Friday, 25 March 2016

Performance Series: 'A'- Frame skiers: Part 1

You are most likely to have come across the term 'A'-frame if you have done a BASI or high performance course.  However, awareness of and ability to correct an A-frame position can have a positive effect on ski performance and help to decrease injury risk. 'A'-frame skiing is a fairly large topic, so I am going to divide it up over the next two weeks. In this weeks blog, I am going to talk about why the 'A'-frame position may occur and next week I will be talking about training methods to help improve this.

An 'A'-frame skier is 'knock kneed'.  They typically have their ankles further apart than their knees, as shown in the first picture below, rather than 'well-stacked' in parallel lines as the second picture shows.

              
               'A'-Frame position

Parallel
 
In medical terms, we call this a valgus knee position (or more specifically Genu Valgum).  A person may be affected on one or both sides.  

In skiing, this position can make it very difficult to stand on the outside edge of the ski, it may cause the skis to diverge and the turn may feel jerkier and less controlled as a result.  It can also make turns in powder a challenge.

From a medical point of view, an 'A'-frame position can increase the strain through the inside of the knee joint, compressing the medial meniscus (inner knee cartilage) and increasing the strain and forces through the soft tissue.  Although there is no scientific evidence for it, some suggest that this position can increase the risk of early onset knee arthritis.

Below, I have discussed some of the reasons that an 'A'-frame posture may occur.

Postural and position awareness

Firstly, simply being aware of this position and aware of how you train off the hill may be a key element in correcting an 'A'-frame posture.  Many people are not aware of having a valgus knee position and why should you be unless you have had a knee problem, a personal trainer or are being treated by a physiotherapist?

If you have been told that you are an 'A-frame skier or if you would like to work out if you may suffer from valgus knees, the first thing to do is perform a double or single leg squat in front of a mirror. Repeat this a few times.  Are your knee caps well aligned over your 2nd and 3rd toes as you repeat this movement?  Do you knees drop inwards?  If so, can you correct this simply through awareness and the feedback of watching yourself in the mirror?

In the pictures below, a single leg squat is being practiced. In the first picture the knee is dropping inwards, however in the second picture this has been corrected.  If you are able to correct this position simply through being aware of where a well aligned position is, repeating this movement in front of a mirror on a regular basis over a 6 - 8 week period often helps to improve the position.   You will develop improved proprioceptive (bodily) awareness and improved motor patterns which should carry over when you put your skis on.
                    
   

Weak hip abductors and external rotators (muscles which turn your hip out and away from the body)

During assessments of 'A'-frame skiers, one of our main findings is a weakness in the hip abductors and external rotators.  The gluteus medius muscle in the side of the hip is often a major culprit.  As you can see in the diagram below, a weak gluteus medius can cause the pelvis to drop on the opposite side. When this happens, the knee is also forced inwards and will inevitably result in a 'A'-frame ski position.


If you are able to correct your valgus knee position when performing squats in front of a mirror, but with repetitions you are unable to sustain the correction, perhaps a weakness in the hip is the cause.

There is a lot of evidence to suggest that weakness in the hip area can be a large cause of knee pain.  In fact, there are many physiotherapists that only treat the hip when treating patella femoral conditions.  I will talk more about this in the future.

Tight Adductor muscles

Your adductors are the muscles on the insides of your thigh and run from your pelvis down to your knee.  When they are tight, they can pull the femur (thigh bone) in and across your body, thus accentuating the 'knock kneed' position.  Tight adductors are often coupled with weak abductors. 

Tight ITB (iliotibial band)

If you have a weak gluteus medius muscle, this will often be coupled with a tight ITB which is likely to overwork to compensate for the weakness in the hip.

The ITB is a thick band of fasica that runs down the outside of the thigh.  One of its roles is to help stabilise the knee and therefore it is commonly tight in runners, cyclists and skiers from overuse. The ITB is made of thick connective tissue and has a relatively poor blood supply which means that is does not easily stretch.  When it is tight it can pull the thigh inwards and therefore cause skiers to be 'A'-frame.

One of the best ways to improve this fasical band is through foam rolling, however I will be talking more about this in next weeks blog.

Foot over-pronation

If you are a runner or advanced skier, you may well be aware of your foot position. Although the research is mixed as to whether an overpronated foot position may increase injury risk, we do know that it contributes to a valgus knee position. If your foot rolls in, so does your knee.

Figuring out why the overpronation is occurring is key to applying the correct treatment. Often, a progressive program to correct muscle imbalances in the lower limbs is sufficient, other times orthotics or foot beds are necessary.

Hip Joint

Occasionally, an 'A'-frame skier may not be able to correct their position because the cause is inherent within the ball and socket joint of the hip.  Femoral anteverison describes the inward rotation of the hip and this torsion is usually due to someones genetic skeletal make up and is unlikely to respond to treatment.  A physiotherapist should be able to gauge if this may be the cause, although an x-ray is the most accurate way of determining femoral anteversion but would only be required in extreme cases.  Newborn babies are routinely scanned for skeletal hip problems at birth, therefore people are often aware when they have a severe case.  

Osteoarthritis and Rheumatoid arthritis of the Knee Joint

Arthritic conditions can cause the inner aspects of the knee to wear down, which then has an overall affect on alignment and result in valgus knees.  This may be improved by specific exercises or the use of wedges to help the force distribution through the knee joints.  In extreme cases, surgery may be required, but this is usually more of a concern later in life.

Next week, my blog will go into more detail on off the hill exercises to help 'A'- frame skiers improve. Hopefully this will be of interest for not only skiers struggling to correct their position, but also to instructors and coaches who may be looking for ways to improve their clients performance and despite implementing some great drills, just aren't making progress.

Disclaimer:
We do not recommend that you introduce these exercises without consulting a physiotherapist if you have any current injuries or back issues. We do recommend seeking advise from a healthcare or fitness professional when starting new exercises.  
The purpose of this blog, is to provide general information and educational material relating to physiotherapy and injury management. Bonne Santé physiotherapy has made every effort to provide you with correct, up-to-date information.  In using this blog, you agree that information is provided 'as is, as available', without warranty and that you use the information at your own risk.  We recommend that you seek advise from a fitness or healthcare professional if you require further advice relating to exercise or medical issues. 
LSA
       Bonne Santé          info@bonnesantephysio.com         0033 (0) 4 79 06 07 27

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Thursday, 17 March 2016

Performance Series: Tips to help rotational separation

What is rotational separation?  Generally it describes the movement of the lower limbs rotating independently of the body.  The shoulders are facing the direction that your centre of mass wants to go while the legs turn beneath. The torso may stay fairly ‘quiet’ or it may have a role depending on the snow and terrain. A good core is necessary to provide a stable base from which to pivot below. Rotational separation is necessary for good ski technique, both in combination with lateral separation during piste performance and in the bumps, for short radius turns and when skiing off piste. The movement requires blending pressure and rotation through the skis and it enables us to balance on the outside ski and to exit a turn smoothly.

So, lets take into account the various physical components that you need to achieve rotational separation.  Firstly, you need good mobility and flexibility in your hips and good flexibility in your waist, specifically through your obliques (the muscles in the side of your waist).  You also need good length through your iliotibial band which runs down the outside of your thigh.  If we look at this in terms of our fascial system, as we did with lateral separation, rotational separation majorly involves the spiral line.  


www.anatomytrains.com


We do use rotational movements a lot in day to day life, such as when picking some thing off the ground to our side, looking over our shoulder or passing objects across our body. However, most rotational movement on a day to day basis occurs throughout our whole body, rather than separating at the waist, or the movement occurs from our torso, which isn't necessarily what we aim to achieve with rotational separation in skiing.  

As well as flexibility and mobility, for optimal rotational separation you also need good balance, coordination and good core stability so that your legs can move underneath a stable platform.  Often, people find the act of moving their lower limbs in isolation of their torso quite challenging.  We recommend initially starting with some basic exercises to help dissociate your hips and pelvis. By re-creating the movement patterns off the hill, you will help create neural pathways and remember movement patterns to transfer to your skiing. These simple mobility exercises can help. 

Start simply with knee rolling.  Lie on your back and roll your knees from side to side as below: 

If you wish to increase the range of movement and the stretch through the spiral line, progress into a spinal twist by rotating your upper body in the opposite direction to your legs, as below. 

                              

If you wish to progress to higher level flexibility work for your hips, try a 'z' sit.  This is a fairly high level stretch for your hip joints.  Do not perform this movement if it gives you any pain.

Start by sitting on a small block or cushion.

 


Then roll your legs one way into a 'Z' position and hold for 5 - 10 seconds. Then repeat on the other side. You can follow your legs with your shoulders as per the first picture, or to increase the stretch rotate your shoulders in the opposite direction (see picture below).  


Once you have the mobility and flexibility exercises finely tuned, you can increase your focus on core stability and balance exercises.  

Have a go at a single leg stand with a rotating knee lift, as below.  Your pelvis should stay facing forwards, whilst your knee lifts and your twist from the hip.  This challenges your balance, engages your core to stop your pelvis rotating and helps with hip and pelvis dissociation.  


When this becomes easy, you can introduce some theraband resistance to further challenge your balance, core and increase your gluteal muscle activity.  Again, ensure that your pelvis stays facing forwards and does not twist or sway through the movement.  We hope you all find that this exercise makes you as happy as it makes Andreas!


To increase the focus on your core, you can introduce some pilates based exercises.  A strong core is essential in rotational separation and it plays a large role in helping to provide a stable base through your pelvis. 

Lie on your back in a neutral position and lift your legs into the table top position demonstrated below.  Take care not to over arch your back.  We usually advise having supervision from a physiotherapist or pilates instructor to learn this movement. 

Once you have a strong table top position, you can progress into knee turn outs.  Keep one leg fixed in table top and allow the other leg to turn out from the hip.  Make sure your pelvis stays fixed and does not lift or rotate on the opposite side.  Only allow the moving leg to turn out as far as the pelvis will allow without tilting.  Then return that leg to midline and repeat on the other side.  

Table top
knee turn outs

A higher level progression of this exercise is to start in table top then allow both legs to rotate to one side.  Start with you knees bent and progress to your legs straight.  Do not attempt this if you have any back problems.  Again, ensure that your pelvis is fixed and the movement is coming from the hips and below.  

           




Another great exercise to develop your core and agility is hanging twists.  I have not yet managed to get a photo of this exercises but I will aim to post one to facebook over the next few days. 

Find somewhere to hang, such as a climbing frame, monkey bars or a pull up bar.  Bring your knees to your chest but as you do this twist them side to side.  Keep your upper body as still as possible.  This is a fairly high level exercise and it will work your core and lower abdominals hard.  

The above exercises are great ways of building together the components that you need for the physical movement of rotational separation.  However, we like to progress to movement specific tasks so lets look at some more functional exercises. 

The first exercise we'd like to introduce is twisting squats in doorway.  Find a floor that is tiled, laminate or a shiny surface.  Stand on a towel in a doorway.  Support yourself in the doorframe and keep your upper body facing forward through the doorway.  Then add in some rotational squats, as demonstrated in the pictures below.  Alternately twist your hips knees and feet from side to side whilst keeping your upper body still facing through the door frame.  Amongst other muscles, this will help train your quads for skiing and further enhance the dissociation between the upper and lower body.  


   

Multidirectional lunging is also a great functional movement to develop rotation.  Stepping in all directions and rotating through your upper body with the addition of holding a medicine ball out in front of you is a nice way to progress. 

Finally, you can also incorporate some plyometric training. This is specifically a good focus if you are training for bumps skiing.  Do not introduce plyometric work if you have any pre-exisiting injuries without seeking advice from a physiotherapist first.  Start with a series of tuck jumps.  Aim to bring your knees up to your chest and don't break at the waist (see picture below).  Aim for good height, symmetrical legs and a quiet, well absorbed landing. Once you have mastered this, progress to a rotating tuck.  Keep your upper body facing forwards and aim to rotate your hips, knees and feet towards to corner of each room. 
Repeat this in a rebound fashion.   










Everyone will have different needs in terms of the exercises above.  Some people may have excellent core stability but poor hip flexibility.  Others may struggle with the coordination of the movement to achieve rotational separation.  It is difficult to be specific about the frequency of exercise and numbers of repetitions, therefore please do contact us for further advise or for a biomechanical assessment for an individual programme. 

The drills above are just a few ideas of how you can incorporate rotational movements into your training. There are many more ways of doing this and everyone will have different requirements necessary to achieve the movement patterns for high performance skiing. When you are doing any off the hill training, always remember to ensure that you are warm and in a safe environment.  Also remember to make your training progressive so that you can continue to develop your skills, strength, power and stamina.

Disclaimer:
We do not recommend that you introduce these exercises without consulting a physiotherapist if you have any current injuries or back issues. We do recommend seeking advise from a healthcare or fitness professional when starting new exercises.  

The purpose of this blog, is to provide general information and educational material relating to physiotherapy and injury management. Bonne Santé physiotherapy has made every effort to provide you with correct, up-to-date information.  In using this blog, you agree that information is provided 'as is, as available', without warranty and that you use the information at your own risk.  We recommend that you seek advise from a fitness or healthcare professional if you require further advice relating to exercise or medical issues. 

LSA

       Bonne Santé          info@bonnesantephysio.com         0033 (0) 4 79 06 07 27


Please like us on Facebook to stay up to date with news and developments: Bonne Santé Physiotherapy 
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Friday, 4 March 2016

Performance Series: Drills to help lateral seperation

With the amount of snow that we are currently having, I'm not sure my performance series blog is best timed.  However, many things that I am going to discuss can be incorporated into training programmes to be of future benefit so here goes! 


Lateral separation works in a side to side plane of motion.  The BASI (British Association of Snowsports Intructors) manual discusses lateral separation as 'when some parts of the body tilt with the skis and others don't'. It states that 'sometimes we will actively seek to separate laterally and other times it is a natural reaction to the movements we are already making'.  It is a movement pattern required to optimise long turns on the piste with the aim of being balanced over the inside edge of the outside ski. This movement pattern is easily identified when watching Giant slalom and Super G racing. An angle is created through the body as the lower body moves towards the centre of the turn while the pelvis remains relatively stable. If you are unable to achieve lateral separation, you are likely to inclinate (tilt as a block) more, increasing the pressure on the inside ski, thus affecting your balance, pressure and the ability to influence the ski turn. 

If you are struggling to achieve lateral separation or if your coach has identified room for improvement it may well be down to technique. However, off hill analysis can help to identify any restrictions in the body which may be contributing and training can be focused to improve it.  Read on to find out more. 


Lateral separation is achieved through movement of the ankles, knees, hips and spine. The amount of movement made determines the turn shape.  The ankles are required to pronate and supinate (tilting onto the inside and outside of the soles).  The knees are required to flex and extend, whilst linking with the abduction (outwards) and adduction (inwards) motion of the hips.  A good amount of hip flexion is required and there will also be some degree of rotation through the ball and socket joint of the hips underneath a relatively stable pelvis.

Before I go into tips and drills to improve lateral separation, first we need to understand what is involved.  It's not often that we perform sideways movements in day to day life. Walking, running, stair climbing etc are all in a very linear plane, whereas skiing is asking our bodies to adapt to new demands in the lateral plane (amongst others). Some of the key elements that are needed for lateral separation include:
  • good flexibility
  • good range of movement in your hips
  • high levels of core stability
  • good agility
  • balance and righting reactions
  • good strength in your hip abductor muscles to prevent 'A'-framing
So lets start with flexibility.  When analysing the considerations here, I do not necessarily want to think of muscles as individual units, but as a whole fasical train or sling. Fasica is the biological fabric which holds us together (https://www.anatomytrains.com/fascia/), wrapping around our muscles, bones, organs and bodily structures. A fascial train is a sling of connective tissue that links individual muscles into functional complexes and is essential for coordinating stability and movement

In lateral separation, one of the main fascial trains we are concerned with is the lateral fascial train:

The lateral fasical train
                    
www.anatomytrains.com




To lengthen and to gauge the flexibility of your lateral fascial line, simply try a side bend (figure 1). Ideally, you should be able to reach your fingers below your knee crease on the side your are reaching down.  Reaching your arm over head increases the stretch (figure 2) and keeping your arm close to your ear enhances the movement further. 


Figure 1: Side Bend
Figure 2: Side bend with over head reach
During lateral separation, your lateral fasical sling lengthens and shortens as you move from turn to turn.  Within the lateral fascial line, your quadratus lumborum muscles are key players in lengthening and contracting.  Test your ability to perform this by reaching your arms over head, then reach over to one side (figure 3a & 3b).  Allow your hip to sway in the opposite direction as you do this.  Then return to the middle.  


Figure 3b
             
figure 3a
If this is easy, you can introduce a medicine ball overhead to start to load the muscle.  

figure 4 a
figure 4 b

Good flexibility is also required through your hip and gluteal muscles.  You can open your lateral hip by doing the stretch shown below (figure 5). 


Figure 5
Lateral lunges that vary in depth and tempo will help with hip mobility and lateral control (figure 6a, b & c)
                
Figure 6 a
Figure 6 b
Figure 6 c














Good balance and core control can be worked individually or in combination.  The picture below demonstrates lateral leg lifts whilst standing on a bosu ball (figure 7).  The addition of a 3 kg medicine ball greatly adds to the challenge and helps to engage your core.   


figure 7
To challenge your balance further, introduce more dynamic drills such as some side to side touches. Stand on one leg and touch the ground to one side (figure 8 a). Stand tall and then reach to the other side. Progress this by increasing the length of your reach out to the side (figure 8 b).  To challenge yourself further, stand on a unstable surface (such as a bosu ball or wobble cushion) as your perform the reaches or hold a light weight in your hands.   


figure 8 a

figure 8 b
General conditioning and agility drills for lateral movements can also include:
  • high lateral step ups
  • sideways shuttle runs
  • lateral box jumps
  • side to side hopping
I will write a future blog on 'A'-framing, because this is a whole new topic in itself, however having good hip stability and strength is a key factor here.  Ensure that when you are performing any squatting movements that your knee is centred over your middle toes.  Try and correct it if it drops in. If you are unable to correct it, you may need further analysis.

It is difficult to be specific about the number or sets and repetitions, frequency of exercise, weights and resistance, because every individual is different with different needs, however feel free to contact us for advise or book a biomechanical assessment for an individual program.  We had some great feedback following an assessment from a level 3 trainee ski instructor recently:

'Verdict on the knee is startling improvement, hardly noticeable now to others.  All trainers are most impressed with the change and asking what stretches I am doing.  Re: long turns, again stretching before enabled me to engage edge and carve with a noticeable improvement.  It was noted by my ski instructor that my skiing style is changing daily in line with physio and much progress is being made'.

The drills above are just a few ideas of how you can incorporate lateral movements into your training. There are many more ways of doing this and everyone will have different requirements necessary to achieve the movement patterns for high performance skiing.  When you are doing any off the hill training, always remember to ensure that you are warm and in a safe environment.  Also remember to make your training progressive so that you can continue to develop your skills, strength, power and stamina.

Disclaimer:
We do not recommend that you introduce these exercises without consulting a physiotherapist if you have any current injuries or back issues. We do recommend seeking advise from a healthcare or fitness professional when starting new exercises.  

The purpose of this blog, is to provide general information and educational material relating to physiotherapy and injury management. Bonne Santé physiotherapy has made every effort to provide you with correct, up-to-date information.  In using this blog, you agree that information is provided 'as is, as available', without warranty and that you use the information at your own risk.  We recommend that you seek advise from a fitness or healthcare professional if you require further advice relating to exercise or medical issues. 

LSA

       Bonne Santé          info@bonnesantephysio.com         0033 (0) 4 79 06 07 27

Please like us on Facebook to stay up to date with news and developments:
Bonne Santé Physiotherapy 

Follow us on twitter: @valdiserephysio

Follow us on instagram: Bonne_Sante_Physiotherapy