Prepare to Compete: Arch and leg mobility and strength are essential! 

By Dr. Marc Bochner

Many of the runners and triathletes I see for lower extremity, hip and spinal conditions are surprised when I find that foot/ankle dysfunction is related to their symptoms further up in the knee, hip or back. Even though it makes sense that improper alignment/motion at the foot will affect the motion of the joints above, attention is often given first to the anatomical site where pain is being felt-- where the symptoms are. However, imbalances such as weak arch muscles, tight ankle ligaments and related calf muscle tightness and/or weakness can be "hidden” causes of pain and injury elsewhere. 

Additionally, research also shows that weak arch muscles can be responsible for running speed decreasing with age and with increased risks of falling in the older population (1-5). The research also says that by doing some specific foot and leg strengthening exercises, loss of speed and balance can be avoided! Thus, evaluating the function of the foot/ankle is essential. 

Here are a few screening tests you can do for the key joint and muscle dysfunctions often found in the foot, ankle and leg. Mobility and strength exercises to help correct each condition are described as well.

1) DECREASED OR INCREASED ARCH HEIGHT AND ARCH MUSCLE WEAKNESS AND/OR TIGHTNESS

 Studies show that those with much lower than average arches are at a greater risk of injury with running (6). There actually is less injury risk with slightly lower arches- in one study runners with slightly low arches had the same injury rate as those with neutral arches (6). The much lower height compromises the arch's ability to absorb impact forces and then return that energy during the push-off phase of walking and running. Thus, the arch and leg muscles which both support the arch and help create the "push-off" (these are the toe flexors, soleus, gastrocnemius and peroneals mainly) are overstressed. Plantar fasciitis, "shin splints", posterior tibial tendon injury, and Achilles tendon injury can result. These injuries are almost all seen at the inner (medial) leg and foot as the excessive pronation that occurs with the lower arch stretches and stresses these medial foot and leg structures.

 Meanwhile, with a much greater than average arch height, more impact is felt "up the chain" in the leg, knee and so on as the arch doesn't collapse enough during the stance phase of gait. Stress fractures, lateral knee pain (such as Iliotibial band syndrome) and hip injury can result.

To find out if you have a low, medium (neutral) or high arched foot, we can use the “wet foot test”. To do this test, besides your feet and some water, you will need a sheet of paper that is wide enough for both feet to create footprints. First, thoroughly wet the soles of your feet. Then, step on the paper with one foot, then the other, side by side. The impression your wet foot leaves will tell you which type of arch you have. Neutral- you will see that the ball and heel of the foot plus some of the middle arch have touched the paper as these areas will be wet on the imprint. Low- there will be more of the middle arch imprinting the paper and less dry space. High- there will be a larger “dry” space and the wet pattern will be more of the outer foot than the inner.

 Note- besides being “born” with low or high arches, as we age our arches can flatten and become lower. Obesity, pregnancy and acquired arch muscle weakness can also contribute to a loss of height. As for high arches, they are mostly genetically determined, although if your arch muscles become very short and tight your arch ligaments and tendons could shorten and contribute to less shock absorption along with the higher arch.

Also, "overpronation" is a functional lowering of the arch that occurs with weight bearing and walking and/or running. It involves the ankle bone lowering inward and the foot turning outward. Pronation is a normal motiion, but sometimes it is excessive and thus called overpronation. As noted in the 4th paragraph above, a lower than average arch can lead to excessive pronation. But, overpronation can also occur without lower arches that are "just there" statically (without movement). There are many causes of overpronation. For example, the arch on one side might pronate and thus lower more to compensate for a functional or anatomical leg length inequality (LLI) or other hip or spinal imbalance. An office exam by a sports chiropractor is often needed to screen for this compensation and treatment may be needed. Overpronation and LLI will be covered in a future article, but some of the exercises described below in the section on calf and ankle joint tightness can help if the overpronation is a compensation for those conditions.

Self-Care/Actions to take for your arch height: If you have a lower than average arch, strengthening the arch muscles that support the arch can help prevent injury (7). In fact, the lower your arch height, the more important it is to do toe/arch strengthening exercises. Running performance after a program of arch exercises improved more in the lower arched runners than those with neutral arches. Also, a shoe that has more stability, or an insert (orthotic) that adds medial support, can help to limit the effects of the lower arch. 

For strengthening, The “ToePro” device can be used. It is a new piece of equipment that helps strengthen the arch muscles.  It accomplishes this by strengthening them as they are lengthening (stretching). This is called "eccentric" exercise (when a muscle lengthens = the eccentric phase, when a muscle shortens = the concentric phase). Research shows most gains in strength are accomplished during the eccentric “lowering of the weight” phase, as the muscle stretches. The key muscles are the flexor hallucis brevis, abductor hallucis, and flexor digitorum brevis. The ToePro makes it easier to do these eccentric strength exercises. It is made of a flexible rubber material that ridges to place your toes on. Basically, you step up onto the device into a calf raise while pressing your toes into the ToePro.  Click on this link to learn more about the ToePro and view the exercises: https://humanlocomotion.com/products/toepro-foot-ankle-exercise-platform

Another option is using an "Airex" foam balance pad to do the same eccentric toe exercises as with the ToePro. These eccentric options are an improvement over the traditional arch strengthening "marble pick up" and "towel crunch" exercises usually prescribed, as with eccentrics the toes are strengthened in the same functional position they are used when walking or running (8).

Besides the toe exercises, another way to strengthen your arch muscles is to wear “minimalist’ shoes for daily activities (9). Minimalist shoes are those lightweight shoes that have a very low to zero toe to heel “drop” (the height of the shoe at the toebox vs. the heel). The Altra brand is one example. Minimalist shoes also sometimes have a wider toe box to let the toes spread in the natural way they were meant to and thus have more range to move, which in turn strengthens the same arch muscles mentioned above that the Toe Pro exercises do.

2) FIRST TOE AND ANKLE MOTION, CALF TIGHTNESS, AND/OR WEAKNESS, AND WEAK OR TIGHT PERONEAL MUSCLES.  These are all necessary for normal and powerful foot motion.

 A) First toe motion: For proper push-off to occur, ideally the first or "big toe" must be able to dorsiflex from 70 to 90 degrees. This means that as you walk or run, the foot bends over the planted big toe to at least 70 degrees and also ideally remains aligned with the foot, not deviating inward towards the other toes. When this motion is optimal, the gastrocnemius, soleus and peroneal muscles of the leg can contract strongly to stabilize the foot. This in turn helps the gluteus maximus contract to extend the hip and propel us forward. Thus, this motion of the first toe is essential as besides helping the arch function normally as described above, it affects the entire gait cycle.

 First toe Test and Stretch exercise: Standing First Toe Extension (Dorsiflexion) Test/Stretch:https://vimeo.com/268078467/09dd17b59b

Stand with the foot on the side to be tested behind the opposite foot and raise your heel off the ground until the motion at the toes starts to be limited. The big toe should remain on the ground- the dorsiflexion motion takes place at the first metacarpal phalangeal (MCP) joint. Note the angle the big toe makes with the rest of the foot. Again, 70-90 degrees is the desired range. 

First Toe Self-Care: If the range is limited, self-massage with a golf ball or other massage tool can help release the tight toe flexor muscles as can office treatment to the arch muscles and 1st MCP joint ligaments with techniques such as Active Release. https://vimeo.com/269428879/ad4fd8bcaa

Once the first toe is loosened, the ToePro exercises described above will help to strengthen the first toe flexor muscles in their full range of motion. 

However, if either "Hallux Limitis"(stiffness and/or mild degenerative arthritis of the first MCP joint) or "Hallux Rigidus" (extreme degenerative arthritis of the first MCP joint) is present, they can cause limitation that can be more difficult to treat with soft-tissue techniques and exercises, but they can still help improve the range of motion. If the condition has progressed to "Rigidus" and there is very little joint motion, special shoes with "rocker" bottoms may help produce the toe off motion.  Also, "Hallux Valgus" is another condition that can limit normal dorsiflexion of the first toe. https://vimeo.com/268085613

The first toe is angled towards the other toes in this condition. Treating the first toe adductor muscle (adductor hallicus muscle) with self myofascial release and/or Active Release Technique by a sports chiropractor can sometimes help along with treatment of the 1st MCP joint ligaments. Surgery is sometimes performed for these conditions but should be a last resort!

B) Ankle movement- The ankle bone, or talus, must have the right balance of joint movement and stability for the leg to move efficiently from impact to push off. This movement provides a stable foundation for the more powerful gluteal muscles above to work from and propel us forward. Without the proper ankle motion, the foot can compensate, and the arch will lower as the foot pronates and "toes-out" more to create the motion lacking above at the ankle. Also, lack of talus motion can cause the calf muscles to tighten as well and then in a chain reaction, limit those gluteal muscles above from contracting. "Knee-down" walking and running can result and leads to more stress on the knees and hips. A poorly treated ankle sprain, with chronic scar tissue, will alter the talus motion at the ankle and can lead to this scenario (See “Ankle Pain and Running: What you don’t know can hurt you” article).

Ankle Mobility Tests

1- Ankle Open Chain Dorsiflexion Test: https://vimeo.com/332752022/d196de1f56

     Test: Seated on the floor with your legs straight out in front of you, move your foot first upward towards your leg (dorsiflexion) as far as you can. **This motion should occur at the ankle joint, and not the foot (arch or toes).

     Screens for: Ankle joint range of motion, calf muscle length in the open-chain (non-weight bearing) position. With dorsiflexion, feel/look for restriction in motion of the calf muscles (gastrocnemius and soleus in the back of leg) or the ankle joint itself.  Normal range of ankle dorsiflexion is about 20 degrees from starting with the foot about perpendicular to the floor. The video shows first a normal dorsiflexion range. Then it shows gastrocnemius tightness as the knee flexes/rises some. Next, the ankle joint is restricted and limits motion into dorsiflexion (this also can be due to soleus muscle/achilles tendon tightness). Then, the video shows restricted dorsiflexion with excessive pronation compensating for the loss of ankle motion.

Normal- With dorsiflexion, the foot moves towards the leg to an angle of at least 20 degrees. The foot does not pronate or supinate and stays in line with the tibia in both directions.

Mild Dysfunction- with dorsiflexion, the knee flexes/rises some, indicating gastrocnemius tightness.

Moderate Dysfunction - the ankle joint is restricted and limits motion into dorsiflexion. This also can be due to soleus muscle/achilles tendon tightness.

Severe Dysfunction- there is severely restricted dorsiflexion with excessive pronation. 

2- Ankle Open Chain Plantar Flexion Test: https://vimeo.com/332752028/5c5ed961d6

Test: Seated on the floor with your legs straight out in front of you, move your foot downward as far as you can,  **This motion should occur at the ankle joint, and not the foot (arch or toes should stay in neutral or only move slightly into flexion at the end of the range of motion).

Screens for: Ankle joint range of motion, length of anterior leg muscles (the dorsiflexors= tibialis anterior, toe extensors) in the open-chain (non-weight bearing) position. With plantarflexion, feel/look for restriction in motion of the muscles, or the ankle joint itself.  Normal range of ankle plantarflexion is about 50 degrees from the neutral (foot parallel to the ground) position. The video shows first a normal plantarflexion range. Then it shows tightness as the foot doesn't reach 50 degrees and tightness if felt in the anterior leg muscles. Next, the ankle joint is restricted and limits motion into plantarflexion. This also can be due to tibialis anterior muscle/tendon tightness. Then, the video shows restricted plantarflexion with excessive supination compensating for the loss of ankle motion.

Normal- With plantarflexion, the foot moves away from the leg to an angle of 50 degrees. The foot does not supinate and stays in line with the tibia.

Mild Dysfunction- with plantarflexion, the leg does not reach 50 degrees, indicating tightness.

Moderate Dysfunction - the ankle joint is restricted and limits motion into plantarflexion. This also can be due to extreme tibialis anterior muscle/tendon tightness.

3- Standing Ankle Flexion Test: https://vimeo.com/268911305/af665d6b0e

Purpose: To assess functional ankle joint mobility and deep calf (soleus) muscle flexibility. Significance: Lack of ankle dorsiflexion is a proven risk factor for foot and ankle injury, as well as injuries further up in the knee, hip and lower back. Compensatory foot pronation may occur.

Starting Position: Standing with legs shoulder width apart, hands at sides.

Action: Without bending at your waist, kneel forward from the ankles and knees.

Scoring: None/mild Dysfunction- Upon bending there is at least 30-35 degrees of leg motion (tibia moving from vertical downward toward the foot) and no foot pronation (ankles rolling in).. 

              Low Moderate Dysfunction: There is less than 30 degrees of motion on one or both sides. The feet do not pronate/knees do not move inward; they stay relatively stable.

              High Moderate: There is less than 20 degrees of motion. The feet may pronate (ankles roll in) and the knees may move inward on one or both sides. 

              Severe:  There is little to no motion at the ankle joint in dorsiflexion (less than 10 degrees) and/or extreme foot pronation on one or both sides (Severe is not shown on video).  

C) Calf tightness and/or weakness independent of the above 3 factors (arch height, 1^st toe and ankle mobility) can also exist and then lead to the same compensatory pronation and chain reaction up to the leg, knee, hip and back. The self tests for calf tightness are also the Open Chain Dorsiflexion/Plantarflexion and Standing Ankle Flexion tests just described above. 

D) Weak and/or tight peroneal muscles/tight lateral ankle ligaments- the peroneals are on the outside of the leg which contract to stabilize the ankle (preventing ankle sprains) and as noted above play a role in helping the foot provide a stable base of support for movement.

Self-tests for Peroneal Tightness (no video):

For tightness, assess by sitting with your leg to be tested crossed over the opposite knee. Grab the foot with the opposite hand across the arch, thumb on the inside. Next, move the foot into “inversion” by pulling it with your hand. The normal range should be about 30-40 degrees. If you feel a pull or tightness on the outside of your leg, anywhere from the ankle up the outside of the leg to just below the knee, you have some degree of peroneal and/or lateral ankle ligament tightness. Mild is just a slight stretch, Moderate is a restriction in the foot/ankle motion also, and Severe is a lack of any foot/ankle motion.

Ankle and Leg Muscles Self-Care:

 Mobility Exercises

-Foam Rolling Videos and Instructions: Using a foam roller on a daily basis and pre and post exercise can help release “adhesions” and “trigger points” that form from overuse and strain as well as lack of stretching and sitting too much. Active and static stretching also work better after a muscle has been “rolled out” as these tight spots are difficult to stretch and can even be strained by forcing a stretch. 

• Calf: https://vimeo.com/269427635/0c83846406
• Side of Leg (Peroneals): https://vimeo.com/269428552 
• Rolling Front of Leg: https://vimeo.com/269427797

-Manual Self Mobilization of the Ankle (no video): sit with the ankle to be mobilized crossed over the opposite knee. Grab the foot with the opposite hand across the arch, thumb on the inside. Next, move the foot into “inversion” by pulling it with your hand as far as you can, stretching the lateral (outer) ligaments fully. Then, push the foot back laterally stretching the medial (inner) ligaments fully. Repeat moving the foot back and forth 5-10 times in each direction. Next, still holding the foot with the opposite hand, stretch the front of the ankle by pulling the foot downward as far as or will comfortably go, and then stretch the back of the ankle by pushing the foot back up as far as it will go. Repeat 5-10 times in each direction. 

 Strength/Balance Exercises

-Manual Strengthening of the Ankle (no video): Positive or “concentric” pressure- sit with the ankle to be strengthened crossed over the opposite knee. Place the fingers of the hand of the side you are strengthening along outside of the foot, and the fingers of the other hand on the inside of the foot. Next, move the foot inward against the fingers there as far as it will go, providing resistance with the hand. Then, without letting the foot move back at all, makes sure the fingers on the outer side are flush against the foot and then move the foot back outward as far as it will go. Repeat 10 times in each direction for 2 sets. 

Negative or “eccentric” pressure- from the same position, now, instead of pushing the foot against the fingers, push with the fingers against the foot in each direction for the full range of motion. You will be now “resisting” the pressure from the hand instead of pushing against the hand, just as when you slowly lower a weight with an exercise like the bench press or bicep curls. As noted above with the ToePro description, the “eccentric” or “negative” phase of a strength exercise is more effective at causing strength gains than the concentric if you move slowly.

-Strengthening of the Ankle: Resistive Bands

These resistance band exercises are done in 4 phases as the videos show. Progress through the phases over time' usually a week to 10 days is needed for each phase. Perform these exercises daily or at least 3-5 days per week. For each exercise, sart with 10 seconds and 6 reps for a total of 60 seconds. As you improve, gradually work up to two sets of 30 seconds.

Phase 1: Slow and short range. Find the "mid-range" between the ends of the full range of motion. Next, move slowly back and forth just 5 degrees in each direcction.

Phase 2: Fast and short range. Again find the mid-range and now move fast 5 degrees in each direction.

Phase 3: Slow and full range. Now, move through the full range of motion but slowly.

Phase 4: Fast and full range. The last phase is full range and fast motion.

Ankle Dorsiflexion: https://vimeo.com/451670231/3ff30cf53b

Ankle Plantarflexion: https://vimeo.com/451674531/9829f3337f

Ankle Internal Rotation: https://vimeo.com/451665151/94219c4373

Ankle External Rotation: https://vimeo.com/451667104/10f4f8c76b

-Traditional Standing Double and Single Leg Calf raises (no video): Double- Stand with just the ball of your foot on a step or raised exercise platform, with the leg in the stretched position (heel lowered below the surface as far as it will comfortably go). Next, raise up using your calf muscles so that your weight shifts further forward onto the toes and your calf muscles tighten. As with the ToePro exercises, focus on putting weight on the big toe as you rise. Hold for half a second and then lower your body back into the starting position. Repeat for 2-3 sets of 15-20 reps. Single leg calf raise- Repeat the same exercise but after raising up, bend one knee so you are standing on just one leg. Then, slowly lower your body weight on just the single leg. *For Achilles tendon strengthening, work up to spending 10 seconds in the lowering phase. This slow “eccentric” exercise helps to stimulate collagen…

-Single Leg Stance with Knee Hug and with Calf Raise, plus Marching Calf Raise (no videos):  For a more advanced exercise, perform a standing knee hug with good posture, maintaining a neutral spine (slight lower back arch). The knee should reach mid-chest level if you have good range here. Next, do a single leg calf raise, hold for a second, and return. *Maintain pressure on the first toe to keep the ankle from rolling outward (inverting) and thus activating the peroneal muscles (everters). Repeat 10 times. For an even more challenging exercise, “march” forward as you do the calf raise, and alternating the knee hug side, marching across a 10-15 foot distance. Again, maintain the peroneal muscle activation as you move forward. This exercise is a great challenge for ankle stability and balance.

Performing these self-tests and then exercises to work on mobilizing, stretching and strengthening as needed can help you maintain arch and leg strength and mobility as you age. Note: There are many other exercises that can be done; these are just a few and a good place to start.

Office care of course may also be necessary to balance out your feet: including specific myofascial release of stubborn scar tissue in the ankle ligaments, calf, and arch muscles/fascia from previous strain/injury. And adjustments to the spine and pelvis and ankle can be performed to ensure proper leg length alignment and joint motion. 

 1. Moon D, Kim K, Lee S. Immediate effect of short-foot exercise on dynamic balance of subjects with excessively pronated feet. J Phys Ther Sci. 2014; 26:1.

2. Sulowska I, Oleksy L, Mika A, Bylina D, Sołtan J The influence of plantar short foot muscle exercises on foot posture and fundamental movement patterns in long-distance runners, a non-randomized, non-blinded clinical trial. PLoS ONE. 6/23/2016, Vol. 11 Issue 6, p1-12.

3. Kokkonen, J, et al. Improved performance though digit strength gains. Research Quarterly for Exercise and Sport. 1988. 59:57-63.

4. Beijersbergen CMI1 , Granacher U, Gäbler M, et al. Power training-induced increases in muscle activation during gait in old adults. Med Sci Sports Exerc. 2017 June 7.

5. Endo M, Ashton-Miller J, Alexander N. Effects of age and gender on toe flexor muscle strength. Journals of Gerontology. Series A, Biologic Sciences Med Sciences. 2002. 57A(6):M392-397.

6. Nielsen R, Buist I, Parner E, et al. Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study. Br J Sports Med. 2014;48(6):440–447.

7.Zhang X, Pauel R, Deschamps K, et al. Differences in foot muscle morphology and foot kinematics between symptomatic and asymptomatic pronated feet. Scand J Med Sci Sports. 2019;29(11):1766–1773.

8. Kitai T, Sale D. Specificity of joint angle in isometric training. Eur J Appl Physiol Occup Physiol. 1989;58(7):744–748.

9. Ridge S, Olsen M, Bruening A, et al. Walking in minimalist shoes is effective for strengthening foot muscles. Med Sci Sports Exerc. 2019;51:104–113.

SKI/SNOWBOARD SAFELY THIS WINTER!

How can you be healthy, fit and ready to ski safe this winter, whether downhill, snowboarding or x-country?

Note: Please click on the words in bold italics to see the treatment technique info or video of the exercise being described/referenced

If you haven't been very active the last few months due to COVID limitations, the first step is to perform a self assessment of both your musculoskeletal health and your fitness before starting to exercise again, especially if you are planning on going skiing. Our Prepare to Compete(R) system (PTC) can help you with this assessment and with a plan to fix problem areas and get in shape to ski injury free!  And if you are not a skier, the advice below still is valuable to help you prepare for any sport or activity.

As with all sports, there is a base level of healthy joint/muscle function and fitness necessary to ski with less risk of injury. The PTC system has three steps:

 1) Assess your "Present State"- posture, range of motion, stability and movement control.

2) Correct any imbalances with home exercises and office treatment if needed.

3) Train for general fitness and sport specific fitness and participate/compete in your favorite activities. Continue to self monitor with the tests from step (1) to maintain normal muscle and joint function with self-care and office care if needed as in step (2).

If you haven't had a general cardiovascular exam recently, or you are over 50 or have a family history of heart disease, see your doctor before beginning this or any exercise program.

 Ski Readiness Step 1: Key area to assess for skiing: How are your hips? Everyone knows the knees are at risk of injury when skiing, and they should be in good shape locally regarding range of motion and strength, however the hips are where the attention is often needed, and a key area to assess in the PTC system. Hip problems often cause knee problems.

Internal rotation, lateral or "side to side" motion and flexion/extension of the hip all must be checked and are necessary for proper turning and to take pressure off of the knees. These motions are "closed chain", meaning they occur with the feet on the ground (on the skis actually in this case) and must be evaluated while standing as well as improved if necessary with standing exercises. Non-weight bearing exercises also can be done but progress must be made in the standing, functional position for full ski readiness to occur. For internal rotation, the hip on the "downhill" ski side is where the rotation has to occur for the body to turn "around" the hip. At the same time, the pelvis must move side to side and the hip lets this happen through abduction and adduction. And finally, to power us down the mountain with controlled speed, the hips also flex and extend along with the rotation and side to side movement.

To see these three motions in action, look at these series of pictures showing a parallel ski turn progression- note how the skier's thighs are parallel of course the entire time, but see how in the 2nd photo he is more flexed at the hips and there is more space between his thighs, and then gradually through the photos he extends at the hips while the left hip rotates internally, and then as he finishes the turn his hips start flexing again, yet his thighs still remaining parallel. The ski edges are used to create the turn along with the hip internal rotation and pelvic movement opposite, to the right. The internal rotation occurs along with the hip extension (coming out of the more squatted position) which makes biomechanical sense as our hip joints rotate internally easier when in extension than in flexion (they externally rotate more easily with hip flexion).

·     To self-assess your standing hip internal rotation, stand and bend one leg at the knee while centering your body over the standing hip and leg (you can maintain balance by holding onto a wall or doorway frame if needed). Next, while maintaining a neutral spine and upright torso, rotate your torso towards the standing side. The normal range should be at least 45 degrees (your torso will be facing the side you are testing). A restricted side may feel "jammed' at the front of the hip or groin tightness might be felt.

·     To self-assess for standing lateral/medial, meaning the "side-to-side" hip motion, perform the standing lateral lunges in both directions, laterally out and across. Evaluate by comparing left vs. right sides for both directions for both range of motion and how smooth or controlled the movement is.

·     To self-assess for standing hip flexion and extension, perform the standing lunges as shown in these videos: Forward and Backward. Again, evaluate by comparing left vs. right sides for both directions for both range of motion and for how smooth/controlled the movement is.

Ski Readiness Step 2: Corrective exercises for hip range of motion restriction: Self myofascial release and specific stretches.

·     Muscle tightness in the outer hip muscles (gluteals, TFL, piriformis/hip rotators) as well as the adductors (inner thigh) and hip flexors can cause restricted hip motion. Rolling the hip flexors and gluteals, piriformis and TFL is essential here for self care. *Also, we must remember to check key "myofascial" areas. Connective tissue called "fascia" wraps our muscles and connects them up and down the body and can tighten in one area and then cause tension or weakness in another. Thus, foam rolling or other self massage should also focus on the arch of the foot, the calf, the ilitotibial band, the latissimus dorsi, and the upper back.

·     After the muscles/fascia are loosened with rolling, perform both active and passive stretching. Isolated hip flexor stretching should be done along with standing functional movement. This standing movement activation exercise works both the lateral hip movement and rotation described above as well as some hip flexion/extension. Also, the same test movements described above in step (1) can be used to improve mobility and movement control. And strengthening exercises for the hip extensors should be performed.

·     Finally, basic core strength and pelvic alignment exercises may need attention, as well as office care including both manual myofascial release such as ART (Active Release Technique) and spinal/extremity adjustments. Hopefully any restriction felt in the self-tests described above is muscular and not an "abrupt" hard stop with pain at the front of the joint or into the groin. The later could mean you have some degree of hip joint degeneration or impingement, which should be assessed for treatment as well.

Ski Readiness Step 3: Train to gain fitness to ski and then...ski! Enjoy the winter activity at your chosen intensity level while maintaining health by using recovery self-care and treatments. Train for both general fitness and ski specific fitness, ideally starting a few months before your first ski day, building up workout intensity gradually and then maintaining fitness between skid days/trips as the season progresses. See the paragraphs below for a sample program. Also continue to measure your present state (repeat Step 1 a few times per week, even daily as part of your warm up) thus self-monitoring for the earliest signs of Injury.

Ski Fitness: All sports require a combination of cardiovascular endurance (aerobic fitness), muscular strength and endurance, agility/balance and range of motion.

Cardiovascular endurance of course is needed and developed by x-country skiing, but is also needed for downhill skiing to help you recover between runs and deliver oxygen to the working muscles efficiently, especially if skiing at altitude!

·     If you haven't been active the last few months, take at least a few weeks to get back in a routine before hitting the slopes: Indoor cycling, running/fast walking at least 3X/week can help develop basic cardio fitness.

·     Start with 20-30 minutes and build up time gradually.

·     Once you establish a new "base" of fitness, you can increase intensity and progress to short, intense interval workouts that will more closely mimic the "bursts" of exertion followed by rest periods that downhill skiing involve as you do run after run or take breaks during longer runs.

For strength and agility, a body-weight exercise routine including squats, lunges in multiple directions (lateral and rotational motion strength and stability is key with skiing), push up variations and pull ups and/or elastic resistance band standing pulling exercises can be effective. Holding a medicine ball during your lunges and squats raises the difficulty level.

·     These exercises simultaneously work your core, and if you move quickly between exercises you can also train the cardiovascular system at the same time.

·     However, as noted above in step (2), if your core is very weak you first may need to also perform floor core stability exercises such as "Dead Bugs" and "Bird Dogs" to ensure proper form with the standing exercises. Or, on the other hand, if you are already very fit and want an more advanced ski prep workout, jumping (plyometric) exercises such as Front and Side Jumps can be added.

Finally, before you ski, check your gear! Make sure your ski/snowboard equipment is in good shape as well. If you own your own skis, check your boots for wear and tear at the buckles, and have your skis professionally tuned up so that the bindings are aligned properly with correct tension.

Following these steps can make it more likely that you enjoy safe skiing at any age and also gain and maintain fitness through the winter months!

***For guidance on implementing the above advice, feel free to contact Dr.Bochner at ptcompete@gmail.com or call the office at (212) 688-5770 to set up a check up appointment and also to gain access to the full library of self-assessment tests and self-care exercises and tests on traininghistory.com. For those working at home outside of NYC, or who no longer in the NYC area, Virtual Visits are still available.

Sitting Fit: How to remain healthy and fit while sitting!

by Marc Bochner, DC, CCSP

Many studies have demonstrated the negative effects of a sedentary lifestyle, from back pain and obesity to an increased risk of developing many chronic diseases (see Sitting Fit: Prevent "Movement Dystopia")(1)

Unfortunately, this already serious problem has been exacerbated as the pandemic lock-downs and working from home has led to decreased physical activity for many people who already might not have been moving enough. It is all too easy for both adults and children to become less active, especially during the winter. (2) But you can manage the "movement dystopia" of sitting and prevent musculoskeletal pain, injury and other health issues.

“Sitting for a living” is very risky:

 Muscle tightness: Hip flexors, lower hamstrings, calves, chest, shoulder and forearm muscles all tighten when sitting in the 'flexed" posture, and the opposite "extensor" muscles weaken. Intervertebral discs: The spinal discs are like jelly donuts, and the "jelly" like center, or nucleus, can start to compress and bulge through the dough, or layers of ligament tissue.

Heart and blood pressure: BP goes up as the lack of muscle movement hinders venous blood return and cardiac output decreases.

Metabolic levels: Triglycerides and "bad cholesterol" levels rise along with insulin resistance.

Bone Density: Has been shown to be lowered in women.

Cancer: Prolonged sitting also increases colorectal, endometrial, ovarian, and prostate cancer risks, and it has been reported to increase cancer mortality particularly in women.

However, there is good news -- increasing your physical activity can help prevent these negative health affects!

Use the acronym "WORK" to remember these 4 key steps:

1) Evaluate your Workplace Set-Up, 2) Organize Breaks, 3) Restore Health, and 4) Keep Healthy.

1. Workplace set up: Do an ergonomic check of your home office set up (desk, chair, screen, keyboard).

Desk: This may involve purchasing or creating a standing desk as the easiest way to avoid the sedentary effects of sitting is to...not sit, or not sit as much! "Active" sitting is best- active means you still use your core to minimize the vertical pressure of the chair seat pushing back against the spine by using your core muscles.

Chair: An active sitting chair  that has an slightly "unstable" seat can be used to achieve this or you can use the Sit-Disc.

If you must use a "regular" chair, sitting on the front edge of the seat can also activate the core by helping to maintain the lower back arch instead of the rounded, slumped posture that compresses spinal disks and stretches and weakens deep back muscles. Or, you can recline back in the chair to reduce compressive forces on the spine- but this reclined posture is not practical for most desk work so it may be best to use for a break from the upright posture.

If you use an adjustable "ergonomic" chair with contoured support, and sit "straight up" and against the back of the chair, you must make sure your lower back and mid back are aligned properly so that the upper back rests on the chair arch, which takes the weight of the mid back off of the lower back. However, even though these ergonomic chairs are very "supportive", unfortunately they inactivate the core muscles which can lead to atrophy and long-term weakness if used regularly. Thus, I do not recommend using a traditional office chair as your main sitting strategy.

Finally, no matter what chair is used, the neck should be in neutral, not flexed, and the head should not be translated forward. The shoulders should also be relaxed and not shrugged up and/or forward. T help relax your shoulders, make sure the chair height is adjusted so that your arms rest low enough on any arm rests or on the desk edge and thus you don't need to hold them up with the arm and shoulder muscles.

Keyboard: keep your wrists aligned with your forearms (no sharp angles) and in neutral (not flexed or extended) and keep your elbows at a 90 degree angle or more, not less.

Computer screen: the top of the monitor should be at eye level, and the screen should be about 20-30 inches away from your face. You shouldn't need to flex your neck down or arch it up to see the screen center.

     2.  Organize BREAKS from your work/sitting to minimize the negative effects of sitting:

Micro- take a 20 second break every 15 minutes and stand and stretch your neck and hip flexors, shoulder/chest and hamstrings/calves.

Mini- take a 5 minute break every hour and walk around the office or outside your home.

Macro- take a lunch break workout of 30-60 minutes or workout before or after work.

    3. Restore health to already tight/weak/injured areas: Use both self-care (foam/ball rolling, targeted stretching, strength exercises) and office care if needed (myofascial release /adjustments/rehab programs/exercise training).

    4. Keep healthy by maintaining normal joint and muscle function by proactively self-treating with the above restorative methods and scheduling check up visits for chiropractic and manual muscle treatments when needed. Using our self-monitoring system, traininghistory.com, can help you track the status of key areas (neck, shoulder, wrist/hand, lower back) and also help you learn when to self treat and when to seek professional care.

(1) Sedentary Lifestyle: Overview of Updated Evidence of Potential Health Risks

(2) Physical activity and screen time of children and adolescents before and during the COVID-19 lockdown in Germany: a natural experiment

Post Marathon Recovery: How to make sure your last marathon isn't your last marathon!

By Dr. Marc Bochner

It’s November, and many runners have just finished a fall marathon. For some it may be their first, others may have raced to a personal best. Hopefully, you finished “feeling good” and that feeling has carried over into your recovery period. However, if you plan to jump right into heavy training again, you may be in for trouble in the months ahead, in the form of injury or “burnout” from running. Here is some information you can use to ensure that your last marathon won’t be your last marathon.

No matter if it’s your 1st or 50th marathon, a certain amount of time is required for our bodies, and minds (not to mention family and friends), to heal before the next race or season.

Understanding just what recovering means when it comes to exercise in general and actually a race of any distance, not just a marathon, can help with planning you’re next few weeks and months.  After any exercise session, our body systems- musculoskeletal, hormonal/metabolic, nervous, immune- are stressed and must adapt to be ready for the next bout of exercise.  Of course, a marathon will cause more damage and need a longer recovery time than a shorter race. Other stressors, such as lack of sleep, poor nutrition, work or family obligations- can also combine with the exercise session to stress these systems.  We must monitor our response to these stressors as well to exercise, when planning our post-exercise recovery. No matter if it is a hard workout or a marathon, the same principles apply. 

Post-race recovery can be broken up into 4 stages: the immediate hours after the race, the first week, the first month, and returning to regular training after the first month. This article will assume you successfully navigated the immediate post-race walk, hydration, and nutrition and the rest of your marathon Sunday and did not have an acute injury or medical condition.

For the musculoskeletal system, the monitoring during the last three recovery stages can be as simple as charting your post-exercise soreness levels during regular daily activity such as walking, and also ranking your tenderness to touch.  Often after exercise that stresses our bodies past current ability levels, the maximum soreness will not occur until about 48 hours after the exercise session.  This is called “delayed onset muscle soreness” or DOMS. However, by three or four days after the race, this soreness should be dissipating. Thus, if you are still experiencing significant soreness with daily activities (walking downstairs and bending your legs to squat, for example) after the third of fourth day post-event, you may be recovering slowly the first week. And, if you have soreness or tenderness to the touch that is only on one side of your body, this may be the first sign of a developing injury, as DOMS is usually bilateral and equal in intensity and duration on both sides.  If high impact exercise such as running is resumed too early in this healing process, the soft-tissues that are still in a weakened state will not have the strength to resist more muscle/soft-tissue damage and recovery can take longer and injury risk can be higher. 

To help athletes and patients in general self-monitor their recovery from regular workouts and from races such as the marathon, in addition to monitoring the post-injury return to exercise such as running,  I have developed an online training long and electronic health record system called traininghistory.com.  Training History includes an “Activity Readiness Score” which takes into account not only injury symptoms, but the underlying status of your muscles. Often injury will occur or re-occur if non-symptomatic muscle dysfunction in not identified and treated. The goal of training history is to provide a method for you to note when key areas that may lead to injury are dysfunctional, before the full injury develops.  For post marathon recovery, this score can be valuable as it can help you take some of the guesswork out of planning your return to exercise and running.  The self-monitoring muscle dysfunction ranking for the Activity Readiness Score is as follows:

Level 1:  None= little or no soreness to even heavy touch/stretching/motion.

Level 2: Mild= mild soreness to medium to heavy touch/stretching/motion.

Level 3: Moderate= moderate soreness to light touch/stretching/motion.

Level 4= Severe= severe soreness to even light touch/stretching/motion.

Now, to the specifics of the post-marathon exercise plan for the first week and month. Light stretching and walking for regular daily activities is fine for the first few days and will help circulate blood with healing nutrients as well as remove waste products. If you have a foam-rolling and self-massage routine that you follow, you can use that routine as a self-monitoring tool. Just be careful the first few days post-race (those with low pain tolerances will not want to go near their rollers much the first week). For everyone, waiting at least one week before running again, or doing other lower body aerobic exercise (even the elliptical) is a wise choice.  Those who were either under-trained or over-trained, raced beyond their fitness level, or were fighting a specific injury before the race may need more recovery time than the more properly prepared and/or experienced runners. Using the self-monitoring system described in the previous paragraph, if you are still a 3 or 4 on the muscle rating scale, meaning you have moderate to severe soreness to just light touch or with light motion, you should not be doing running or other weight-bearing impact exercise yet no matter how many days have passed since the race. Just regular light walking during your daily activities should continue. Non weight-bearing exercise such as swimming may be OK. 

Once you score a 1 or 2 on the scale, which usually will be after about a week, then you can hit the elliptical or other non-impact exercise and try easy running. If your legs still fell heavy, lifeless, and sore after a week of light runs or workouts, continue to go easy or take some more rest days. If not, you can run a little faster and longer and more frequent the third week.  By the fourth week, you can run almost normal pace, distance and frequency for weekday runs, but you should not run a long run similar to your long runs in training or increase your mileage to “base building” levels.  Information on the return to regular training after the first month is given near the end of this article.

If after 7-10 days you are still experiencing any specific soreness with motion or tenderness to the touch, and are still a 3 or 4 on the muscle recovery scale, it may be wise to see your sports doctor for an exam to rule out a specific injury.  A post-race massage and/or chiropractic treatment is a good idea in any case at this point. Also, if you were injured during training and still did the race, or want to prevent future injury, scheduling a visit for a full sports chiropractic biomechanical analysis and treatment plan to correct any imbalances and altered movement patterns is essential. My Prepare to Compete© program has helped many endurance athletes use their “off-season” to work on their weakness and injury-proof their bodies.  It is difficult to correct imbalances during the intense training and racing parts of the year, so once you are past the one month recovery point after the marathon, such a rehab/prehab program can begin.

Finally, to plan the rest of your marathon recovery past the first month, and to avoid injury and recover fully, it may be helpful to think of the training year as a continuous circle, with the day after your last big race as the first day of the next season. This is because what you do now will determine what you can do over the winter months, which will then determine what type of shape you are in when your next race arrives. If you are planning to run some “off-season” winter races, even just for fun (which can be a good idea to help you avoid the post-marathon winter “blues”) you should keep some type of aerobic base. Most should decrease their weekly mileage and add some other forms of aerobic activity, such as swimming, cycling, deep water running, or cross-country skiing.  Those who enjoy downhill skiing or snowboarding can fill in the added non-running weekend days with those activities. And if you like to play a sport such as tennis, or even basketball, those can help maintain fitness as long as you are careful and gradually get used to moving laterally and with quicker movements. In addition, an weight-training program that includes upper body and core (from the hips to the shoulders) strengthening should be part of you winter fitness routine, and range of motion work such as yoga should be used as part of this routine. “Functional exercises” such as single leg squats, lateral lunges, single leg deadlifts and plyometric exercises can also be utilized once any weak links and imbalances are rehabbed with a program like Prepare to Compete.  Traininghistory.com also has a full prescription of recovery, correction, rehab and fitness exercises for each stage of recovery and for the racing season.

When should you start transitioning back to a more running-centered plan and increasing running mileage again? The answer depends on what your goals are for next year. Those who plan to “peak” for two marathons next year, one spring and one fall, such as Boston and New York, or have an early season triathlon, will want to start building a base earlier, such as January. But even if you are not racing “long” until next fall, don’t wait until July to start building back your base, as you will leave less room for error and more room for injury. Ideally, for a fall marathon, you should reach half-marathon distance by the end of May, no matter what your ability level.

 If you follow these steps, chances are you will avoid the common post-marathon injuries that often appear in the winter months, such as iliotibial band syndrome and stress fractures. Better yet, you will enjoy your winter racing or cross-training, and you will have both the body and the energy to “reach new peaks” next year.