Overpronation is one of the most frequently used terms I hear in fitness. This is from both trainers and clients. The plethora of pronation control shoes has plucked the word from the world of anatomy and physiology and biomechanics into everyday terminology.

Although the word is widely used it is not widely understood. Overpronation can happen in many ways and for multiple reasons but is generally used as a generic term and no more attention is paid to it.

Lets first define pronation. It is the triplane action of dorsiflexion, eversion and abduction at the rearfoot.  These joint motions are relative to the bone motion of the talus which is the primary moving bone in a closed chain scenario. This rearfoot motion will also create relative forefoot dorsiflexion, inversion and abduction. The forefoot can have quite an impact on rearfoot pronation that we will talk about later in the blog!

Now lets look at the different ways in which we can overpronate.

1. Range-I think this is the "classic" definition of overpronation. The amount of distance that the joint goes through. Obviously far too much range places stress on the joint and muscles all through the kinetic chain of the lower limb. The associated tissues have to work hard to control the excess range. Common problems that can arise are posterior tibialis syndromes, Achilles problems and ITB problems.

2. Rate-Along with range goes the rate or speed/acceleration of pronation. The larger the range, the more distance to accelerate into. This again causes problems for the muscles/tissues that have to decelerate this increased acceleration.

3.Sequence-This is the most overlooked element of overpronation. Pronation should occur at initial heel strike and be followed by supination. If the range and rate are excessive then the foot is unable to reverse the motion in time to go into supination. This means that someone may pronate through midstance and also through the propulsive phase of gait. If any of the motions associated with supination are restricted it may also lead to a return to pronation late in the gait sequence.This can also be because of the instability created by the pathomechanics of different foot types. This can lead to plantar fascia problems and HAV bunions as the foot remains in its unlocked mobile state rather than becoming the rigid propulsive unit that the supination process creates.

The question most often overlooked when it comes to pronation problems is WHY??           A good knowledge of foot dysfunction is required to really answer this question. The most overlooked area in my opinion that causes pronation problems is ontogenic (developmental) forefoot positioning relative to the rearfoot. However I am also really interested in the spatial location of the STJ (subtalar joint) axis. The medial  deviation of the STJ will increase the moment arm of GRF (ground reaction forces) associated with pronation and decrease the moment arm of the supinatory muscles. It will also increase the area of the foot laterally to the STJ that  cause pronation to happen when force is applied. The lateral deviation will do the opposite with more internal muscular supinatory force and decreased GRF pronatory force occurring and increased medial area of the foot that will cause supination.

Anyway, back to the forefoot!! An inverted or varused forefoot position will be compensated for at the rearfoot by excess pronation. Another scenario is that the foot is able to get into supination but the extra instability of the varused forefoot causes a pronation response to get the forefoot on the ground and create stability. This would happen late and out of sequence in the gait cycle. This means that just controlling the longitudinal arch as many pronation control shoes do, does not gain quite the control anticipated.

Many times I also see short or half foot orthotics. These orthoses have arch control but do not provide stability at the forefoot. This is done by bringing the ground up to the foot, to stop the foot trying to search out the ground. Without the forefoot control I see the foot unable to pronate to compensate because of the arch control, instead using the transverse plane to rotate the foot and tip onto the forefoot. This maybe a reason behind a medial heel whip!! A similar thing can happen when the STJ axis height is high and favours transverse plane motion over frontal. The STJ axis height should be around 42 degrees from the transverse plane, slightly favouring frontal plane motion.

I realise this a bit of a big post, but is also a really big subject. Much more complicated than many give it credit for, so thanks for reading. Until next time....

Ben Cormack

This blog post is all about the foundations that we build our treatment or training on. First however I want to take this opportunity to tell you all about the new educational company Cor-Kinetic that I have set up. After delivering some weekend courses I thought that I wanted to make it a little more formal and this is the result. I will keep you updated through the blog and also for your functional fix check out the facebook page.

http://www.facebook.com/#!/pages/Cor-Kinetic/213918865295605.

Right, lets talk about foundations. Foundations form the basis of how we go about doing what we do. For me they are a checklist to make sure what I am about to do is right for the job in front of me. It is not what I did to the person before, it is not what I saw someone else do and liked the look of. It is the right and applicable thing to do based on the foundations of what I have learned and applied many times to refine the technique I am about to use.

I always make sure I understand fully the reasoning behind what I am doing. In fact many times I have steered away from doing things till I feel I have the proper knowledge to apply them. It may mean reading additional information or learning new terminology, but I feel that this leads to a more rounded approach in the end, even if it takes more time. In fact it has led to lots of frustration until the penny clicks, but when it does it becomes a more powerful tool in the box.

We have become a very technique based industry but without the underpinning knowledge or foundation are we less effective with these techniques?? Some times we need the basics before the fireworks. No learning of knowledge is a waste even if you can't apply straight away, but it may serve you well in the future you just may not know when!!!

Also when we do learn new stuff are we suddenly a master? Or do we need to refine the process?? Did the person who taught us dream it up or did they teach from years of experience, mistakes and eventually refinement into something tangible to pass on. This practice forms part of our foundations. If we just learn from picking up what others do it becomes monkey see monkey do, almost a game of Chinese whispers with a barely recognisable outcome to the original concept.

Make sure you have your foundations in place!!!

Ben

 

As the oft quoted saying goes "if your not assessing your guessing". Well today's blog post is all about assumption.

In the fitness industry we are often guilty of assuming that one type of dysfunction will lead to another or create a certain posture type. While I definitely believe there are trends and patterns to peoples movement and movement dysfunctions, when we start to believe they are truths is when we start to let our clients and patients down.

I often read claims from people that they can tell amazing things just from looking at one part of the body. One thing I have learned about the body in my years of dealing with it is that the body has more ways than anyone can imagine to compensate for dysfunction. I always take the time to back my assumption up with rigorous testing that lets me know exactly what is going on in each segment of the body. Someone I respect very much makes a vast number of assumptions but makes it his job to prove them right. And guess what, he does it through rigorous testing! If proved wrong then on to the next assumption but he would never leave it at the assumption stage with out proving it as fact.

Another classic is when we pin the blame on a muscle when hearing of a chronic injury. "Its the hamstrings" is a favourite of mine or a joint motion "dorsi flexion" being another favourite. I have often thought to myself certain things about why someone may have a problem when hearing about their exercise history and I have been proved many times to be right but also wrong.I have done this through assessment.

The biggest tool any one dealing with sports injury can have in their tool box is a solid function based assessment process. This is a foundation to use all of our techniques from. If we are going to treat tissue are we being symptomatic?? So many times injury site is far removed from the source. In fact I will be as bold as to say that often the more better functioning joint in the chain is the one taking the hit. Chronic problems tend to be chronic because we take a symptom only approach to treating. That's easy, point to where it hurts!! The hard part is having the assessment tools to truly find out why the tissue is in pain. Usually we need to look above and below the joint in question and many times it can be problems with both ends creating pain. The only way will know is to test and not ASSUME!!!

I was reading an article recently about celebrity personal trainers. There seemed to be within the article a real obsession with what the trainers charged and who they trained rather than actually what they did or had learned or achieved.

The article left me with the feeling that they felt the more you charged the better you were at your job. In my experience in the fitness industry this simply is not true. Does this give the message to up and coming trainers that it is more about who you train or charge than what you actually do??!! For an industry with such little regulation this is a poor place to be in terms of quality control. If someone is willing to pay an outlandish fee for an hour of someones time then that is between the two people making the transaction. However let us not fall into the trap of believing that the fee or person makes someone better at what they do. A great job with a super model is no better than a great job with a housewife, let us make no mistake. You are not who you train by proxy. If you want to be a celebrity do it through what you do and say, not who you do or charge.

By default generally the more you charge the less people you will see. Although there will always be exceptions to every rule!! As the amount goes up the smaller the pool of people able to afford your charge. This means that only the very experienced, educated and with a long track record of success should charge the most. Why I hear you ask?? Well if you are seeing less people then you are able to gain less experience and also practice your skill set less. This is where success is built, the hard yards of practicing and refining your craft to get to a level where you can justify your increased cost. We cannot expect to walk straight out of a training course and have a skill set that is worthy of an inflated arbitrary figure. It is the application of knowledge over time to a wide variety of different people that allows people to be able to have those "go to" moments that differentiates them from the crowd and justifies the higher charge.

Ask yourself the question am I worthy of what I charge. It may be that you are undervaluing yourself, but if you are gaining valuable experience to add up to the 10,000 hours of experience that is talked about as being a measure of an expert then almost you are being payed for your education.

If you don't have the level of experience or education and hence skill set and are charging more than those that do, you have to ask yourself why!!?? If it is to be the best then this is clearly not true. If it is to earn more, then money and status is more important than your craft, which is fine if we hold our hands up and state this loud and proud.

The old Stella Artois advert that stated "reassuringly expensive" does certainly not ring true for me in the fitness industry!!

I have read so much recently about barefoot training/running and the amazing ability of the foot. While a lot of what I read tends to have many elements of scientific truth to them I don't think the people writing them always have an understanding of the foots effect on the system as a whole.

Barefoot training seems to be heralded as a "one size fits all" fix to whatever problems people have. Suddenly shoes have become the pariah of human function. Understanding the function of an area of the body is important however we seem to do this only in an "ideal" sense. If A + B = C, then everything would be fine, we could take our shoes off and never have any problems ever again. If we look back however at every other amazing resolution that has been thrown at us over the last 10 years and take stock, we still have people with the same problems seeking help.

Maybe a key to this is understanding dysfunction. Only by having knowledge of the many things that can affect the foot to disrupt its success can we truly find an answer. Lets look at an example. On a localised level the foot will create an environment that makes it successful. This however may not be successful for the system as a whole. A Varus deformity of the forefoot will 99% of the time cause the foot arch to collapse, if it is able to compensate then the forefoot will stop the body having a top down influence on the foot (which will also cause a bottom up inhibition!). This creates a success of stability at the forefoot but will reduce motion elsewhere in the functional chain. Now the question is will taking my shoes off help this??

The are a few points to the answer of this question (which I am not totally sure I have the answer to!!). Firstly a shoe might limit the range the STJ goes through to get the Forefoot to the floor improving joint start position, motion and systemic influence. Much has been made of the cushioning affect of footwear on proprioception.  While this maybe true, in the example of the Forefoot Varus however, a reduction of force maybe advantageous to a system that cannot attenuate force through muscular deceleration because of joint position or osseous restriction. This can lead to shin splints, stress fractures and forces being absorbed by structures further up the functional chain. A point going one step beyond would relate to more sophisticated interventions such as orthosis. Now by creating tailored stability to enhance the success of the system we will improve the environment around the foot that barefoot training cannot do. This is because the dysfunction of the foot will not allow it. If I could simply tell people to run and train barefoot and all these problems would go away then believe me I would!!! We need to go back to the principle of individuality that tells us that no one thing will work for all. Only by individual assessment and also understanding of why and how things go wrong can we find the appropriate cure.

This brings me on to my favourite quote by Betrand Russel:

"The trouble with the world is that the stupid are cocksure and the intelligent are full of doubt"

Now I would not regard anybody as stupid in the context of the topic of this blog but sometimes those that lack an understanding of dysfunction can tend to make bold or "cocksure" statements regarding "cure all" methods of training!

This brings me on to my second topic in this rambling blog. This relates to a conversation I had recently with a very intelligent Osteopathic friend of mine. We were talking about dysfunctions in the system and the use of interventions such as orthosis. He did not seem convinced about the need for such things. I do certainly agree that the body has the ability to "heal" itself to some degree. However my belief is that when we factor in scenarios such as short legs (a favourite topic of mine) that the body in certain cases (generally people with problems) cannot overcome them. Factor in changes in training e.g. running a marathon, and this tends to become to much for the system to deal with leading to pain. Now the demand on the tissue has become to great and keep up with change in function we need to create a better environment for the body or cease the increase in activity.

I suppose the real question is can we as practitioners create a systemic change that is able to cope with the structural deformities presented to us through manipulation and exercise. Of course the answer maybe yes in some examples, then the question would be how long would that take and what level of activity could they continue to do. Many times I believe the answer is no, foot deformities being a good example, the localised problem can cause to big an influence on the chain reaction of the system that cannot be "compensated" for anymore or allow us to increase demand such as training on the system. We cannot change bony orientation or length and the muscles and connective tissue cannot cope with the demand any longer, this is why we have many cases that are chronic (for years even) until we can find the problem in the system that is causing various chronic problems. Many time the only way to solve these structural problems is to add in a structural intervention!!!!

I am sure this will be controversial but I believe good debate is something we can all learn from if we are less "cocksure" at the risk of sounding cocksure of course!!!

Ben

A fair while since my last blog post but I have been so busy it has fallen a little by the wayside!! A couple of recent highlights have been training one of my Pro boxers Phil Gill for his 11th pro fight on the 30th of April and Olympia, and also a great day with a bunch of Osteopaths going through the functional assessment process down in Brighton. I am also really looking forward to the upcoming functional assessment course in London on the 16/17th of April which has had a great response but require lots of prep!

The topic of this blog post is about a client I have been seeing recently who had lower back pain. When I assessed him I discovered a minor short leg (2-3mm) but was so small and short leg assessments so unreliable in terms of actual measurement that I payed less attention to it than I normally would a short leg. Short legs can be hugely destructive on the system and create a myriad of compensatory patterns.

The upshot was we created much better motion in the sessions but this reduced when he went off and did stuff on his own. Something else in the system was shutting it down. Very frustrating for me, but I think I may now know the reason why!

A usual compensation pattern that I see in the feet is that the long leg pronates to become shorter and short leg stays inverted or supinated to remain longer. With this individual however the long leg also had a large uncompensated Rearfoot Varus. This means that it cannot pronate and takes away this compensation mechanism and actually makes the short leg shorter in comparison (or the long leg longer!!) and therefore more significant and destructive on the system. The uncompensated rearfoot varus will create a lack of shock absorption in the chain and the inability to compensate for the short leg will create an obliquity in the system which can also cause it to shut down motion in favour of stability.

I have addressed this temporarily with a small heel riser, although a full length lift is always better because we do not create so much plantar flexion and shorten the calf. Watch this space for an update on the progress of this interesting case.

This definitely shows that when more than one structural deformity presents itself then things do not follow a set pattern. We must always remember the principle of individuality when helping our clients. A + B does not = C!!! We cannot simply have solutions without a thorough assessment process that takes many things into account.

This is something I will be teaching the guys on the upcoming functional assessment course!!!

 

 

Today's blog has come about from a conversation I had with a friend of mine who is running the marathon. Like many runners when they get beyond then 10 mile mark he has been struck down by IT band pain.

After consulting the physio he was given some classic stretches for this. General hip ADuction off weight bearing etc. This got me thinking about the predominant view of muscle function and how if we length or strengthen a muscle then it will do this by default.

First of all the ITB and muscles that attach to it maybe individually fine, but when they interact with the foot in a functional position such as stride stance this may change.

A flat or high arched foot may cause excessive lengthening or a lack of lengthening of the IT band and associated muscles. However much we lengthen or strengthen these muscles in isolation, when placed in a functional chain they will be limited or affected by other sections of the chain e.g. the foot. This means that in isolation and decompressed from gravity these muscles will appreciate the stretch but this may make little difference to their ability when back in a functional position during such as during running.

Many times I have treated people who have foam rolled and performed all manner of stretches in an isolated way but to no avail. Once we have found a cause rather than a symptom they have become much better.

The real point here is just because we spend time lengthening or shortening a muscle it may not choose or be able to use the motion or strength we have given it in a functional scenario. It maybe that another part of the system will not allow it to or the muscle or group of muscles have to perform another role because another part of the body has not done its job.

Another example of this would be kyphosis. People send hours retracting the scapulae to 'strengthen' the muscles of the upper back but their postures never change. This maybe because something further down the chain such as the hips and ankles are not able to effectively flex and attenuate the ground reaction and gravitational forces. This means the upper back will have to lengthen to decelerate the spine flexing forward so that the neck and head can remain in a relative upright position. In this scenario would these muscles choose to lengthen and decelerate motion to create relative upper thoracic and cervical extension or, shorten and force the superior distal segments at the cervical to lengthen disrupting head/eye function. I believe the latter regardless of the 'strength' we have given them. One thing we cannot 'beat' or get away from is gravity and ground reaction (unless you have a spaceship of course!!!)

This maybe a reason why people with limited thoracic motion get an anterior head position. The inability of the spine to relatively extend means the neck muscles have to decelerate the forces and end up at lengthened and at end range.

Just some thought out loud really!!!!

Ben

I had an interesting debate today with two guys I really respect for their knowledge and passion about the body and fitness. It centered around what we would describe as "shin splints". One opinion was shin splints were more on the medial border of the tibia while the other opinion was more central shin pain in the anterior tibialis.

I think the key to shin splints muscle pain can be mid tarsal joint. The anterior tib inserts onto the medial cuneiform and first ray, much like the peroneus longus which runs down the lateral malleolus rather than the medial molleolus that the anterior tib inhabits. When the fore foot smashes into the ground it will invert and lengthen these muscles. If the supination process does not happen effectively the forefoot will not evert and lock up and these muscles will stay loaded throughout the propulsion phase leading to pain. This would be a similar scenario to why plantar fascia pain can occur.

One thing to check is the big toe. By lifting the toe up when weight bearing we can check to see if the arch will rise giving an indication of if the foot will become a rigid structure ready for propulsion. A manual inversion of the rear foot and eversion of the forefoot will also give an indication of the foots ability to lock up for propulsion.

Foot type and the individual flexibility in the foot can affect the propulsion process. If we had a valgus forefoot for example, as the forefoot hits the ground it will be unstable due to the lateral border being unsupported by the ground. An approach by the foot maybe to supinate early during midstance, however the foot will then be unstable on the lateral border leading to a pronatory compensation from the STJ at toe off or propulsion. This disruption in the foot sequence leads to an unlocked foot meaning an added lengthening load to the anterior tib and subsequent shin pain. An osseous restriction of the forefoot such as a valgus will also affect big toe function reducing the dorsi flexion of the first ray and the locking up of the foot.

Another topic of conversation was transverse plane motion at the STJ during the front foot phase of gait (I know, what geeks right!!!). Some people describe motion at the calcaneus as adduction. My opinion is however that most motion in the transverse and sagittal plane is blocked by the ground and therefore the plantar flexion and adduction of the talus will create relative abduction and dorsi flexion at the joint. This would be a case of the proximal segment moving faster than distal!! This talar motion now means the navicular portion of the talonavicular or mid tarsal joint will be abducting!! What fun we had!! Really a pointless piece of knowledge but a good reasoning process.

I have had a great response to my AFS/functional assessment process weekend in April so places are limited. Email me at bencormackpt@hotmail.co.uk if you are interested. We will be looking at how to understand the assessment process better and applying knowledge as discussed in these blogs. After the success of the sports specific course in January I am planning another one in June. Please let me know if you are interested!!

Have fun.

Ben

I am no golfer but understand a bit about the biomechanics. I have been involved with a golfer recently trying to improve his swing. Obviously when we look at the swing we see two ends or transformational zones (TZ) for those who have GIFTed or seen a video digest. The third zone or ball strike could be called the performance zone.

Now, many times we look at the load and strike of the ball and don't pay much attention to the other end or deceleration of the swing. This for me maybe the most important part. With this golfer the load was perfect but the ball strike not. The question to be asked is does the second TZ affect the performance zone. For me the answer would be a resounding yes!!! If the body does not feel it can decelerate the motion then this will affect the down swing right from the top of the backswing. It has to work out a way to decelerate the motion and this will change the swing dynamics and result in inconsistent and erratic shots.

This was certainly happening in this case. The gentleman in questions left hip did not like to internally rotate. The huge rotation of the left foot gave that away when swinging!!! The internal rotation demand on the left hip is pretty large in the down swing especially with the larger clubs. Working on the follow through has produced pretty amazing results in this case. Little time has been spent looking at the loading on the backswing apart from working on the left calcaneal eversion. This probably has an impact on his left hip in gait as well as golf which showed up pretty quick in testing.  Pretty happy with this one!!!!!

I also saw a lady this week who had had her ankle put back together with medical meccano after an accident. Sometimes AFS can give us accelerated results, other times we have to settle in the for he long haul. I think this is one of the latter scenarios.

Her Dorsi flexion was hugely limited and it is hard to know what can be got out of it with the mechanical restrictions. The dorsi flexion was worse when coupled with inversion and limiting hip extension, creating a little limp onto the right leg. She was also suffering from some left shoulder pain. Her spinal motion was limited into left rotation so it maybe the hip also has some capsular problems both anterior and posterior ligaments affecting the front foot TZ in gait when the T spine is left rotating.

I used the BAPS for driving inversion through the external rotation of the leg in a load bearing single leg stance and it really seemed to help. The mechanical energy always seems to get stuff going!!

Watch this space for info on the progress.

Catch you soon!! Ben

Its been a little longer than I would have liked since my last post. I have been flat-out however!! I ran my first course last weekend and had a great turn out of over 20 including 8 GIFT fellows both past and current!!

Always great to be around passionate and intelligent people who were there to learn and not just to make themselves look cleverer than everybody else. I myself selfishly probably learned the most from those guys and I was the one taking the course!!! Hopefully I imparted some of my experiences on those guys too. The mark of a good teacher not being how much you know but how much of your knowledge your students know.

I think I may run the next one on the assessment process and strategies. The feedback was that this could be a popular and useful course for the AFS community. Let me know if you are interested!

It's great to have started off the year so well. A wonderful course. An audio symposium upcoming on PTonthenNET and being asked to talk at some international conferences. All exciting stuff but pretty tiring organising it all and having lots of clients to deal with.

An update on my last post: My client Paul was displaying some right foot problems and also definite capsular tightness on the right hip. My strategy for the foot was although it was pretty flat I wanted to see if I could get some load and explode out of it through FMR before I decided to go down and orthosis route.

Although it was at endish range I think sometimes the talus can get stuck in a position and needs to move to drive proprioceptive info in the system. This really needs to be hands on I find motion does not tend to free them as effectively (although follow up with motion)

Although in this scenario success in eversion maybe driving the dysfunction, a small load to explode strategy can create some positive reactions in supinating the foot. I created a load on and off weight bearing and also unload mechanics to the foot tissue. This had a positive impact instantly and also seemed to have some carryover to the next time I saw Paul.

I hit the hip capsule in a non weight bearing positions to minimise the elastic mechanisms of the hip muscles. Then created 3d motion and finally got some movement going to create strength and stability. It all worked pretty well and Paul's stiff spinal motion was noticeably altered by a change in hip motion. I finished by driving hands on FMR of type 2 spinal motion to the right that Paul noticeably lacked and also a little upper cervical type one with left rotation where Paul was also limited and again gave some lightly loaded motion after.

I find that when presented with an excessive arm swing during gait analysis sometimes driving spinal and scapula motion (both hands on and off) is not enough. A little cervical driver possibly at the same time really creates proprioceptively authentic information to the scapula and can have some great results. The neck can really lock down when presented with a spine fixed in a position and can need a little help to free up!!
Paul was a little surprised at how quickly he could notice a significant difference after seeking more traditional help previously. This is the power of AFS people!!!

Until next time.

Ben C