Ankle Sprains: Diagnosis, Treatment and Return to Sport

What are Ankle Sprains?

Ankle sprains are one of the most common injuries that people experience.  These injuries account for one million physician visits each year.  Lateral ankle sprains, also known as inversion sprains, are the most common.  They are particularly common in sports.  Forty percent of all traumatic ankle sprains occur during sports.  However, only 50% seek medical attention. The lack of medical care results in an increased risk for developing chronic ankle stability.  There are 3 different grades of ankle sprains, which progressively worsen with each grade.  Healing times vary from a couple of days to up to 6 months depending on severity.

Grades of lateral ankle sprain

What are Lateral Ankle Sprains?

Lateral ankle sprains occur when the outside of the ankle is stressed .  This usually occurs when the ankle is forcefully turned inward. This can happen when stepping on an uneven surface or landing awkwardly after jumping. The lateral ankle sprain typically occurs with stress to 1 of the 3 ligaments that stabilize the outside of the ankle. Depending on whether the foot is up (dorsiflexed), neutral, or down (plantarflexed) different parts of lateral ankle ligaments can be injured.

Lateral ankle sprains

How does a Physical Therapist Diagnose a Lateral Ankle Sprain?

A physical therapist can use tests and measures to diagnose ankle sprains. Typically this will involve checking ROM (range of motion) and strength of the ankle and lower leg.   Additionally, special tests and joint mobilization testing  can bias the ligaments to determine which are involved.  Movement analysis such as the FMS (functional movement screen), hop testing, and running/agility tests can also be used to help determine some of the impairments that may have contributed to the ankle sprain.  If you are seeing a physical therapist with direct access (seeing a PT first without going to a physician) they will perform other tests and screening procedures to make sure physical therapy is appropriate.  If your physical therapist feels you need different services, he or she will direct you to the best healthcare provider.

How are Ankle Sprains Treated?

Depending where you are at in the recovery phase and your goals, a physical therapist will approach your care differently. Early in treatment crutches or a boot may be used and a physical therapist will focus more on pain, swelling and maintaining motion and strength.   As your recovery progresses, your treatment will progress to more active treatments.  This will include manual therapy to improve ankle motion,  proprioceptive training, training for return to activity and strengthening exercises targeting areas that the therapist has found to be weak.

How do you Know you are Ready to Return to Sports?

Physical therapists have a great deal of experience in determining if you are ready to return to sports, work, and other activities.   A few of the tests a physical therapist can use to determine if you are ready to go back to your sport are the FMS, Y-Balance test, hop testing, tuck jump assessment, and the Landing Error Scoring System.  A physical therapist can also give you recommendations on footwear and proper training tips to help avoid ankle sprains in the future.  Contact your physical therapist to learn more about managing ankles sprains.

References

  1. Vuurberg G, Hoorntje A, Wink L, van der Doelen B,van den Bekerom M, Dekker R, van Dijk C, Krips, R, Loogman, M, Ridderikhok M, Smithuis F, Stufkens S, Verhagen E, de Bie R, Kerkhoffs G. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline.British Journal of Sports Medicine 2018;52:956
  2. Doherty C, Delahunt E, Caulfield B, et al. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med 2014;44:123–40
  3. Verhagen EA,van Mechelen W,de Vente W. The effect of preventive measures on the incidence of ankle sprains. Clin J Sport Med 2000;10:291–6
  4. McGuine TA,Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med 2006;34:1103–11
  5. Kobayashi T,Tanaka M,Shida M. Intrinsic Risk Factors of Lateral Ankle Sprain: A Systematic Review and Meta-analysis. Sports Health 2016;8:190–3
  6. Ivins, D. Acute ankle Sprain: An update. American Family Physician. 2006:741714-1720
  7. Wolfe M, Uhl T, Mattacola C, McCluskey L. Management of Ankle Sprains. Management of Ankle Sprains. 2001,63:93-1004
  8. EIM 2018 Sports Physical Therapy Competencies 2018 Lab Manual

Low Back Pain: Get Started with Abdominal Exercises

Low back injuries usually do not occur from one single incident or event like lifting a heavy box.  Instead, most back injuries occur from small incremental stress or load applied over time.  Sitting slouched for prolonged periods at a desk or repeatedly performing bending and twisting can overload sensitive spinal structures.  These structures include the muscles, facet joints, ligaments, discs, and nerves.   Muscle weakness, poor endurance, poor position awareness, and previous history of injury can make one more susceptible to low back injuries.  Most of these injuries are not serious and do not require extensive testing or treatment.

The core muscles function to spare the lumbar spine and surrounding structures from excessive load.  These muscles include the abdominals, low back musculature, diaphragm, and pelvic floor muscles.  No single muscle is more important than the others.  Human movement and low back pain are more complex than one muscle or structure.  Instead, all muscles should ideally function together in coordination.  Pain interferes with coordination and control.  The specific task being performed determines the magnitude and timing of core muscle activity.  Some tasks require a very low load and level of muscle activity such as bending to tie the shoes.  Other tasks require greater muscle activation patterns at high speeds such as swinging a baseball bat.

Exercises to train the core musculature should begin with low loads focusing on control and endurance.  Exercises performed lying on the back targeting the abdominal muscles is a great place to start.  The following exercises can be performed by those with low back pain or those with a history of back pain looking to prevent recurrences.  Once these exercises are no longer challenging, progression is needed.  Future articles will address proper progressions.

Abdominal Bracing

Begin lying on your back with the hips and knees bent.  Find a neutral spine position by gently rocking your pelvis back and forth.  Your neutral position is somewhere between a fully arched and fully flattened position.  In your neutral position, you should be able to hold a small grape under your low back without crushing it.  Maintain a neutral spine and gently contract your abdominal muscles in the front and sides continuing 360 degrees around to the low back.  This muscle contraction should be gentle and no movement should occur.

Once a neutral spine can be maintained with gentle bracing, breathing is added.  Diaphragmatic breathing is performed while maintaining a neutral spine and gentle bracing.  This involves expanding through the belly and rib cage in a 360-degree fashion.  Minimal or no movement occurs in the upper chest and shoulders.  Five deep slow breathes are performed while maintaining a neutral spine and bracing.  No breath holding or movement of the spine should occur.  It is helpful to place one hand on the abdomen and the other hand on the chest to ensure a proper breathing pattern is maintained.   This exercise forms the foundation for all subsequent abdominal exercise progression to follow.

Bent Knee Fall Out

The bent knee fall out is performed after abdominal bracing and diaphragmatic breathing have been mastered.  Begin with a neutral spine, bracing, and diaphragmatic breathing.   Lower one knee to the side towards the floor in a slow and controlled fashion.  No movement in the spine or hips should occur.  It is helpful to place the hands on the hip bones to ensure no movement is taking place.  With each repetition alternate sides.  To increase the challenges add a resistance band around the thighs.  Perform 10 slow repetitions on each side.

90/90 March

This exercise begins with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate lowering the heels to the floor.  Gently touch the heel to the floor without relaxing.   Perform 10 slow repetitions on each side.

Heel Hover

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate extending of the knee so one leg straightens without touching down.  As you lower the legs, it is important that the low back does not arch away from the floor.  Perform 10 slow repetitions on each side.

Double Leg Lift

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Both knees and feet are then simultaneously elevated so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly lower the legs together.  Do not touch down or relax the feet to the floor.  It is important that the low back does not arch away from the floor.  Perform 10 to 20 slow repetitions on each side.  To increase the challenges add a small ball to squeeze between the thighs.

Closing Thoughts on Abdominal Exercise for Low Back Pain

Pain interferes with how our brain transmits signals to our muscles.  This is especially important when your low back pain has persisted for more than several weeks.  These 5 abdominal exercises re-program the lost connections between the brain and core muscles.  Slow coordinated and controlled movements are crucial for success.  Absolutely no holding of the breath should occur.  Breathe holding increases tension throughout the body and interferes with retraining of the muscles and nervous system.   Practice these exercises, master them, and improve your endurance by increasing repetitions.   Once these goals are achieved, you are ready to build strength and resilience with more challenging exercises.

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Gluteus Maximus Exercise: Training in Multiple Planes

The gluteus maximus is the most powerful hip extensor.  This is important for functional activities performed in one plane such as walking, running, and climbing stairs.  However, this muscle also has important functions outside of straight ahead planes of movement.  The gluteus maximus also helps control balance and generate power in other planes.  Rotational and lateral movements in everyday life and sport require important contributions from the gluteus maximus.

Training the gluteus maximus should incorporate single-plane hip extension exercises and exercises in multiple planes.  Single-plane exercises such as the squat and hip hinge do not fully develop the glutes.  Training programs should also include exercises with rotation of the trunk or lower body on one leg.  These types of exercises prepare athletes for changes or direction, throwing, and jumping from one leg.   Performance improvements and reduced risk for injury often occur with long-term training in multiple planes.  The five exercises included in this article are only examples.  Many other exercises can be adapted to train the entire body with rotational movements.

Crossover Step Up

The crossover step up helps expose and improve any side to side difference in gluteus maximus strength.  Stand to the side with your left leg next to an elevated step or box.  Cross your right foot in front and step up onto the box.  Keep your hips square throughout the exercise.  Next, cross your right foot behind the left while stepping down to briefly touch the floor on the opposite side.  When descending think about sitting back into the hips.   Reverse the movement in the opposite direction.  Perform the exercise slowly with control.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hands or close to the chest.

1-Leg RDL

The single-leg Romanian dead lift (RDL) is a single-leg exercises which requires stabilization of the trunk on the lower limb in multiple planes.  These exercise begins by standing on one leg with the opposite hip and knee extended.  The weight bearing knee can be slightly bent throughout the exercise.   Initiate the movement by slowly flexing at the hip, keeping the back straight.  The non-weight bearing leg extends straight back behind the body.  Both the descending and ascending parts of the exercise should be performed in a slow and controlled manner.   Also, maintain control and the position of the weight bearing leg during the exercise.   Perform 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

Transverse Lunge

The transverse lunge starts standing with the feet near each other and hands on the hips.  Throughout the exercise the trunk is maintained in an upright position, so the knee and hip of the lunging leg can be flexed to 90°. This prevents the knee from moving forward past the toes.  Also, the knee remains over the toes so it does not cave inwards into valgus.  During the transverse lunge, the body is rotated 135° towards the lunging side.  This involves twisting behind the body and lunging in one motion.  Add load by holding a dumbbell or kettlebell in the hand opposite the lunging leg or against the chest.  This exercise shows high activation of both the gluteus maximus and gluteus medius.

Skater Squat

The skater squat introduces rotation of the trunk on the lower limb.  The exercise begins by standing on one leg and performing a squat to a comfortable depth.  The depth is determined by the ability to maintain balance and good control of the trunk and entire lower extremity.  The non-weight bearing leg extends at the hip and flexes at the knee. The torso slightly rotates and the arms swing reciprocally as if skating.  The toe of the non-weight bearing leg can touch the floor between repetitions if needed.  Hold the downward position for 2 seconds then return to the starting position.  Add load by placing a resistance band around the thighs just above the knees.

Rotational 1-Leg Squat

 The rotational 1-leg squat is a progression of the skater squat.  Both exercises have a rotational component to the squat.  This exercise further challenges the balance and stability of the hip.  Begin by balancing on one leg holding a medicine ball in both hands.  The non-weight bearing knee and hip flex to approximately 30°. Slowly lower toward the floor being sure to maintain control of the trunk and supporting leg.  The depth of the squat is determined by the ability to maintain balance and control the movement.  Rotate the hands and medicine ball upwards and towards the weight bearing leg as you perform the squat.  Return to the starting position and keep the knees over the toes to prevent knee valgus throughout the exercise.

Glutues Maximus Exercise: Closing Thoughts

Gluteus maximus weakness is common in those with chronic back pain, hip bursitis, hip arthritis, knee arthritis, and runner’s knee (patellofemoral pain).  Training the glutes primary function of hip extension is important but often not enough for most demands of sport and everyday life.  These five exercises are challenging and not for everyone.  If you are unable to maintain balance and stability on one leg try other exercises first (basic gluteus maximus exercises).   If you are still unsure how to start, contact your physical therapist for help.

 

Power Training in Seniors

Typically training for power is thought of as something that is more for the younger, athletic population. However, today older adults are trying to stay more active with activities such as tennis, golf, hiking, or dancing.  All these activities require some component of power.  Are older adults performing any power-based exercise to help with these activities?

What is Power?

First of all, what is power? Power is simply adding speed to a movement.   Power is a combination of strength and speed.   When exercising, we typically encourage slow and controlled movement, but when you are able to control during the exercise, what’s next? We can add resistance to the movement, or sometimes we can add speed. Why would we add speed? Say you are playing tennis and have to move across the court for a drop shot, how do you move to get the ball? Is it slow and controlled or quick? Does it make sense to only strengthen with slow and controlled motions? Or should we think about adding some speed to the movement you are training?

Muscles change with age and they also change with the demands we put on them. As we get older and stop doing fast movements is it fair to expect the body to continue to move quickly to react to a drop shot, field and ground ball, or even jump to catch a ball when playing with grandchildren?

Adding Power Training to an Exercise Program

Adding power to an exercise routine is simple, and can be fun.  You can simply do a movement or exercise that you can do properly and add some speed to it. Another idea can be bouncing a medicine ball or any ball that can bounce onto the ground or a wall. Mini jump hops are also another way to add speed and dynamic movement.

In Closing

Seniors are continuing to stay active in sports and similar to any athlete, they need to train to play the sport they want to do. A lot of the sports and activities seniors do on a daily basis are not slow and controlled. Power is something to think about with a regular workout routine as we age.  If you are not sure how; give your physical therapist a call.

 

Bulgarian Split Squat Variations

The rear-foot-elevated or Bulgarian, split squat is an excellent exercise to train the lower body for sport or everyday life.  It is unclear where how this exercise received it’s name but this is of little importance.  The split or asymmetrical stance of the lower body introduces unique deands on the muscles and nervous system.  Acceleration, deceleration, change of direction, sprinting and jumping all require stability of the lower body in similar positions.   Elevating the rear foot increases the difficulty by allowing a deeper squat.  The Bulgarian split squat trains the hip to support the upper body while also controlling the knee position in an athletic stance.

A traditional squat is performed with the feet placed symmetrically side by side.  This creates challenges in primarily one plane.  The Bulgarian split squat is performed with a narrow split stance creating challenges in multiple planes.  Raising the rear leg on an elevated surface shifts the load to the front leg.  The front leg assumes approximately 85% of the total load.

There are many variations to the Bulgarian split squat.  Progressions and regressions can be tailored for the beginner or advanced lifter.  The purpose of this article is to describe several of these modifications.  The Bulgarian split squat can be modified so those new to strength training can incorporate the exercise.  The advanced progressions are best suited for athletes or those with several years of training experience.  The exercise can be modified to challenge balance and stability using lighter loads.  It can also be performed with heavy loads.  Under these conditions, maximal strength development is emphasized similar to training with common multi-joint exercises such as the back squat.

Muscles Involved with the Bulgarian Split Squat

The main lower body muscles involved in the Bulgarian split squat is the quadriceps, hamstrings, and gluteus maximus.  The quadriceps is the first muscle to fatigue, especially when heavier loads are used.  This then requires the gluteus maximus to compensate.  The gluteus medius and minimus are involved to maintain proper positioning of the pelvis and balance. The hip rotators are recruited in order to control the inward or outward movement of the thigh and knee.  The ankle muscles are highly active in order to maintain balance in the narrow stance. The abdominals and low back muscles help maintain a neutral spine position and balance.

Set-Up and Positioning

Taking time to position yourself before the movement will allow for proper performance of the exercise.  Assume a split squat stance with the trail leg just in front of a support box/bench on the floor. While shifting the weight toward the lead foot, place the top of the trail foot on the support box/bench.  The distance from the lead foot to the trail foot support is approximately the length of one leg.  Adjust the support box/ bench distance so the lead knee is directly above the toes. The trail leg support can range from approximately 6 inches to knee height.  This may require some experimentation.  Start with a lower height and adjust as needed.  For stability and balance, the top of the trail foot should remain in contact with the support box/bench throughout the exercise.  The width between the front and trail leg is approximately hip width.

TRX-Assisted Bulgarian Split Squat

Once proper set-up has been achieved grasp the suspension trainer in both hands.  Bend the elbows and hold the straps close to the chest.  This will assist with maintaining proper balance and a vertical position of the trunk.  Maintain this vertical trunk throughout the exercise.  A forward lean is difficult to control with the split stance and rear foot elevated.  Keep the weight of the lead foot distributed in the middle of the foot or near the heel.  Perform the movement by “sitting back” so the trunk remains vertical and the lead knee does not track excessively past the toes. It is acceptable to have the knee pass slightly ahead of the toes.  Lower the trail knee only to a position 1-2 inches above the floor.  Complete the desired number of repetitions on one leg before switching legs.

Bodyweight Bulgarian Split Squat

For many, the weight of the body is enough to provide a training effect.  Progressing away from using the suspension trainer increases balance and stability challenges.  Place the hands on the hips or arms across the chest.  If you are unable to perform the exercise without the arms in these positions you many lack adequate balance.  If this is the case, regress back to the TRX-Assisted exercise or try holding two light dumbbells with the arms at the sides.

Kettlebell (Goblet) Bulgarian Split Squat

There are a few advantages to performing the Bulgarian split squat with a kettlebell held at the chest.  First, this promotes a vertical position of the trunk.  Other variations, such as holding dumbbells at the side of the body or a barbell on the back, require the trunk to slightly dip forward.  Second, the kettlebell helps activate the core musculature and cue proper positioning of the rib cage on the pelvis.  It is important to stack the lower rib cage on top of the pelvis.  The abdominal muscles are primarily responsible for this.

2-Arm Dumbbell Bulgarian Split Squat

Holding two dumbbells to the side of the body lowers the center of mass.  For some, this improves balance and stability compared to the bodyweight exercise.  Start with light loads and progress as strength improves. If you prefer, try holding two kettlebells instead of the dumbbells.

1-Arm Dumbbell Bulgarian Split Squat

Holding a dumbbell in one hand increases balance and stability challenges.  Hold the dumbbell in the hand on the side of the trail leg.  This will increase activity to the hip musculature, especially the gluteus medius of the lead leg.  This exercise is more challenging than it looks.

TRX Bulgarian Split Squat

This variation is performed with the trail foot placed in the suspension trainer loop. Position the suspension loop so the trail lower leg is parallel to the floor.  Maintain the trunk in a vertical position.  Maintain the hands on the hips.  The knee of the lead leg should not track excessively past the toes.  Compared to the bodyweight split squat, this exercise shows greater activation of the hamstrings, adductors, gluteus maximus, and gluteus medius.  The suspended position increases stability and balance challenges.  This is a more demanding exercise for the hip muscles.  It is a progression from the bodyweight Bulgarian split squat.  To further increase the challenge, try holding a dumbbell in the hand on the side of trail leg.

Barbell Bulgarian Split Squat

Performing the exercise with a barbell allows for the progression of the load for strength development.  The barbell also causes the trunk to angle slightly forward to support the load.  Before positioning the bar, pull the shoulder blades back.  Place the bar on the base of the neck resting over the trapezius muscles. Tuck the elbows to your side and maintain the retracted shoulder blade position.  With barbell training, heavier loads and fewer repetitions are optimal.  Start with a weight which allows you to perform 6 to 8 quality repetitions.  As always, focus first on proper technique before progressing load on the bar.

Closing Thoughts

The Bulgarian split squat is an excellent exercise for rehabilitation, injury prevention, and strength development.  This exercise requires stability in multiple planes and challenges the hip muscles to control the position of the lower limb.  Performance in many sports involves lower-body, weight-bearing skills in positions similar to the split squat. Sprinting, change of direction, throwing, and kicking require the transfer of forces from one leg in a similar fashion.  If you are unsure about how to best incorporate the Bulgarian split squat, give your physical therapist or strength coach a call.

Muscle Loss in Older Adults: Prevention and Treatment

Loss of muscle with advancing age is referred to as sarcopenia.  This process begins in the fifth decade of life and proceeds at a rate of almost 1% each year.  Declines in muscle strength usually progress faster than muscle size.  Muscle loss with advancing age is associated with many chronic conditions.  These include diabetes, cancer, reduced mobility, disability, and mortality.   It is estimated that 200 million people worldwide will experience sarcopenia that could affect their health over the next 4 decades.

Muscle loss with aging

Muscle loss is quickly becoming a major public health problem with significant clinical, economic, and social consequences.  Prevention and treatment strategies are challenging due to the growing number of older adults above 65.  Exercise and nutritional strategies are considered the primary treatments for age-related muscle loss.  The rest of this article summarizes findings from research on muscle loss in older adults and offers some practical solutions related to exercise.

Diet, Supplements, and Muscle Loss

Muscle is made of proteins.  Amino acids are the building blocks of proteins.  In younger adults (18-30 years old), eating sufficient protein can stimulate some muscle growth by itself.  This can occur with or without exercise in younger adults.  However, muscle growth does not come so easily in older adults.  Therefore, larger amounts of protein in the diet are needed for older adults to preserve or increase muscle.  Younger adults show increased muscle protein rates with the ingestion of 20 grams of protein during a meal.  Older adults require about twice this amount, or 40 grams, to stimulate muscle growth.

Recent research has investigated the role of protein and amino acid supplements for older adults.  The evidence suggests supplementing with protein or amino acids without engaging in an exercise, does little to preserve muscle mass in older adults.  However, increases in muscle size and strength through exercise can be enhanced by certain foods or supplements.    Diets rich in dairy and fish containing polyunsaturated fats make the muscle more sensitive to exercise.  There is also evidence showing protein supplements and creatine monohydrate is beneficial.  Most importantly, research shows that a specific type of exercise, resistance exercise, has powerful positive effects on muscle in older adults.  Resistance exercise is the key to preserving or increasing muscle size and strength as we age.

Resistance Training

Exercise is a highly effective strategy to offset muscle loss.   Exercising with weights has numerous beneficial effects for older adults.  These include increases in muscle mass, strength, power, mood, energy levels, walking speed, balance, and functional performance.  Other forms of exercise, such as aerobic exercise, do not confer these same benefits.  Aerobic exercise, including regular walking, is not enough to prevent muscle loss in older adults.

Contrary to popular belief, adults older than 75 years old can grow significant muscle through resistance exercise.  Heavy weights are not required.  Lighter weights with higher repetitions can result in significant improvements in muscle size and strength regardless of age.  In all cases, the success of any exercise program depends on adherence and staying committed for the long run.  Therefore, it is important to make exercise as enjoyable as possible.  Choose resistance exercises you prefer.  Exercise with friends.  Choose environments (gyms, classes, or in the home) you are most comfortable with.   If you are unsure about how to start, work with a personal trainer or physical therapist.

Developing an Exercise Program to Fight Muscle Loss

Many individuals are unsure about how to structure an exercise program.  Those without resistance training experience or those recovering from an injury have questions about what is safe and appropriate.  How often?  Which exercises?  How many sets?  High or low repetitions? How long should I rest between sets?  These are all excellent questions.  Below I have outlined a list of recommendations for older adults engaging in resistance exercise.  These recommendations are based on research evidence conducted on healthy older adults.

Length of the program

1 year to optimize results but small improvements are often evident after 6-8 weeks.  Ideally, a lifetime committment is best.

Frequency per week

2-3 sessions preferably with one day of recovery between sessions (i.e., Monday, Wednesday, Friday).

Duration of each session

Approximately 1 hour including rest periods between sets and exercises.

Exercises per session

6-8 exercises involving the major muscle groups of the upper and lower body.

Sets per exercise

2-3 sets have been shown to result in greater improvements than single set routines.

Intensity

50-80% of a one-repetition maximum which is the most amount of weight you can perform properly for one repetition.  An easier guide is to use the recommendations for repetitions per set below.

Repetitions per set

7-9 repetitions per set have been shown to be optimal for strength and muscle development.  This means you should only be able to perform 1-3 more repetitions beyond this range before fatigue becomes limiting.  If you can perform more than this amount without requiring a rest break you can increase the weight.

Duration of each repetition

6 seconds or slow controlled movements are recommended.  Muscle power development requires faster tempos of movement.

Rest between sets

1-2 minutes is optimal.  If this seems like a long time, perform some aerobic activity, such as brisk walking between sets.

Choosing Which Resistance Exercises to Perform

Contrary to the opinions of some, there are no good or bad exercises.  The selection of exercises should be based on several considerations.  This is where a personal trainer or physical therapist can help you get started.  As mentioned, the most important consideration is to choose exercises you enjoy performing.  Beyond this idea, I’ll provide some general recommendations and a few examples.

First, incorporate exercises performed in standing positions as opposed to seated or lying down.  For example, the body weight squat is preferred over a seated leg press.  Second, choose free weights over machines whenever possible.  All machines are not bad but using free weights requires greater muscle activation, control, and coordination.  Third, exercises using multiple joints are preferred over single-joint movements.  For example, the cable row is preferred over a biceps curl.   Finally, incorporate at least one exercise for the fundamental movement patterns such as the squat, hip hinge, upper body push (presses), and upper body pull (row).

Closing Thoughts

Aging is accompanied by a decline in physical activity and function.  Loss of muscle contributes to these changes and is also a consequence of them.  This creates a viscous cycle characterized by muscle loss, weakness, declining function, and developmennt of chronic conditions. Other negative consequences ensue such as osteoporosis and increased body fat.  Exercise can slow down these processes and even reverse them.  In fact, resistance exercise is one of the most effective means to combat the effects of aging and many chronic diseases.  Some have referred to resistance exercise as the, “Fountain of Youth.”  Dietary strategies and supplements can enhance the effects of exercise.   However, there is no magic pill.  Success requires goals, a plan, positive habits, and a commitment.  If you are not sure how to get started, call your physical therapist today.

 

 


 

Gluteus Medius Exercise: Advanced Progressions

Athletes are required to perform explosive powerful movements during sport.  The hip muscles, including the gluteus medius, help generate and transfer forces during sport-specific activities such as running, cutting, and throwing.  These types of athletic demands require high intensity training in the gym.  Gluteus medius exercise which emphasize multiple planes of movement in single-leg or asymmetrical stances are advantageous for these demands.

The advanced exercise progressions included here should first be performed in a slow and controlled manner with an emphasis on technique.  As technique becomes adequate, the speed of movement and load can be increased.  Under any conditions, control of the movement and body positions are extremely important.  Remember, the primary function of the gluteus medius is to stabilize and control the position of the pelvis.  This is mandatory for the rest of the body to generate, transfer, and dissipate forces optimally.

Skater Squat

The skater squats begins by standing on one leg and performing a squat to a comfortable depth.  The depth is determined by the ability to maintain balance and good control of the trunk and entire lower extremity.  The non-weight bearing leg extends at the hip and flexes at the knee. The torso slightly twists and the arms swing reciprocally as if skating.  The toe of the non-weight bearing leg can touch the floor between repetitions if needed.  Hold the downward position for 2 seconds then return to the starting position.   Challenge to the gluteus medius can be increased by placing a resistance band around the thighs just above the knees.

Transverse Lunge

The transverse lunge starts standing with the feet near each other and hands on the hips.  Throughout the exercise the trunk is maintained in an upright position, so the knee and hip of the lunging leg can be flexed to 90°. This prevents the knee from moving forward past the toes.  Also, the knee remains over the toes so it does not cave inwards into valgus.  During the transverse lunge, the body is rotated 135° towards the lunging side.  This involves twisting behind the body and lunging in one motion.   Challenge to the gluteus medius can be increased by holding a dumbbell or kettlebell in the hand opposite the lunging leg.

Rear Foot Elevated Split Squat

The rear foot elevated, or Bulgarian, split squat is an excellent exercise to target the gluteus maximus, gluteus medius, quadriceps, and hamstring muscles.  For this exercise, the rear foot is placed up on a 6 to 12 inch step or box.  The supporting leg should be positioned approximately one leg length in front of the box or step.  This may need to be adjusted based on comfort and balance.  However, it is important that the hip and knee of the front leg is able to flex to 90 degrees during the movement.

It is also important to maintain good upper body posture with a natural curve in the low back and the chest up.  This position should be maintained during the descent and ascent of the movement. Excessive trunk flexion or side bending are common errors.  The front knee should not move forward past the toes.  The knee should remain over the toes so it does not cave inwards into valgus.  Perform 8 to 10 slow and controlled repetitions before switching sides to the other leg.  Challenge to the gluteus medius can be increased by holding a dumbbell or kettlebell in the hand opposite the front leg.

Lateral Step Down

The step down exercise begins with the hands on the hips standing with one leg on the side of a step or 8-inch high box.  Maintain balance on 1 leg and slowly squat to lower the heel of the other leg toward floor.  Gently tap the heel and return to the start position.  Throughout the exercise the trunk is maintained in an upright position.  Avoid leaning the trunk to the side or waving the arms.  The knee should not move forward past the toes.  Also, the knee should remain over the toes so it does not cave inwards into valgus.  Perform 8 to 10 slow and controlled repetitions before switching sides to the other leg.

1-Leg Squat

 If the lateral step down can be performed with proper form, the next challenge is to progress to performing a single-leg squat.  Begin by balancing on one leg with the hands on the hips.  The non-weight bearing knee and hip are flexed in front to approximately 30°. Slowly lower toward the floor being sure to maintain control of the trunk and supporting leg.  The depth of the squat is determined by the ability to maintain balance and control the movement.  Return to the starting position and keep the knees over the toes to prevent knee valgus throughout the exercise.   This exercise can be performed with or without the assist of a chair.  Many times the chair is needed initially until control and strength improve.  Challenge to the gluteus medius can be increased by holding a dumbbell or kettl bell in the hand opposite the supporting leg.

Closing Thoughts

These five exercises require practice to perfect.  Often, a trainer or physical therapist is needed to coach an individual through these types of exercises.  These are higher level exercises which are not for everyone.  However, mastering these types of dynamic movements often translate to improved coordination, strength, and power on heavier compound lifts such as the squat or deadlift.  Team sport athletes often see improvements in explosiveness and agility on the field.  Unfortunately, many become frustrated with the amount of practice and effort it takes to perform these types of exercises.  If needed, regress back to perform less challenging exercises in non-weight bearing (here) or weight bearing positions (here).  This is all part of the process.  Be patient and stick with it and you will see results down the road.

Gluteus Medius Exercise Progressions

The primary role of the gluteus medius is to stabilize and control movement of the pelvis during weight bearing functional activities.  This is required for efficient walking, climbing stairs, running, jumping, and throwing.  All of these activities require at least a brief period of single leg support.  The gluteus medius maintains a level pelvis and prevents the opposite side from dropping.  Without adequate functioning of this muscle, balance, strength, power, and performance will be compromised.  Also, abnormal movement patterns, such as dynamic valgus, occur in the presence of inadequate gluteus medius function.

It is advantageous to progress exercises for the gluteus medius from non-weight bearing to standing positions.  The exercises included in this article are 5 options but there are many others.  The most important aspect of these exercises is that they performed in a slow and controlled manner with appropriate body alignment.   The emphasis should first be on proper technique before adding repetitions or resistance.

Band Hip Abduction

Band hip abduction is performed with an elastic band tied around the ankles standing in an upright position with the feet together.   The feet are then pulled slightly apart.  Stand on one leg while keeping the pelvis level.  Abduct the other leg about 25° while maintaining the trunk in an upright position.  The most common mistake is to abduct too far and tip the body to the other side.  It is also important to keep the toes pointing straight ahead throughout the exercise.  Tension should be maintained on the band so the feet do not touch.  Both the supporting and moving side gluteus medius are very active during this exercise but the standing leg receives the greater training effect.

Band Internal & External Rotation (IR/ER)

Band IR/ER is performed with an elastic band tied around thighs (just above the knees) standing in an upright position with the feet together.  Once the band is in place, separate the feet to shoulder width or slightly wider.   During the exercise the knees and hips are flexed about 30°.  The hands are placed on the hips.  Initiate the movement by slowly moving one knee inwards over a 2 second period.  Maintain the position of the opposite knee.  Then slowly pull the knee outwards over a 2 second period.   Perform 8 repetitions in a slow and controlled manner on one side before switching to the other leg.

Lateral Band Walk

The lateral band walk is performed with an elastic band tied around the ankles standing in an upright position with the feet together.  During the exercise the knees and hips are flexed about 30°.   The hands are placed on the hips.   Sidestepping is initiated by leading with one leg over a distance slightly wider than shoulder width.  It is important to keep the toes pointing straight ahead and the knees over the toes throughout the exercise.  Tension should be maintained on the band so the feet do not touch.  Three slow steps are performed in one direction followed by 3 steps in the opposite direction.  Each cycle constitutes 1 repetition.  Typically, 6-8 repetitions are performed each set.   To increase the challenge of this exercise, two bands can be used.  A second band can be placed above the knees.

Dynamic Leg Swing

The dynamic leg swing begins by standing on one leg with the opposite knee flexed to 90 degrees.  Initiate the movement by swinging the non-weight bearing leg (with the knee flexed).  Move into hip flexion and extension at a rate of 1 second forward and one second backward.   Move through a smooth range of hip motion and do not allow the trunk to move out of the upright position.  Also, maintain control of the position of the weight bearing leg during the exercise.   Perform the 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

1-Leg RDL

The single-leg Romanian dead lift begins by standing on one leg with the opposite hip and knee extended.  The weight bearing knee can be slightly bent throughout the exercise.   Initiate the movement by slowly flexing at the hip, keeping the back straight.  The non-weight bearing leg extends straight back behind the body.  Both the descending and ascending parts of the exercise should be performed in a slow and controlled manner.   Also, maintain control and the position of the weight bearing leg during the exercise.   Perform the 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

Closing Thoughts

These 5 exercises can be used as a standalone program for improving gluteus medius activation and strength.  However, all 5 exercises do not need to be performed.  Choose 2-3 exercises to perform 3 days per week.  These exercises are also ideal for athletes and exercise enthusiasts to incorporate into their warm-up routines.  Specifically, try 2 or 3 of these exercises prior to performing compound lifts such as the squat or dead lift.   Next week we’ll highlight some more advanced progressions to load the gluteus medius.  If you any further questions, give your physical therapist a call.

 

 

Gluteus Medius Exercise: Getting Started

In a previous article, we discussed the importance of the gluteus medius muscle in controlling lower extremity alignment during the squat.  This muscle also plays a critical role in positioning and stabilizing the pelvis in many other functional activities.  This includes any activity with requires a period of single-leg support such as walking, climbing stairs, and running.  Individuals with knee pain, chronic back pain, hip arthritis, and ankle injuries have all been shown to have weakness in this  important muscle.  Glutues medius exercise can help.

Getting Started with Gluteus Medius Exercise

Basic resistance exercise for the gluteus medius can be initiated in non-weight bearing positions such as lying on the side.  Progressions can include partial weight-bearing positions such as on all fours or plank positions.  As muscular endurance and strength improve, exercises can be progressed to weight-bearing positions in standing.  Standing exercises are initiated in a double-limb stance, or with both legs fixed to the floor and then progressed to single-limb stance.  Each exercise should be performed 2 to 3 times per week to optimize improvements in muscular endurance, strength, and hypertrophy.

It is recommended that each of these basic resistance exercises be initiated with 3 sets of 8 to 15 repetitions.  When 15 repetitions can be performed, the intensity of the exercise can be progressed by adding weight or increasing the resistance band strength.  Muscle strength and hypertrophy can be achieved with any range of repetitions.  However, to optimize strength, higher intensities with lower repetitions are needed.   The main objective of this strengthening program is to progressively overload the gluteus medius so that muscular control, endurance, and strength are developed in a systematic manner.

Clam Shell

Begin by lying on one side with the hips flexed to approximately 45 degrees.  The knees are flexed and the feet kept together.  A resistance band can be placed around the thighs just above the knees.   Start the exercise by rotating the top hip to bring the knees apart.  Hold this position for 2 seconds and then return to the start position slowly.  Be sure to remain lying completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake with this exercise.   The clam shell is a great exercise to start with because it elicits high levels of gluteus medius activity with minimal activity of the tensor fascia latae (TFL).  This is beneficial because the TFL is commonly overactive in individuals with hip and knee pain.

Side-Lying Hip Abduction

Begin by lying on one side with the bottom hip and knee flexed.  The top knee remains straight.  The top hip is maintained in neutral or slight hip extension with the toes pointed forward.  The toes are pointed forward to orient the hip in slight internal rotation.  This increases gluteus medius activation and decreases TFL activation.  Initiate the movement by lifting the top leg about 30 degrees.  Hold this position for a count of two and then slowly lower the leg to the start position.  Ankle weights can be added for resistance once 15 proper repetitions can be performed.

This exercise activates the gluteus medius to a greater level than the clam shell.  However, it is also more challenging to perform correctly.  Similar to the clamshell, it is important to remain completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake with this exercise.   Also, as the muscle tires, the leg will drift forward into hip flexion.  It is important to maintain the leg lined up or slightly behind the trunk and upper body.

1-Leg Bridge

Begin by lying on the back with both hips and knees bent.  Perform a bridge with both legs by raising the hips to a neutral trunk, hip, and knee position.  A common mistake is to excessively arch the low back.  Be sure to achieve the bridge position by extending through the hips.  From the bridge position, straighten the knee of one leg while keeping the upper thighs parallel.  Be careful not to allow the pelvis to drop on one side.  Hold this position for 2 seconds then return the leg to the bridge position.  Lower the body back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with the other leg.  Resistance can be added by placing a band around the thighs just above the knees.

Prone Plank with Bent Knee Hip Extension

Start facedown supported on the elbows in a plank position with the trunk, hips, and knees in neutral alignment.  Initiate the movement by lifting one leg with the knee bent.   Extend the hip slightly past neutral by bringing the heel toward the ceiling.  Hold this position for 2 seconds.  Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.  A common error with this exercise is to arch or overextend the spine when lifting the leg.  Also, as the abdominal muscles tire, the hips may rise.  Be sure to maintain a neutral trunk, hip, and knee alignment throughout the exercise.

Side Plank with Hip Abduction

Start side-lying supported on one elbow with the shoulders, hips, knees, and ankles in line. Rise to a side plank position with the hips off the floor to achieve neutral alignment of trunk, hips, and knees.  Maintain the side plank position and raise the top leg into abduction approximately 30 degrees.  Hold this position for 2 seconds then slowly lower the top leg. Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.

A common error with this exercise is to allow the pelvis to tip forward or backward.  Also, as the top gluteus medius tires the abducting leg will move into flexion.  As the bottom side tires, the side plank position will be lost.  This exercise has been shown to activate the gluteus medius on both sides at very high levels.  It is also very challenging and may not be an option for everyone.

Closing Thoughts

These 5 exercises do not need to all be performed at once.  Instead, choose 2 to 3 exercises to get started with.  Exercise selection is based on your preferences and the level of challenge each presents.  The clam shell is the least challenging and side plank with hip abduction is the most challenging.  Within 6 to 8 weeks, the exercises may feel less challenging indicating a need for progression.  Progression may include adding resistance or substituting with a new exercise.  Next week we will highlight 5 more exercises which can be performed in standing.

 

Gluteus Medius: Controlling Knee Position during the Squat

The gluteus medius is a broad thick muscle on the outer part of the pelvis.  The muscle spans from the buttock to the upper aspect of the thigh bone (femur) on the bony part of the outer hip (greater trochanter).  The primary function of the gluteus medius is to stabilize the pelvis and femur during dynamic activities such as walking or performing a deep squat.  It is responsible for preventing the opposite side of the pelvis from dropping during walking.  The gluteus medius packs many short muscle fibers together.  This allows it to generate high forces.  However, a trade-off to its structure is its inability to produce large forces when in lengthened positions.

Poor squat due to gluteus medius weakness

The gluteus medius is lengthened when the hips flex and internally rotate.  This causes the knee to cave inward during the squat.  This may be more obvious during a 1-leg squat or landing from a jump on one leg.  This movement strategy is sometimes called, dynamic valgus, and is believed to be disadvantageous.   The gluteus medius is unable to accomplish its primary role of stabilizing the pelvis when in extreme joint positions.  This is the case when the hip is in flexion and internal rotation.  Hip internal rotation during the squat also impairs the ability of the gluteus maximus to extend the hip.  However, the hamstrings and adductors can often overcome this deficit to compensate.  Squatting with the hip internally rotated increases the demands of the gluteus medius and may be a compensation for the weakness of this muscle.

Gluteus Medius & Injuries of the Lower Extremity

It is commonly believed that squatting with hip internal rotation or dynamic valgus is indicative of hip weakness.  This is particularly thought to occur in those with knee pain and those at risk for anterior cruciate ligament (ACL) injury.  Other injuries which are characteristic of this pattern include runner’s knee, iliotibial band (ITB) syndrome, labral injuries of hip and femeroacetabular impingement of the hip.  In many cases, this pattern is likely a compensation for the weakness of the hip musculature.  Hip internal rotation may increase the force capacity of the weakened gluteus medius.   This allows for performance of the squat but subjects the knee and hip joints to excessive stress.

Lifestyle Factors Contributing to Gluteus Medius Weakness

Side sleeping with the leg crossed can place additional stress on the gluteus medius tenddons

Gluteus medius weakness can be the result of previous injury or lifestyle factors.  Standing with the body weight predominantly on one leg with the pelvis swayed sideways can lead to an underdeveloped muscle on one side.  Sleeping on one’s side with the top leg flexed and crossed over the other leg results in an elongated muscle.  Both of these scenarios can potentially weaken the muscle over time.  Repeated running on crowned roads or surfaces can also potentially lead to weakness of the gluteus medius on one side.

Closing Thoughts

Hip internal rotation and dynamic knee valgus negatively impact the gluteus maximus and increase the force generating demands of the gluteus medius.  This movement strategy may be a compensation to increase gluteus medius force production and a cause of gluteus maximus weakness.   In any case, this movement strategy should be addressed with resistance exercise targeting improvements in strength and hypertrophy of both muscles.  Next week, I will post an article about initiating and progressing exercises for the gluteus medius.