The restoration of stability and motor control should progress after resolution or at least noted improvement in “bad energy” (pain, inflammation and toxins), and “blocked energy” (limited and asymmetry mobility) has occurred. The restoration of motor control and stability occurs best via task and constraint cues that implicitly cause change rather than verbal cues to explicit suggest change. Externally focused movements are more effective and more efficient than internally focused movements. [74, 75]
74. Marchant, D.C., et al., Instructions to adopt an external focus enhance muscular endurance. Res Q Exerc Sport, 2011. 82(3): p. 466-73.
75. Marchant, D.C., Attentional Focusing Instructions and Force Production. Front Psychol, 2010. 1.
In this movement preparation drill, the China Women's Volleyball Team had a strong tendency to pattern their squatting with a flexed trunk. I cued them to touch the hands of the person across from them. When they still dropped hands (and thus trunk into flexion), I changed it to "high-five" their opposite. This introduced wrist extension which stimulated an extension pattern.
Without verbal coaching, I introduced an external focus that changed behaviour.
We must remember the three P's to get into the game and stay in the game - positions, patterns & power.
Yet, in many sports, these may not matter as much as what happens once in the game – the application of sports-specific skill.
As such, we must remember that our role, as performance and support staff, is to give athletes back to their technical and tactical coaches. Our role is not to detract from their ability to spend time practicing the game or sport they are in. That is why adaptability to forces, energy and load, ie durability, matters
When is an Achilles tendon pain or ankle restriction not primarily an Achilles tendon problem or ankle mobility problem?
About 80% of ankle mobility problems are associated with hip and knee mobility problems.
Let me simplify it. I treat your hip, often the thigh, and the ankle mobility problem goes away. Similarly the achilles pain.
This ain't a joke. It's common within about 80% of cases.
Let me explain. When undergoing an assessment, I use the SFMA. It includes 7 fundamental movement patterns, assessed against criteria (Glaws, K. R., et al., 2014)
Within the SFMA is an assessment of lower limb triple flexion, the half-kneeling dorsiflexion test.
The half-kneeling dorsiflexion test should demonstrate 40-45 degrees of dorsiflexion, or 4 inches (10cm) in tibial tuberosity progressing in front of the toe. The half kneeling dorsiflexion test requires triple flexion (ankle, knee and hip). A person who doesn't get the requisite/minimum 40 degrees in tibia angle doesn't necessarily have an ankle mobility restriction - they have a pattern restriction as measured at tibia angle - the actual restriction could be anywhere in the kinetic chain that impacts triple flexion.
If you did a standing dorsiflexion test, you don't involve the hip and knee to the extent you do in a half kneeling test and you can miss the impact these have at the ankle. As an example, recently a client saw me with bilateral achilles pain. The pain was reproduced in walking on tip toes. The client had 35 degrees tibial angle in the half kneeling dorsiflexion test bilaterally, and a positive Modified Thomas Test for anterior lower chain extensibility dysfunction. I treated her anterior thigh for about 6-7 minutes, then retested her walking on her tip toes - she had next-to-nil achilles tendon pain. Her half kneeling tibial angle increased to 41 degrees. How many people would have put her on an eccentric calf program for her achilles tendon problem, or mobilised her ankle or treated her tight calf?
On this occasion, the SFMA revealed a lower anterior thigh tissue extensibility dysfunction. Treating that changed the ability to flex across the hip and knee which permitted further excursion of the knee over the weightbearing ankle in half-kneeling - the result was an increased angle of inclination of the tibia. The significant reduction of achilles tendon pain is not surprising - indeed this is a very common finding.
The Modified Thomas Test indicated a restriction of tissue extensibility when the hip is extended and knee flexed. Another very common finding is a loss of hip flexion. Treating hip flexion mobility restrictions by joint mobilisation, or hip tissue extensibility treatment, has also commonly seen ankle dorsiflexion increase and achilles tendon pain reduce or abolish.
Rather than say, "give it a try", I'd say, use a systematic assessment to reveal dysfunction - address that and recognise the effect it has on patterns of movement that include parts you'd normally just go straight to. Going straight to a part to treat minimises the likelihood that you'll capture contributing, complicating or causative patterns or other body parts. Missing contributing or complicating factors leaves risk factors for recurrence on the table.
Not able to get to a live SFMA Level 1, but want to get started?The SFMA Level 1 Online Prerequisite Course is your first step.
The next live SFMA Level 1 course I'm presenting at is on the Sunshine Coast in Queensland, Australia, May 27th and 28th.
Glaws, K. R., Juneau, C. M., Becker, L. C., Di Stasi, S. L., & Hewett, T. E. (2014). Intra- and inter-rater reliability of the selective functional movement assessment (sfma). Int J Sports Phys Ther, 9(2), 195-207.
Last week during a lecture on integrating functional exercise into program design, I declared that every exercise is both functional and non-functional for everyone, until two things happen:
How I define functional will be included in an upcoming article.
How we evaluate a person and their "function" is to use reliable, discriminately valid, sensitive to change, modifiable and easy to administer processes. You know what that is.
Watch this space.
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