Cycling Series: Knee Pain

The cycling season is in full flow in the alps and the Tour de France is well underway. Last Sunday, the Col d'Iseran was shut to motor vehicles while around 200 road cyclists climbed the Col.  Cycling is a wonderful way to exercise, whatever your level or age, with a host of health benefits. It’s also a great way for skiers to maintain their fitness throughout the summer season.

However, cycling is a highly repetitive sport, therefore niggles can soon develop into overuse injuries if the cause is not identified and corrected.  Overuse injuries most commonly occur to the knee, back, neck, hand / wrist, calf / achilles region and the foot.

Cyclists are also at risk of traumatic injuries, which most commonly result from falls and crashes. As well as bumps and bruises, fractures most commonly occur to the collar bone and scaphoid (small bone at the base of the thumb) often due to landing on a shoulder or outstretched hand.

The following extract was taken from www.cyclingtips.com:

A review of studies on injuries in professional cycling was undertaken by Marc Silberman and published in Current Sports Medicine Reports in 2013. Silberman observed the following:

• In a 4-year study of 51 top-level professionals, 43 cyclists experienced 103 injuries, with 50 (48.5%) traumatic injuries and 53 (51.5%) overuse injuries. Twenty-nine cyclists (67.4%) experienced more than one injury. Twenty-eight fractures occurred, with the clavicle having the most common fracture (11 cases). Only eight cyclists (15.6%) were injury free (De Bernardo, Barrios, Vera, Laíz, & Hadala, 2012).
• In another study in elite professionals, 38% of injuries were traumatic and 62% overuse injuries (Barrios, Sala, Terrados, & Valenti, 1997).
• More than two-thirds of traumatic injuries occur in the upper extremity, and two-thirds of overuse injuries occur in the lower extremity (De Bernardo, Barrios, Vera, Laíz, & Hadala, 2012).
• Cyclists are exposed to high traumatic risk racing in a peloton, at high speeds, on various road and weather conditions. By stage 9 of the 2011 Tour de France, 14 fractures occurred and 16 riders retired from the race, with one in intensive care (Greve & Modabber, 2012).
• Data from 2009-2010 looked at 93 cyclists. A total of 117 injuries (1.2 injury per cyclist per year) were reported, the most common types of which were abrasions (63%), contusions (23%), and strains (8%). Most injuries were located in the upper (47%) or lower extremities (47%) – with the knee (18%), wrist and palms (16%), shoulder and clavicle (16%), elbow (14%) and femur (14%) the most common sites (Bagherian and Rahnama, 2010).

I have not recited this data to put people off cycling. Cycling is a challenging sport and I feel that highlighting such data can only help to initiate appropriate injury prevention strategies. This data has been collated from professional cyclists and it clearly shows a high rate of injuries in this population. To my knowledge, there is very little up to date research on injuries in amateur cyclists, therefore a lot of my blog will be based on my professional experience treating cycling injuries. However, I did come across a study from 2014 (Van der Valt et al.) which collected injury data from 3300 amateur cyclists and found that non-traumatic injuries were reported by 88% of the respondents! The areas of pain were neck 34%, back 41%, hand/wrist 41%, buttock/perineum 41%, hip 7%, knee 33% and foot/ankle 24%.


Over the next few weeks, our blog will focus on different overuse injuries that can occur in cyclists. We will discuss why injuries occur, how to avoid them and what to do if you are suffering. Today, we will start with knee pain which Van der Valt (2014) cited was the injury that was most responsible for the need to stop training in the largest percentage of respondents.


Knee pain is often cited as the most common injury seen in cyclists and is usually due to the highly repetitive motion of the knee flexing as the pedal goes round. A knee normally moves directly above the line of the toes as the pedal goes around which helps to generate the power through the leg and into the pedal. Poor bicycle set up or excessive sideways motion of the knee can accentuate the forces going through the joint and lead to inflammation, overuse or wear and tear on the various structures around the joint.

In cyclists, knee pain commonly affects the following structures and / or causes the following conditions:

• Iliotibial band syndrome. A seat that is too high or too far back may lead to excessive strain on the ilio-tibial band which a strong fibrous structure that runs down the side of the thigh from the hip to the outside of the knee. 
• Patella-femoral pain. This can be caused by increased stress between patella (knee-cap) and the femur (thigh bone). A seat that is too low can cause pain under or around the knee cap due to prolonged time spent pushing whilst too bent. 
• Tendinopathy: This can occur in both the quadriceps tendon (above the knee) and the patellar tendon (below the knee). This is usually as a result of overuse (too much too soon), lack of strength training to prepare for cycling and incorrect bike set up. Again, if the saddle is too low you put the patellar and quadriceps tendon under increased strain. 
• Medial knee pain: Amongst other conditions, Pes Anserine Bursitis may occur through overuse and / or wrong cleat rotation. The pes anserinus is an area on the front and inside of the shin bone and a bursa provides cushioning. 
• Posterior knee pain: This can affect a range of different structures behind the knee, such as the popliteus tendon and the hamstring tendons. Saddle height, fore-aft position and cleat rotation may all contribute.

Tips to avoid knee pain: 

• If you are new to cycling, or have just returned to the sport after the winter make sure your training is gradually introduced and well paced. Knee pain often occurs when cyclists are too ambitious and do too much too soon. Like with any sport, the muscular system needs time to adapt to new demands placed on the body and you should gradually increase you milage over a series of weeks. 
• Strength and flexibility training is important in conjunction with cycling. In the lower limbs the gluteal muscles, quadriceps, adductors, hamstrings and the calf muscles are ares that must be kept strong and flexible. Like with any sport, cross training and varying your exercise / fitness routine is important in helping to prevent overuse injuries. 
• Ensure your bike is well 'set-up' by a professional fitter. Mal-alignement can cause undue stress. Points to consider include: 
• Saddle height and fore-aft position. Having the correct saddle height is one of the most important ways of reducing stress through the knees. The saddle may also need to be moved forward or backwards to create a good knee position over the pedal. 
• Handlebar position - consider both height and width. 
• Cleat position and rotation. If incorrect, this will increase rotational forces on the knee. Ideal cleat position may be very different for men and woman. Women tend to have larger hips, therefore the cleats will need to be adjusted to help maintain their legs in a more 'natural' alignment to minimise stress through the knees. This will often be by moving the cleats to the middle or even inside of the shoe.



September 2012, Top of Col d'Iseran.

Rapid weather change in a short space of time.

• Length of crank arm.
• Weather and Attire: Do your research before you set off. I have supported bike rides where the weather at the bottom of the Col has been warm and pleasant, however the top of the Col has been a different story. It can be very difficult to plan effectively, however getting cold as you climb is a big factor in muscle strains and increasing tension through the knee joint.

How can physiotherapy help?

If you have knee pain during or after cycling, it is important to identify the cause. A physiotherapist will take a thorough history and will carry out a detailed assessment in order to get to the root of the problem. From there, a treatment program is tailored to a persons individual need.

If you have knee pain, rest from cycling until the cause has been identified. However, this doesn't mean doing nothing. Stretching (as long as this doesn't reproduce your symptoms), foam rolling and alternative exericse that doesn't exacerbate your symptoms are usually fine to continue with.

Physiotherapy may involve soft tissue release, taping techniques and biomechanical correction through education and exercises. If in doubt, please call for advise. Physiotherapy treatment will usually speed up recovery and get you back on your bike a lot quicker than an untreated injury.

LSA

References: 

www.cyclingtips.com

Non-traumatic injury profile of amateur cyclists. A van der Walt, 1 MB ChB; D C Janse van Rensburg, 1 MD; L Fletcher, 2 PhD; C C Grant, 1 PhD; A J van der Walt, 3 FCP (SA).  South African Sports Medicine Association · November 2014

Disclaimer:

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. We recommend seeking advise from a healthcare or fitness professional when starting new exercises. 

Bonne Santé info@bonnesantephysio.com 0033 (0) 4 79 06 07 27
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Spring into action with a steady pace. Guest blog on returning to running

Once the snow and ice disappeared from Val d’Isere village there was a great increase in the number of people out running. It really brought a different sort of energy to Val d’Isere. This started me thinking about how many people are keeping an eye on their weekly mileage. Overuse injuries are extremely common in runners and most common in the first year of running. Although biomechanical issues can play a role in these injuries more often than not it can be due to a sudden increase in demands on the person’s soft tissues.

Commonly in clinic we see people who are very fit cardiovascularly, but took the winter off running. They kept their fitness up through cycling, swimming or skiing so when they returned to running they could keep going for miles without fatigue. The next day or the day after is when they may feel the strain in the soft tissues or joints that are used in a specific way in running. If these tissues do not get enough time to recover this can lead to overuse injuries. So, here are a couple of top tips that can get you back running this spring and keeping you running through the summer.

Start off steady… running is an impact sport that needs your legs to spring repeatedly more than a thousand times per mile. If you haven’t done any of this over the season then a walk run or beginner/intermediate 5km training programme could be the right place to start. There are lots of great plans I have used in the past but here are two I’ve found most useful: Bupa training plans and nike+ running app.

The 10% rule… There is no strong evidence about the exact amount you should increase per week but a very good guideline which is helpful is the 10% rule. If you run 9 miles per week, the next week you could add just under a mile. This could be broken into 2 x 3 miles and 2 x 2 miles depending on how you feel.

Review your progress… If you’re following a training programme and after one week you feel like the mileage/intensity is too much, either go back a week or stay at the same week. Don’t move onto the next week until you feel ready. Generally muscle soreness or mild joint ache can be normal if it dissipates in 24 hours. However, pain that changes your stride, gets worse as you run or keeps you awake at night is not ok and a sign you should consult your GP or Physiotherapist for advice.

Walk run or cross train… If you know 2­-3 miles is your capacity but want more exercise, add in some walks at a brisk pace. This can burn just as many calories and get your heart working out just as much as a jog. The added benefits are that you are still loading those leg muscles. If you know that two days of running per week is enough for your body, then instead of doing an interval run session do an interval bike, row or crosstrainer.

Keep strong... Whilst running it is really the muscles that have to absorb the impact of about 750 steps per foot per mile. To do this effectively you have to be strong. A recent study in the British Journal of Sports Medicine showed that strengthening 2­-3 times per week reduced risk of overuse injury to ½ while stretching did not show the same benefit.

Thanks to our fantastic guest blogger Gemma.  Gemma can be found working at Physio 4 All in London.
Gemma Gillen, Physiotherapist

Disclaimer:

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.

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

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The lifts have closed!

The lifts in Val d'Isere have now shut for the 2015-16 season, although the lifts in Tignes remain open for another week.  We woke up this morning, on the 1st May to a fresh snow fall overnight. There was up to 40cm of fresh snow up top and it has continued snowing all day. What a great end to a fantastic ski season.

Our exciting news is that we will be open for the summer.  A large reason for this is increasing client demand for physiotherapy in Val d'Isere, Tignes and surrounding resorts during the summer months, especially with the increasing popularity in alpine summer sports. However on a more personal note my gorgeous little girl is progressing so well with her french language that we are keen for her to stay immersed during the summer.  I will be sad not to return to the Blackberry Clinic (www.blackberryclinic.co.uk) where I have spent the last 9 summers working, however I am very much looking forward to a summer in the Alps.  I'd like to take this opportunity to say a huge thank you to Dr Simon Petrides and the Blackberry team for having me back each summer and for being such a fantastic team to work with.

Dr Simon Petrides and I at the London 2012 Olympics

We're very much looking forward to our first summer in the Alps and being able to take part in some of the fantastic summer alpine activities on offer here such as hiking, trail running and biking. For mountain bikers, chairlifts are adapted to carry bikes and are free to use over summer.  The Col d'Iseran is a popular challenge for road cyclists and is renowned for being one of the highest roads in Europe.  There is also golf, climbing, fishing and summer skiing available.  The water sports in Tignes will also be a treat with a huge waterside into the lake and pedalo's, paddle boards and kayaks available to hire.

On an injury prevention note, this past week I have been seeing people who have returned to running or cycling for the first time in six months and overdone their initial sessions.  The knees seem to have taken the brunt of this with meniscal (cartilage) compression injuries, patella femoral dysfunctions and soft tissue trauma resulting.  When you reintroduce a sport that you have not done for a while, pace yourself and gradually increase the intensity, frequency and distance.  If you have spent the last six months in ski or snowboard boots, then your body will need time to adapt to new activities and new demands.  Do not expect to restart at the level you finished last autumn.  Too much too soon will result in injury so ensure your training is progressive.  Adapt your training in the gym or general conditioning to prepare for your summer sports e.g. if you are a tennis player you will need to focus lower limb exercises on cutting and changing direction and upper limb work on strength, control and plyometrics in a range of planes and movements.

We would like to take this opportunity to say a huge thank you to our friends and clients for all your support this season.  We would also like to thank the tour operators and ski schools that kindly recommend our services to their guests and clients.  We could not run without your support and we will maintain our commitment to you by continuing to strive towards clinical excellence in both our injury management and eduction.  I also need to thank an amazing team for a fantastic season. We've had great fun, excellent training sessions and incredible client feedback.  A large focus for us as a team this season was on the functional fascial system and we have had some great results incorporating this to improving ski performance.

If you have enjoyed our blogs, please continue to follow us on social media as we will continue our blogging during the summer.  Please also share our blogs with your friends and invite your friends to like us on Facebook.  We really appreciate the support, hope to continue to grow our profile and welcome new followers.  During the summer, our blogs will initially focus on summer sports, with a guest blog on springing into action with steady pace running coming soon.  In the autumn our focus will be on preparing for the season ahead and getting fit to ski.

Finally, I'm proud to say that I've done what I set out to achieve this season.  I've produced a regular blog on ski injury prevention, ski fitness and seasonal life.  As I've said before, I'm new blogging so any feedback is most welcome, as are suggestions for future topics.  Blogging is not without its challenges, mostly finding the time to research and write regularly.  Thank you to my husband for putting up with me tapping away on the computer in the evenings, for putting up with my lack of conversation and the late nights!

Disclaimer:

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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ACL rupture: an insiders point of view

Knee injuries are all too common in skiers, with the anterior cruciate ligament (ACL) being one of the most common and most feared injuries we see. In Val d'Isere this season, we have seen high numbers of ACL injuries occurring, greatly influenced by the snow and conditions.  This has led to this weeks blog on the recovery journey. At the end of the winter season, people are often deciding whether or not to have surgery or starting the recovery process after the operation.
This blog aims to highlight that whilst an ACL injury can be a huge shock, there is light at the end of the tunnel.  As much as a serious injury can have a negative impact, long term people often come back fitter and stronger with a better understanding of their body.

As physio's we can usually tell if an ACL is ruptured through taking a detailed history of the injury and through the tests that we perform, however ultimately an MRI scan will confirm this. The diagnosis of an ACL injury is often a huge blow but it does not mean the end to your skiing career. In fact, it is very unusual not to be able to return to the slopes once you have recovered from an ACL rupture.  Lindsey Vonn, Ted Ligety, Bode Miller, Jenny Jones and Mikaela Shiffrin are a few examples of alpine professionals that have all made successful comebacks post ACL injury.  

Recovery after an ACL reconstruction can be a long road and it is important to pay attention to your emotional and psychological needs as well as your physical ones.  People have different coping strategies to get through such difficult times and if the emotional impact of an ACL injury is overlooked it can have a detrimental effect on a persons rehabilitation and performance.  Post ACL injury, it is not uncommon for people to report feelings of frustration, isolation and disengagement. Rehabbing from ACL injury takes huge commitment and motivation which can be affected by negative thoughts. If you are struggling with the emotional impact of an ACL injury, seeing a sports psychologist can help.

To gain a better insight into the journey after an ACL tear in skiers, we have asked some fantastic instructors about what they went through when they ruptured their ACL.  As a physio, it is bad enough telling someone that their ski holiday is over if an ACL rupture is suspected, let alone having to tell a ski instructor that is likely that their season is over! Rehabbing from an ACL injury is a very personal process with many highs and lows. As you will see from the answers below, every journey is different. Sincere thanks to the instructors that have given us a personal insight to what they went through.

1 - When you injured your knee, did you suspect that it was your ACL at the time, even before it had been examined?

Clare Angus (CA) http://www.tdcski.com/val_disere/about_tdc_valdisere/

No - didn't hear a pop and it didn't swell massively but it was a bit unstable and sore. As I have rather lax joints anyway and have had a minor knee injury before I assumed it was a tear rather than rupture

James Allen (JA) http://jamesallenskicoaching.com/val_disere_ski_instructor.html

Yes because I was skiing with a few guys who'd previously torn their ACL and they thought it was torn for sure. That said i had my doubts as i was able to ski down to the bottom of the run so thought maybe it wasn't fully torn

Joe Harkness (JH) http://www.tdcski.com/val_disere/about_tdc_valdisere/

After an evening in denial, with the swelling in back of the knee, I knew it was the ACL.

Nicko Braxton (NB) http://www.tdcski.com/val_disere/about_tdc_valdisere/

Knew both times (or was pretty sure). Couldn't stand on them.


2- When an ACL rupture was confirmed, how did you feel?

CA - I was anxious prior to first being examined as I knew it wasn't going to be great news. It was early season training so the whole season lay ahead. First diagnosis was as a tear which was pretty devastating as I was meant to do another 4 weeks race training and also had a number of ISTD exams booked and I wasn't sure how things were going to go. I spent 6 weeks off skis then got back on with ISTD teaching and technical exams and also did my EMS training exam and carried on training for exams and eurotest, so all in all things were looking ok. It wasn't until my knee still felt a bit wobbly 6 months later that I got an MRI and rupture was confirmed. However by this point I knew what it was still capable of and so was not too disheartened by the diagnosis.

JA - I knew what was ahead of me as I was lucky to have people there who'd been through it previously. I was determined to make a full recovery, what ever it took!! I looked upon it as a challenge to myself to prove i could rehab correctly and take it seriously from start to finish and come back stronger than ever.

JH - As I already suspected it, I was ready and accepted the injury and was just keen to get on with the rehab process and treatment to get back on my feet

NB - Miserable. Sat in a wheel chair in the restaurant at the bottom of the motte and burst into tears


3 - What was the worst part of the journey?

CA - I had 6 weeks off skis early season when meant to be training. Having to make decisions about how to proceed. But all in all I have, so far and touch wood, been very lucky.

JA - Having to watch everyone go up skiing in great conditions whilst i stayed indoors resting wasn't easy, but i knew i'd had some great times in the past and also knew i'd have them again, so didn't let it get to me too much. Also having to hold back on the rehab and do as i was told by the physio was tough as I felt I could take things to the next level sooner but had to do it all by the book, otherwise risk the long term recovery!

JH - The steps backwards you take after surgery and the slow process around 3-4 weeks after surgery. The rehab initially was so slow I found it frustrating after being so active.

NB - Perhaps 2-3 months post op. Still on boring repetitive exercises.


4 - What surprised you most about the process after ACL rupture?

CA - The fact that I had a ruptured ACL that I skied to a high level on for such a long time before finding out it was ruptured!

JA - How soon i was able to push weights in the gym and generally how well the whole rehab process went.

JH - The huge loss of strength in the hamstring from losing the tendon for the graft. 2 years on and still need to do so much work to minimize imbalance between left and right legs.

NB - The amount of time you must dedicate - like a full time job but no one is paying you.


5 - What positives have your taken from your journey?

CA - What doesn't kill you makes you stronger!

JA - Plenty!! I now know what's required to recover well and more so that I'm able to recover from something as serious as this without it being a major hinderance to my life in general. I've learnt a lot about good nutrition, health and fitness which is all good, especially given the lifestyle and job i do as a sports coach. I'm almost certainly fitter than i was before the injury and probably stronger in general. Knowing that a major injury like this doesn't mean you're off games for a long time as i was able to get out and do sports again pretty soon afterwards. Even more so, the fact i was back on skis the following season and skied hard all season without any major issues.

NB - That you can make a full recovery and you are in control. The operation does not predict the out come.The work that you put in does. You get out what you put in.


6- Any tips for people going through ACL injury.

CA - My advice is to not rush into surgery. I realise some people will need to have surgery but it is not the only option, although I believe most people believe there is no alternative.

JA - One of the best bits of advise I received was from my surgeon which was to hire a 'Game Ready' pro ice machine. I'd highly recommend this for a speedy reduction in the swelling post-op. Minimum 4wks and the results will help you progress in the rehab programme much quicker. Look up online the ideal diet and nutrition for knee ligament rehab and follow this as closely as possible. Be sure to do ALL the exercises your Physio advises, especially in the early stages. Stay positive throughout, it's not as bad as you might think!!

JH - It's hard to stay motivated at times and can feel very slow, but the moment you get the clear to get in a bike was huge for me.... That gave me freedom again, and from that point on I could see the light at the end of the tunnel.

NB - Don't push at the start. It doesn't shorten the healing time. If anything you just endanger the graft. It takes longer as you get older  Be picky about your surgeon - talk to people


If you are unlucky enough to rupture your ACL, you are likely to find that everyone has an opinion on your recovery process. Whilst this can be helpful, sometimes too much information can lead to confusion and uncertainty. We hope that the insights we've been given help to show that each and every person will have a different journey. No two people will go through the same process, even with identical injuries and a full recovery is very achievable. Thank you to Clare, James, Joe and Nicko for sharing parts of your journey with us.

Prior to next season, I will publish a blog on ACL injury prevention.  Follow us on facebook to stay up to date with our blogs.

Disclaimer:

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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Skiing in Slush - Top tips from Val d'Isere Instructors

Love it or hate it, warmer spring weather will result in slushy pistes, especially lower down. Personally, I love skiing in slush, although it took a little while to start to enjoy it. Initially I did not have the right technique and found it hard work, but I now find powering through the slush great fun.

However, if you don't have the most efficient technique or good levels of ski fitness, skiing slush can feel heavy and tiresome. In slushy spring conditions, we see more over use injuries, particularly to the patella-femoral (knee) joint, more calf strains from a 'plant and ride' (where the ski's get stuck in a bank of snow, the bindings don't release and the skier continues over the top) and more knee ligament injuries, especially to the anterior cruciate ligament (ACL).

To help prevent injuries in the slush, listen to your body.  If you are tired, take a rest. At the end of the season, skiers are often tired but keen to push on to make the most of the snow while the lifts are still open. Use rest time to rehydrate, refuel and stretch.  Fatigue is probably the largest cause of why injuries occur in slushy conditions and the ACL is often the unwilling victim.

Good strength and neuromuscular control of the legs and core is also essential to help reduce the risk of injury.  A strong core will help limit excessive movement of the upper body when being thrown around in variable conditions. Good balance and proprioception is necessary to help recovery and prevent falls.

Practicing your balance is probably the best way to help prevent injuries in slush, but you want to make this training dynamic and variable.  You can start by practicing static balance on an uneven surface such as a bosu ball (as shown in the picture).  A pillow or cushion will do if you don't have access to similar equipment.

To further challenge this, try and juggle a tennis ball or take hold of a medicine ball and pass it around your body.  Trying to regain your balance when you move outside of your base of support is great training and will help to sharpen your righting reactions which is important in preventing falls when you are thrown around in variable slushy snow.

It is also important to perform balance practice dynamically, as skiing is never about just standing on one leg!  Star excursions are are great starting point.  If possible, draw a large eight prong star on your patio or in your garage.  Stand on one leg in the middle of this and reach your other leg as far down the first prong as your can.  Repeat this all the way round each of the eight prongs.  Reach as far as you can to challenge the supporting leg.  You can then swap sides.  Introduce a wobble cushion under the supporting leg to make it a lot harder.

Other ideas for improving dynamic balance include:

• hop to deep land.  Hold the landing for 5 seconds. 
• Travelling hop and hold.  As above but vary the direction that you hop in to include forwards and backwards, side to side and diagonally. 
• slack lining

When skiing in slush, our leg muscles work a lot harder and there is a high chance that you may aggravate any pre-existing injury, especially if you have knee or back problems. If your legs are felling particularly tired, stick to easier pistes, take regular breaks and book a massage with us to help accelerate recovery. If you combine good ski fitness and balance with good technique, you will significantly help to reduce your risk of injury.  

We've asked some of Val d'Isere's fantastic ski instructors for their top tips on skiing slush?

Lena Hauritus-Neilson
http://www.tdcski.com/val_disere/about_tdc_valdisere/
Point your ski's and go.  Power through and keep momentum.  Ideally do medium rounded turns.

Rupert Tildesley
http://www.mountain-masters.fr/rupert-tildesley-moniteur-ski.asp
Make sure the ski goes forwards along its length through the slush.  Try not to pivot it assuming it will slides sideways (it probably won't).

Xavier Raguin
http://www.skinewgen.com/instructors/xavier-raguin/
Use your weight to push through the snow and use your speed.

Pamela Nardin
https://oxygene-ski.com/fr/
Don't be too rough otherwise you will get stuck and fall.  Keep your legs active to turn the ski's.

Clare Burns
http://www.clareburns.com/
Stay centered and distribute your weight over the whole of your foot. Use speed and momentum to power through it.

Thank you to everyone that has let me pick their brains.  There are some very useful tips which will hopefully help to prevent injuries occurring.

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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Performance Series: 'A'-Frame skiers - part 2

Before I start, I want to emphasise that there is no 'one size fits all' in terms of ways to help correct or improve an 'A'- Frame position. Every single person will have individual needs. However, the suggestions below have been collated from over a decade of working with skiers and identifying common movement patterns and compensations. This includes work analysing hundreds of instructors working their way through various stages of the BASI system and work alongside BASI trainers to ensure accuracy and carry over between off hill and on hill training.

These exercises can benefit anyone that struggles with an 'A'-Frame posture. They are not limited to ski instructors, but I hope that instructors will find the information useful from not just a personal perspective, but also a coaching perspective.  I also hope this information will be useful to anyone looking to improve their ski performance and hopefully technique.

This blog is designed to follow on from last week on 'why an 'A'-Frame position may occur', so we recommend that you read this prior to continuing below.

In terms of exercise prescription, as a general rule if it challenges you it is probably something that you need to work on.  It is not easy to recommend repetitions, weights and frequency of the exercises but as a general guide aim to practice the exercises that are relevant to you 3 times a week for a minimum of 6-8 weeks to make a difference.   The training over this time should also be progressive, so that the muscles are constantly being challenged as they develop.  The exercises should be made harder and challenge you further every 1-2 weeks.  A static program will not allow for continual progression and will soon become tiresome and uninspiring.

The exercises below are aimed at improving neural connections, movement patterns and endurance for skiing, rather than specifically for strength training.  With that in mind, you ideally want to perform the exercises into fatigue, taking care not to loose form and to ensure good quality of movement.  It is not as simple as saying how many times to perform each movement.  Every single person will be able to work at different levels and perform different numbers of repetitions, therefore assessment and progression by a physiotherapist or personal trainer is highly recommended.  The exercises below are a framework to start from and ideas to share with clients.  They should not be performed if they cause any pain and we recommend seeking medical advise if you have a pre-existing injury.

To re-emphasise, there is no overnight fix to correct an 'A'-Frame through exercises. It is likely to take a minimum of six weeks to start to notice changes when a progressive programme is carried out regularly, however we recommend at least 3 months of training to really make an impact.

Postural and position awareness

Did you know that only a very small proportion of people actually train to get fit to ski before a skiing holiday. Some of our data collection suggests that this figure may be as low as 4%! This figure applies to recreational skiers rather than instructors and professionals, however when I have been presenting to gap ski courses often less than 10% have done any ski specific fitness prior to starting their course!  Its no wonder we see so many ski related injuries on the slopes.

For those that do get fit to ski before coming away, how you train will greatly influence your movement patterns on the slopes.

Right knee falling into a
valgus 'knock-kneed' position

Lets start with simply seeing if you are able to correct a knocked knee position. Stand in front of a mirror with your feet facing forward and ski width apart. Keep your back straight and squat down so your thighs are almost parallel with the floor. Repeat this a number of times whilst watching yourself in the mirror. Do your knees track nicely over your middle toes or do they come together?

Good alignment demonstrated.
Knees tracking nicely over
middle toes.  

If they come together, are you able to correct it?  Can you maintain this corrected position as you repeat the movement?












This is often clearer to see on one leg. Repeat as above but this time perform a single leg squat (you won't necessarily be able to go so deep). Again, watch the position of your knee over your toes. Can you correct this simply through awareness and the feedback of watching yourself in the mirror? Repeat this for at least 60 seconds to see if you can maintain the position, even as you fatigue. We don't usually learn a lot through just one repetition. Movement faults are easier to identify as muscles start to tire.

    

If you are able to correct this, practice and regular repetition will help the body make neural adaptations which will improve coordination and proprioception. Proprioception is a term which describes the unconscious knowledge of the position of our body and limbs. Research has shown that proprioceptive control in a single leg stance may be a key factor in reducing injuries.

To challenge your position sense further, stand on an unstable surface such as a bosu ball and repeat the single leg squats. Maintain optimal knee position through out.




Weak hip abductors and external rotators 

As well as abducting the leg (pulling it in a sideways motion), one of the main roles of the gluteus medius is to stabilise the pelvis. As mentioned last week, a weak gluteus medius can cause the pelvis to drop on the opposite side. At times, people may also attempt to compensate for this on their supporting limb by rotating it inwards and allowing the thigh to draw across the body. Both these actions can result in a 'A'-frame ski position.

The exercises below will start to give you some ideas of how to improve the function of the gluteus medius muscle:

1 - Hip hitch

This is a good starting point for activating the gluteus medius and improving neural connections between the body and the brain.  Stand sideways on a step with one leg free over the edge. Keep your shoulders level and slowly drop and raise your free leg. To increase the difficulty you can add ankle weights.

               

2 - Side planks

Side planks are a great core stability exercise and also a great way to engage the gluteals. Gradually build up how long you can hold a plank position, aiming for 30 - 60 seconds and repeat this 3 - 5 times.

Short lever

Long lever

3 - Monster walk

Place a piece of theraband around your lower legs and stand in a long corridor. Squat down with a neutral back and look forward. Keep your stance wide and maintain good tension on the band. Side step keeping your knees bent and feet wide apart. The deeper the squat, the harder the challenge.

Make sure that your knees are always well aligned over your toes and feet are pointing forward. If your glutes are very weak, the knees tend to buckle in to compensate. Don’t let them!

4 - Hip rotations with theraband resistance

Hook a piece of theraband around one ankle and stand on the other end.  Draw your foot up your shin then turn your knee out. Your pelvis should stay facing forwards, whilst your knee lifts and you twist from the hip. This works your gluteals as well as challenging your balance, engaging your core helps with hip and pelvis dissociation. 

                                     


Tight ITB (iliotibial band)

If you have a tight ITB, it may well contribute to internally rotating your thigh (turning it inwards). As I mentioned in last weeks blog, if you have a weak gluteus medius muscle, this will often be coupled with a tight ITB, therefore one of the first steps I would take in an assessment of the ITB would be to also assess the gluteus medius muscle. If strength or endurance issues were highlighted, I would initiate a hip and gluteal muscle program as above.

I would also recommend foam rolling to help improve the fascial matrix of the ITB.  There are all sorts of foam rollers on the market, but the ITB can be a highly sensitive area, therefore we recommend a standard foam roller to start with. Place the roller under your thigh, as in the picture below. I usually divide my thigh into upper, mid and lower portions and then lever myself back and forth for as long as I can tolerate.

How long should you roll for? Initially I recommend 10 - 20 seconds if it feels very sore but build up to 2 mins of rolling the length of the ITB over a period of 4 - 6 weeks. A good time to roll is after skiing.


                                      

Foot over-pronation

The foot needs a certain amount of pronation to function effectively, however over pronation can often be (not always) more problematic. The feet are highly complex structures and I do recommend seeking professional opinion if you feel that over pronation may be contributing to an 'A'-Frame position.

As I mentioned last week, working out why the over pronation is occurring is key to applying the correct treatment. As a physiotherapist, I aim to work out if there is structural or functional cause of over pronation (or a combination of both). If the problem is structural, it is not likely to change with exercises, however more often that not there is a functional cause or contribution e.g. the muscles, fascia and other soft tissue structures are not doing their job properly! How do you know if your problem is structural or functional? Well, you probably won't without the professional opinion of a physiotherapist, podiatrist or highly trained boot fitter.

A recent study (Hashimoto and Sakuraba, 2014) looked at strength training for the intrinsic flexor muscles of the foot and found a positive effect on muscle strength, the foot arch and dynamic parameters. They concluded that intrinsic foot flexor strength training is useful for improving standing and walking performance, in addition to improving the performance of sports athletes engaged in activities involving greater exercise loads.

This research is just one study in a large body of evidence which adds support my anecdotal findings. If the problem is down to muscle imbalances, the exercises below can be introduced as part of a training program. I would also include gluteus medius work, as shown in the section above. As I mentioned before, these exercises must be performed regularly and be progressive in nature. If its not challenging you, you will not continue to make progress.


1 - Supination Exercises

Wear sock on a shiny surface. Transfer your weight more towards the outer edge of your foot and work the muscles under the arch of your foot.

When you can maintain this position for periods of time, you can also try to maintain it during more functional training such as squats, heel raises and lunges.

The movement is not well demonstrated in these pictures, but if you look closely you will see that in the first picture, the foot is rolling in. The inside ankle bone is more prominent.  This has then been corrected into a 'neutral' stance in the second picture.

2 - Towel folding

This exercise aims to strengthen the plantar fascia and deep intrinsic muscles of the foot.  Stand with a towel laid out on the floor in front of you. Grasp one corner with your toes (not inbetween your toes - thats cheating, aim to scrunch up your toes so the towel is held in between your toes and the pad of your forefoot).  Fold the corner of the towel into the middle, and repeat with the other three corners. Then using the same action, unfold each corner again. Compare one foot to the other. If you find it easy, your probably don't need to practice it.  

3 - Calf raises

Stand on a step. Rise up onto the ball of your toes, pause and then slowly sink your heels down.  You can aim to perform 3 sets of 15 repetitions.  If this is easy, try the same exercise on one leg.

To progress even further, wear a rucksack on your back and add hand weights or bottles of water to increase the resistance and the load on the muscles.   It is important that you perform this slowly and allow yourself to go up and down to the limit of your range.

4 -Big Toe Pushdowns

Stand with your foot and ankle in neutral position. Push down through your big toe without allowing the ankle to roll in or the arch to collapse. Start by holding that for 5 seconds, 10 times on each side (or do both sides at once). As you get stronger, hold the toe down for longer stretches and fewer repetitions. You’ll start to feel that muscle (flexor hallicus) contract under the arch of the foot. As it gets stronger, you’ll be able to consciously engage that muscle whenever you’re performing weight bearing exercise.

5 - Eversion on a Step

This exercise helps to target the tibialis posterior muscle, which amongst other roles helps to support the medial arch of the foot.  Stand sideways on a step so that the inside of the foot is just over the edge.  Very slowly roll the arch of the foot inwards, as if trying to get the big toe down to the floor
Reverse the movement to bring you back up to the starting position. As with the calf raises above, aim for 3 sets of 15 repetitions and if easy, use a weighted rucksack to increase the resistance.

6 - Run around a lawn barefoot

This exercise is as it says on the box.  Let the small muscles of the foot work hard to stabilise the foot and ankle complex over uneven ground.  Lose the support of shoes for a while and allow the muscles to do their job.

Orthotics

Often, a progressive program to correct muscle imbalances in the lower limbs is sufficient, other times orthotics or foot beds are necessary.

Colin Martin, a certified podorthotist based at Solutions 4 Feet in Bicester www.solutions4feet.com was kind enough to contribute the following:

'From a boot fitters perspective we try first to stabilise the foot, then to look at what else is going on, often the client can do exercises to strengthen muscles and get a more neutral stance, other times the natural body shape simply does not allow this to happen, it is then were we can intervene using the cuff adjustment ( often called canting) of the boot. Or but working under the sole of the boot using many methods of TRUE canting to get the best result. SOME PEOPLE ARE NOT CANTABLE sometimes you have to settle for skis flat on the snow and a bow legged or knock kneed stance, other people are lucky and can have perfectly parallel shins AND skis running flat.

Trouble is people want an instant fix and many will not do the exercises so try to insist on fixing the problem using canting, my job is to find the right balance for each individual to give them the best skiing experience'

Hip Joint

As I mentioned last week, 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. I was recently asked what the best thing to do in this case was. This is a tricky question to answer because everyone is individual with different needs. If it's truly an issue with the hip joint, exercises are less likely to help, although often the body does have ways of developing compensation strategies over time, even if an 'A'-frame position can't be completely corrected. For example, people with congenital hip problems (from birth) that haven't needed orthopaedic input are likely to have compensations further down the chain, such as increased external rotation through their tibias. Seeing a good boot fitter or alignment specialist may also be of benefit.

Osteoarthritis and Rheumatoid arthritis of the Knee Joint

If the inner aspect of your knee has been affect by arthritis, it will probably be a structural problem that is causing an 'A'-Frame.  However, I would still implement some of the training above, starting with seeing if you can correct the position in front of a mirror and improve proprioception of the knee joint.  The majority of the time, people with arthritic knees can also benefit from training the hip and gluteal muscles as above.  I would also recommend discussing orthotics, wedges and canting options with an experienced boot fitter, preferably one that has an understanding of arthritic pathology.  

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.


References;

Proprioceptive Training and Injury Prevention in a Professional Men's Basketball Team: A Six-Year Prospective Study. Journal of Strength & Conditioning Research: February 2016 - Volume 30 - Issue 2 - p 461–475 Riva, Dario; Bianchi, Roberto; Rocca, Flavio; Mamo, Carlo

Strength Training for the Intrinsic Flexor Muscles of the Foot: Effects on Muscle Strength, the Foot Arch, and Dynamic Parameters Before and After the Training. J Phys Ther Sci. 2014 Mar; 26(3): 373–376. Takayuki Hashimoto and Keishoku Sakuraba

LSA

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

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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

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

Follow us on twitter: @valdiserephysio