is not usually recommended for 4-6 months post surgery.

The most important thing is to make sure that if you have a shoulder injury you have it treated properly and quickly by a suitable medical professional. Make sure you give it sufficient time to rest and be sure to complete your rehabilitation before you return to your activities or sport.  As well as making sure your shoulder conditioning programme is well rounded and thorough you should particularly make sure your rotator cuff is able to provide enough shoulder control for your sports or activities.

In sports and fitness training a common injury is adductor strains.  They are often caused by poor spinal and pelvic biomechanics, and a biomechanics coach  would be able to find the causes of such injuries.  Fitness instructor and Personal training and qualifications are much stronger and valuable to the client if they have a dual biomechanics coaching qualification.

To learn more about this condition, the adductor muscles comprise five adductor muscles in the groin, stretching between the pelvis and the inside of the thigh bone (femur), and adductor longus is the most commonly injured of this muscle set. Its main function is to pull the legs together (adduction) and it is used extensively when playing football or rugby, sprinting, hurdling and horse-riding.

An important factor not to overlook is the risk of an adductor strain being confused with a sportsman’s hernia (see previous blog); it is sometimes difficult to differentiate between the two, so if there is any doubt, do get it checked by a qualified and experienced therapist or doctor.

Most people usually feel pain in the groin at the top of the adductor muscle, which can radiate down the leg; there can also be swelling and bruising in the area. It usually hurts when they try and pull their legs together against a resistance and can hurt if stretching the leg out to the side. Also, if they were to try and run, it would be very painful in the groin and adductor area.

Muscle tears are graded according to severity. Grade 1 is a mild tear, which presents itself as mild discomfort and a little tenderness. Grade 2 is a partial tear with more discomfort and there is often swelling, usually painful to the touch, which results in limited range of movement. Grade 3 is a severe tear or complete rupture of a muscle and is normally very painful, with swelling and an inability to walk or run. A full tear or complete rupture can be very debilitating and a small lump or gap can usually be felt in the muscle, at that point. 

Injuries are commonly caused by both intrinsic and extrinsic factors. Common extrinsic factors for adductor longus injuries include activities that require high speed acceleration and deceleration, such as sprinting, rapid changes of direction or sports where kicking and jumping are required. It can also be caused in football, when players stretch beyond their physical capabilities to retrieve a ball or perform a tackle.

This injury is much more likely to occur if there are intrinsic causes too. If your clients have a stiff lower back, tight nerves in your hips and legs, stiff hip joints or weakened adductors due to a twisted pelvis, which they may not even realise they have, the risk of tears is much higher. You may be able to get away with either an intrinsic or an extrinsic cause, but a combination of both represents a high risk factor.

The principles of Rest, Ice Compression and Elevation (R.I.C.E) will help with the acute symptoms. A compressive thigh sleeve can help reduce the swelling and, indeed, minimise it if they apply the support soon enough. Once the acute pain has started to subside, a gentle stretching regimen can help healing and restore the muscle’s range of movement. Also, if they see an experienced and qualified sports masseur, they should find this helpful for regaining function in the muscle. Once the pain has diminished, any swelling has gone and they have regained almost full range of movement, you can start to strengthen the muscle. Try exercising with a Cliniband to start working the adductor muscle again.

How to prevent it

To try preventing this injury, you have to consider both extrinsic and intrinsic causes.  Look at the sport they perform and see if it demands any of the actions described above that cause the injury. If so, gradually increase the amount of work they perform in the gym to get their hips, pelvis and spine in good physical condition, and with sufficient flexibility in the nerves and muscles. Also, build up the amount of acceleration and deceleration work they do, although make sure not to rush into a new phase of training too quickly, giving their body time to adapt.

As personal trainers look to increases their expertise and personal trainer qualifications, it is often helpful to have an understanding of various injuries to help understand the body better.  Here we will have a look at the Achilles Tendon or Tendo Achilles (TA) rupture.

The Achilles tendon is a band of thick fibrous tissue that joins the calf to the back of the heel.  In isolation, when the calf muscle contracts it exerts force through the Achilles tendon to point the foot downwards, as if standing on tiptoe; however, when the calf works in unison with other leg muscles, it is a major contributor to running and jumping. The Achilles is typically ruptured about 2 inches above the heel bone and is the most commonly ruptured tendon in the body. Although it can affect anyone, it mostly affects men and is particularly common in those above 45 years old, as the blood supply in the tendon tends to reduce at this age. The tendon can rupture partially or completely: with a partial tear, some fibres of the tendon remain intact, whereas with a complete rupture, there is a gap between two ends of the tendon.

Typically you feel a ‘snap’ at the back of the heel, accompanied by a sharp pain; some say they feel as if they have been shot in the back of the heel or hit by a sharp object. Afterwards, the pain usually settles quite quickly, although a dull ache persists. If you feel the ruptured area soon after the injury, you may be able to feel a gap where the tendon has ruptured just above the heel, but that soon fills with swelling, so it becomes harder to detect. In a non-weight-bearing situation, with your foot off the ground, you may still be able to point your foot, using some of the smaller muscles that are still intact. But the key is a definite loss of power whilst taking weight through the leg and, although you will usually be able to walk, you will find it hard to push off and almost impossible to go onto tiptoes. 

As with most injuries, there are two types of causes: extrinsic and intrinsic. Extrinsic causes are those that produce a high force through the tendon, like when jumping, sprinting or landing on the foot; also, an Achilles rupture is commonly caused by stumbling, tripping or landing when jumping from a height. It is typically amongst ‘weekend warriors’, who play sport or train hard at the weekends, having previously been in shape, then do too much explosive exercise, like squash or football, when inadequately prepared. Intrinsic causes can include previous injuries to the tendon, since a history of Achilles inflammation will render it weaker, or long-term steroid injections on a chronically-inflamed tendon. There is a theory that suggests an inflexible calf can also render the Achilles more prone to rupture.

The solution is to get an early diagnosis; if you feel any of the symptoms described above or even if you are unsure, get medical advice as soon as possible, since any delay will probably compromise the healing. Assuming the Achilles is ruptured, you will have two options and there is considerable debate as to which is the most effective, a surgical operation or non-surgical treatment. The surgical option consists of an operation that repairs the rupture, by ‘sewing’ the two ends together; this is followed by a period of immobilising the ankle in a brace or plaster cast’, before the critical phase of physiotherapy and rehabilitation. Conservative non-surgical measures include putting the ankle in a plaster cast or brace and allowing the tendon to fuse together naturally and, as with surgical treatment a period of intensive physiotherapy will also follow this option. There are inherent risks with surgery, from infection, general anesthetic or the procedure simply going wrong; while conservative treatment still carries the chance of the tendon re-rupturing, as natural healing may not be as strong as the surgical option. So while somewhat radical, it is generally accepted that, if you are young and actively engage in sports, the surgical option is probably the better option. On the other hand, if you are older, less sporty or simply do not want to risk surgery, then conservative measures are probably best. Either way, these options can have good long term prospects.

As usual, prevention focuses on managing the potential causes, both extrinsic and intrinsic. To minimise risk, try and prepare the tendon as much as possible for the type of loads you will be putting the tendon under, within your particular sport. This will also prepare the Achilles for unexpected loads like stumbling or falling. Make sure the calves are flexible, so stretch them regularly both with the knee bent and straight. The basic stretch, where you look like you are trying to push a wall over, with one leg straight behind you is good; however, make sure you stretch the calf with that leg straight, then also bent, to ensure stretching both of the large calf muscles. Once thoroughly warmed up, do some strengthening work in the gym, such as calf presses and seated calf-raising exercises. This can then be progressed to ballistic work in the gym, like bouncing exercises on a small trampoline or suitably cushioned mat. Good warm ups are also important in preventing Achilles ruptures, progressively increasing the amount of exercise undertaken when you are starting a new routine, especially if you have been inactive for a period of time.

Importantly though, if you have a history of Achilles injuries, make sure you are treated by a therapist with experience of sports injuries, then perform the types of exercises described above as part of your rehabilitation, to minimise the risk of further ruptures. Most people can expect to return to normal activity levels after rupturing the Achilles tendon, although it can take anything from 4-6 months of immobilisation and intensive rehabilitation after that, sometimes even longer.

Commonly personal trainers and fitness instructors as well as strength and conditioning coaches come across Achilles Tendon injuries in their clients, so it is helpful to understand more about this injury.  The Achilles Tendon or Tendo-Achilles  (TA) is the thin band of tendon that passes from your calf to your heel.  It is critical to runners that the tendon is functioning well as it provides much of the force that propels you forward when you run. Certain causes exist that predispose the tendon to injury, like over-training, flat feet (over pronation), biomechanical problems with your hips, leg length discrepancies, tight calves or even tight nerves.  So if your clients injure their TA, please think about managing the causes as well as helping them seek guidance over managing the pain.  This is often achieved by seeing a therapist who specialises in biomechanics.

They will know their TA is injured as there is a pain in the tendon itself when it is put under pressure.  Also it can ache when they sit for prolonged periods, but most commonly you’ll find that the TA is stiff in the mornings for a while when they get out of bed.

When their TA is injured, as with any soft tissue injury, the body heels using a substance called scar tissue, which is inherently inflexible and stiff. It is critical then that while this scar tissue is healing, simple methods are used to make sure it gets as pliable as possible.  Once scar tissue has become inflexible and tight, it can be very difficult to mobilise. 

Massaging is a good way of mobilising the scar issue and once the acuteness has settled the massage needs to be quite deep and it may be necessary to do this daily for up to 2 – 4 minutes to break very tight scar tissue.  It is simple for the client to do this themselves by holding the tendon as if they were pinching it from the sides and applying pressure while they rub their fingers forwards and backwards.

Calf stretches should be performed 2 – 3 times daily and be aimed at stretching not only Gastrocnemius (the long slender calf muscle), but also soleus (the shorter, fatter one).  Stretch Gastrocnemius with the knee straight and soleus with the knee bent during the standard calf stretch where you press against a wall with your arms outstretched.  Try and make sue the heel is turned out slightly for the best stretch.  The soleus stretch is the most important, as it makes up most of the fibres of your Achilles tendon.  Hold the stretches for about 30 seconds and try 3 sets.

The stretch where you drop the heel over the edge of a step is not a good one as it is not efficient to stretch a muscle while it is contracted.  It feels like it is stretching, but of course it will – you’re stretching a muscle that is actively trying to shorten at the same time.  It may feel good, but it is not effective in a clinical setting.

As important as stretching is, it doesn’t prepare your clients well for running on its own, stretching is static, while running is very ballistic and so you must prepare them well for this in the gym to compliment their stretching.  The sort of exercises they should be doing are the calf press on the recumbent leg press machine and seated calf raises.  Initially they should try and do a ‘pain free’ amount, which may be 6 reps x 3, but over time start to build up to 20 reps x 4.  When they can do this try some 6 reps sets with a higher weight and also some 20 rep sets with a lighter weight. Start of with slow controlled movements, but as they get used to the movements, try increasing the speed (without loosing control) and start working ballistically. 

To help reduce the pressure on their TA while its healing, you can use a heel raise, which can be very effective at minimising the pain.  Do make sure that they don’t have a leg length discrepancy though first.  The problem is that if their injured leg is longer, due to a pelvic rotation for example, and you put a heel raise in their shoe, you’ve effectively lengthened the leg even more.  If the longer leg was one of the causes of the TA pain in the first place, a heel raise may not be advisable. 

If they have good flexibility in their calves, then orthotics might be helpful.  So if the above hasn’t helped or you’ve caught it too late, it can be worth seeing a podiatrist or orthotist.

Abdominal injuries are common in sport and can cause considerable discomfort.  Quite often they last for a long time because they can be difficult to diagnose and treat effectively. There are many different causes of abdominal pain, here we discuss two of the more common musculo-skeletal disorders, but despite being quite common, there is little written about abdominal pain from a musculo-skeletal perspective.

The common types of abdominal injury your clients will have are:

Incipient (Sportsman’s) hernia

The various muscles of the abdominal wall are penetrated by the inguinal canal, which contains nerves and, in men, the spermatic cord. Where the inguinal canal penetrates the abdominal wall, there is a weak spot and this is where you usually get an incipient inguinal hernia. It is effectively a tear of the muscles and connective tissue around the area.

It can be quite difficult to diagnose but your symptoms will generally include:

1.    Lower abdominal pain

1. Groin pain that is increased by running, sprinting, twisting and turning.
2. After training you may be stiff or sore.
3. The day after training / playing you may have groin pain when turning or even getting out of a car.
4. Coughing and sneezing may also cause groin pain.
5. In 30% of athletes there is a history of sudden injury but the majority find  it to be a gradual overuse injury.

(Courtesy of www.gilmoresgroin.com)

It certainly depends upon the skills of the doctor or therapist as to whether a sportsman’s hernia can be diagnosed, but this problem accounts for many of the unsuccessfully treated abdominal and groin injuries we see in rugby today.  If you complain of these types of symptoms, one of the main areas to get checked first is the sacro-iliac (SI) joint function.  This is a critical joint in your pelvis and sits under the dimples in your lower back.  If there is an abnormal positioning or rotation of the SI joint this can increase the pressure on the oblique muscles in your abdomen and the inguinal canal, causing damage. So as well as trying to manage the hernia, you need to try and correct any biomechanical causes that may be loading the hernia from the SI joint.  In addition, if your pelvis is abnormally rotated, as well causing a leg length discrepancy, it can increase the pressure on the symphasis pubis (the joint at the front of your pelvis) which can also refer pain into the lower abdominals.  The best way to mobilise the pelvis and correct any SI dysfunction through exercise is to perform anti-spasm exercises (a form of hold relax exercise) for the hip muscles. See figs 1 and 2. Once the pelvis is in good biomechanical shape, then core stability work can help to stabilise the pelvis once it’s in a correct biomechanical position and also work on the scar tissue around the inguinal canal to help the healing.  Then when you’re ready, you can progress onto functional stability work. 

It is also critical that you work the adductors of the hip too (the muscles on the side of your hips that pull your legs together). This is because the adductors and the trunk muscles work closely to control and stabilise the pelvis, and for men especially, their adductors are often ‘weak’ or inhibited and may be one of the reasons that they have the incipient hernia in the first place. 

Although today the latest trend is ‘functional movements’, there are times in rehab and conditioning when you need to isolate muscles first, and this is one example.  As Mark Verstegen (American coach) says, “first isolate, then integrate”. Working the hip adductors symmetrically in the seated adductor machine in the gym helps engage the adductors (and core when positioned correctly) and mobilise the symphasis pubis.  Then progressing to asymmetrical adductor work on the total hip machine (hip conditioner), will introduce a more weight bearing challenge with additional rotational force through the pelvis, and then functional movements can be a very effective way of integrating the pelvic and trunk musculature. 

More often than not the incipient hernias can be managed through exercise rather than surgery, just try to make sure you correct the mechanical faults with the pelvis as well as strengthening the relevant muscles, like the obliques (abdominals), the core (part of which are the obliques) and the adductors.

Referred abdominal pain

Referred pain is a term used to describe the feeling of pain in a part of your body adjacent to or at a distance from the site of an injury’s origin. Despite this being studied more often, there is no definitive answer regarding the mechanism behind this phenomenon. Physicians and scientists have known about referred pain since the late 1880s yet the true origins and causes of referred pain is unknown. However, we do know that referred pain can come from a number of areas, like: the thorax (pneumonia, pulmonary embolism, ischemic heart disease and pericarditis), from the spine (radiculitis) and from the genitals (testicular torsion).  Commonly though its pain is referred from your back.  Often you can get pain in your hamstrings, calves, groins, shoulders all referred from your back.  So if you have any uncertainty at all, get referred to a relevant medical specialist. 

If you think there may be some cardiac involvement get referred to a cardiologist and if you are concerned that the pain may be referred from the spine then any good manual therapist should be able to help.  Don’t worry too much about whether it’s a physiotherapist, osteopath or chiropractor, consider the person rather than the qualification. Try to find one who understands biomechanics so they can work out why you have the pain, and also someone who understands exercise.

As long as there is no underlying clinical pathology, exercise is an excellent way of managing musculo-skeletal related abdominal pain and its many causes. The key is to identify the biomechanical causes (rotated pelvis, weak or inhibited adductors, tight lumbar spine, tight thoracic spine etc) and manage them.  Then progressively condition the relevant muscles and the abdominal pain often looks after itself.