Exercise Spotlight: Hip Hinge

The concept of a hip hinge movement pattern is essential for anyone that moves.

What do I mean by "hip hinge"? Hip hinge is a sagittal plane movement where the hips are the axis of rotation between a neutral lumbopelvic segment and a femur (your thigh). (**See below for further discussion regarding hip hinge definition)

This sounds simple, but it can actually be quite difficult to know were your body is in space and to isolate movement to one joint while stabilizing at another joint- especially when you are trying to stabilize a column of many joints (the spine), while only moving at the hip joint.  The ability to control a hip hinge movement is extremely important for optimal mechanics during weight training, yoga, running, cycling, daily activities (lifting, bending), and much more.  It requires coordination between your core stabilizers and your gluteal musculature, as well as a high level of body awareness and motor control. The inability to dissociate hip movement from spine movement can lead to decreased performance and increased risk for injury. At Endurance Physio, we often teach our athletes/patients this concept before we progress to higher level exercises.

Below, are 2 videos that demonstrate how to practice a hip hinge movement (1st video) and how to apply it to a squatting motion (second video).

Once you are able to perform the movement without the cuing of a dowel or mirror, you may apply it to many other movements. To name a few:

• Running/hiking (especially uphill)

• Unloading the dishwasher (that's right:)

• Downward Dog (yoga pose)

• Raking leaves, shoveling snow

• Bending down to pick up your 2 year old child

• Any strength training that involves lunging, squatting, single leg squatting...

I think you get the gist

More on the definition of a hip hinge...

**In the world of olympic weight lifting, the "hip hinge" exercise is generally defined as an exercise where you bend forward with maximal motion at the hip and minimal motion at the knees. This is often also referred to as a deadlift. This is often contrasted by a  traditional "squat," which is more focused on maximizing knee flexion and minimizing hip flexion by keeping the chest upright. The main difference between a hip hinge and a traditional squat is where the the primary torque occurs. In a hip hinge, the torque is focused at the hip, resulting in the majority of the load at the gluteal and hamstring musculature (posterior chain) as opposed to the quadriceps. In the traditional squat, the torque is primarily at the knee joint with the majority of the load in the quadriceps as opposed to the gluteals. Based on my definition of a hip hinge stated above,"a saggittal plane movement where the hips are the axis of rotation between a neutral lumbopelvic segment and a femur (your thigh)," the concept of hinging at the hip can be applied to either exercise. The idea is that you move at the hip joint without flexing or extending in your spinal segments.

More on squats...

A squat can fall on a continuum of the 2 extremes listed above and become more of a hip-dominant exercise that will load the glutes, or a knee dominant exercise that will load the quads. 

So is one way better than the other? IT DEPENDS! From the point of a physical therapist and injury management/prevention, either way can be more beneficial depending on the individual, the injury, and the goal. For example, if you are cyclist with anterior knee pain and an imbalance where your quads are disproportionately stronger than your glutes and hamstrings, I would recommend working on the hip/glute dominant squat pattern in order to load and strengthen the glutes and decrease load to the knee and quads. However, if you are a skier with relatively weak quads and/or patellar tendinosis, I may recommend a more knee/quad dominant squat in order to progressively load and strengthen the quad muscle and tendon. That said, I more commonly see an issue with quad dominance and posterior chain weakness, so it is more common that I work with individuals on mastering a more glute dominant pattern in order to uptrain the glutes and downtrain the quads. In my opinion, if there does not appear to be an imbalance, a squat should be somewhere in between the 2 extremes so that both the gluteals and the quads are loaded and fatigued.

If you have any questions or additional comments regarding this discussion, please feel free to contact me at endurancephysioanya@gmail.com or comment below. Thanks for reading!

Plantar Fasciosis- Why is it happening to me, and why isn't it easier to get rid of?

By Anya Gue, DPT

https://www.consultant360.com/content/plantar-fasciitis-office-management

Plantar heel pain, most often diagnosed as plantar fasciitis or plantar fasciosis, affects approximately 10% of the population. So if you happen to develop this issue, what should you do? Stretch your calves? Buy some supportive orthotics? Strengthen your feet? Unfortunately, there is no one magic treatment that works for all individuals, but I am hopeful that this article will provide a little guidance to help you better understand the next step you need to take in order to get on the right track to rehabilitation.

Most often, the development of plantar fasciopathy can be attributed to one or more of the following musculoskeletal impairments:

• Stiff calf musculature or ankle joint restriction leading to limited ankle dorsiflexion mobility
• Excessively low and overly compliant medial longitudinal arch (pes planus) 
• Excessively high and ridged medial longitudinal arch (pes cavus)
• General foot and ankle muscle weakness
• Poor motor control and proprioception of the foot ankle
• Poor proximal strength of the hip and core leading to impaired mechanics at the foot 
• Significant increase in load to the foot muscles and ligaments over a short period of time. For example: increase in running mileage or intensity; increase in time on feet during the day in general; abrupt change in footwear from supportive shoe to less supportive shoe

Once the overload and acute damage to the plantar fascia tissue has occurred, the best action for treatment should include several different steps:

1. Protect the overloaded tissue to allow for healing and pain reduction to occur (reduce stress to the plantar fascia by reducing time on feet, use of a heel lift and/or orthotic (more on this in the discussion below), and activity modification

2. Address any underlying impairments- this may mean aggressive calf stretching, use of night splint, foot strengthening, and/or movement retraining. You may want to consult with a physical therapist to determine what these are for you as an individual.

3. Address any extrinsic loading issues such as managing training volume, poor footwear, or excess time on feet

4. Progressively re-load the tissue without overloading and causing more damage. This part can be tricky and must be very patient specific. Often the pain that results from plantar fascia injuries is correlated with microtearing and change in composition of the structural collagen fibers. If the tissue is completely unloaded and allowed to "rest," it will likely continue to remain in this state. It must be stimulated to remodel back to its functional form. Most recent research has revealed that this can best be achieved through a loading program that is progressed based on symptom presentation and pain provocation.

Is it worth buying orthotics?

Collapse of the medial longitudinal arch places excess stress on the plantar fascia

It would be nice if treatment was as simple as buying the right orthotic, putting it in your shoe, and BAM...pain is gone. Shoe inserts, or foot orthoses are one of the most commonly prescribed treatments for plantar heel pain, but the evidence to support this as an effective treatment is outdated and conflicting. However, in September 2017  a systematic review and meta-analysis was published in the British Journal of Sports Medicine with some useful results:

A foot orthosis is meant to provide support for the medial longitudinal arch and decrease the stress on the plantar fascia

Do foot orthoses reduce pain? In the short term of 0-6 weeks, there was no significant reduction in pain. There was a moderate reduction on pain in the medium term of 7-12 weeks, and there was no conclusive reduction in pain in the long term of 13 to 52 weeks. 

Are custom orthotics any better at reducing pain than prefabricated? Not necessarily! The results of this study indicated no difference in pain reduction between the custom orthotics (often very expensive) than the prefabricated orthotics.

In conclusion, treatment of plantar fascia pain needs to be individualized depending on the causative factors. Shoe inserts may be an effective way to reduce symptoms, but custom orthotics are generally not necessary. 

If you have any questions or comments regarding this post, please feel free to contact the me at endurancephysioanya@gmail.com or comment on blog post below. Thanks for reading!

 

Reference:

Whittaker GA, Munteanu SE, Menz HB, et al. Foot orthoses for plantar heel pain: a systematic review and meta-analysis. Br J Sports Med Published Online First: 21 September 2017. doi: 10.1136/bjsports-2016-097355

Welcome, Tara!

We are excited to announce that Tara Mund, DPT has joined Endurance Physio! She started with us September 21st and is currently accepting new patients.

Tara has worked in Missoula as a Physical Therapist for the past 10 years specializing in treatment of pelvic health conditions. She has completed extensive post-graduate training in this area including a Certificate of Achievement in Pelvic Physical Therapy (CAPP), and currently is the only therapist in Montana who has completed this training. Treatment of urinary incontinence, pelvic pain, pelvic organ prolapse, and post abdominal/pelvic surgery care, are among the diagnoses that she specializes in treating. 

At Endurance Physio, we are committed to helping patients get back to doing what they love. We are happy to be able to offer Tara's expertise in helping patients achieve this. 

Tara can be reached by calling us at 406-926-2150 or by email at endurancephysiotara@gmail.com.

Please join us in welcoming Tara to the Endurance Physio team!

Taper Tips from Endurance Physio

Tom Robertson Photography

The final weeks leading up to a big race can feel exciting, yet nerve-wracking . After so many weeks of hard training, the time has come to back off and let the body rebuild, refuel, and recover in preparation for the big race. Although the physical demands are are lessened during a taper period, the mental demands are high. Supposedly at this point "the hard work is done," but I find the taper to be particularly difficult to execute properly.

Often, you feel quite ready for such a break from the high volume, but it is not uncommon to experience feelings of anxiety and distrust in the taper process.  You are probably not alone. Here are some common feelings that are experienced during a taper and some tips to ease anxiety and help you make the most out of your taper:

• Feeling like you might be losing fitness with the reduced training volume This is understandable, but remember that you can not fully benefit from the hard training you have put in if you don't allow your body to recover. Resist the temptation to add extra mileage or hard workouts to your training. You are not going to create fitness in the last week before your marathon and adding in "junk miles" or an extra tempo run will probably only tire you out. If you want to make sure you keep your legs ready to run fast, integrate a mile of race pace into your easy run or finish up with a few strides.

• Noticing aches and pains that you didn't have while in the thick of training Now this is nerve-wracking! By nature, a hard training plan will put you on the edge of injury as you purposefully stress your body in order to crease an adaptive response to increase speed, strength, and endurance. The stresses of training can accumulate and your body may fall behind in tissue repair and energy reserves just as you begin to taper. If you are noticing new pain during running during the final week of training, don't be afraid to skip out on a few of your short easy runs. Missing a few of these in the last week of training is not going to make or break you race, but it might give your body just enough time to repair the broken down tissues.

• Feeling abnormally fatigued If you back off on mileage and intensity, you should start to feel fresh and energetic, right? On the contrary, runners will often find they feel extra fatigued during their taper with "heavy legs" when walking up a flight of stairs, or on their easy runs. I can't clearly explain why this happens, but I believe a lot of this is mental: you know you are about to undertake a significant physical challenge and want to be well rested, so any sense of fatigue can be magnified in your brain. You are likely in a form or subconscious conservation mode. When in the middle of your training, you may have been willing to put out every bit of effort possible to make it through your long tempo run. Your body and brain know better at this point and something inside says "whoa there, hold back and save it for the race."Also, although you have reduced training volume and intensity, your body is still working herd to recover from the previous hard weeks of training. This takes energy! Try not to let these feelings mess with your head. Embrace the fatigue and trust that your body will be ready to roll come race day, especially if you visualize and expect it to.

• Slashing calories because you aren't running as much True, you may not need quite as many as with your highest volume weeks, but remember that you still need adequate fuel to rebuild and repair your tissues, as well as to fill those glycogen stores. Now is not the time to try to drop a pound or two before race day. Being in a calorie deficit is the last thing you need at this point.

• "Carb loading" the day before the race You should be filling your glycogen stores throughout the week prior to the race, not just the day before. The best advice I can give here is not to change your diet the week and day prior to the race. For example, if you don't usually eat pasta, don't feel like you should load up on it the night before. This can lead to a belly ache and many unwelcome pit stops during the run.

• Feeling antsy to run more because you simply just love running It makes sense that most people training for a running race love to run. Often runners who don't get to run as much as they want can get grumpy or antsy to run. Inherently, you should be running less than you are used to during a taper. Try to be proactive with this and make a list of things you want to get done in place of running. Mentally prep yourself for swapping a little of your running time for something else. With the amount of time that you have likely put into training, there is surly something out there that you have fallen behind on- garden, laundry, a good book... Enjoy every second of your shortened workouts and know that soon enough, you will get your fill.

• Your physical therapist, doctor, or coach told you to take 4-5 days off to let one of those aches/pains calm down for the race Luckily, as previously discussed, you won't lose your fitness in a few days of no running. The biggest problem here is that you may begin to doubt your body and lose confidence that you can achieve your personal race goals. Best thing to do is let your body rest and rebuild for these 4-5 days (or sometimes longer if needed/possible). During this time, you can visualize yourself running the race and hitting your time goals with no pain. It sounds cheesy, but it really is better than sitting there worried that all of your goals should be forgotten. The day before the race, go for a short test run with some strides (50-100m of faster paced running). If you are still feeling significant pain, then the race will likely not feel much better the following day. If you feel good, then it can give you that mental boost that you may be needing-"maybe I didn't lose it all." While I encourage a positive attitude in this type of situation, it's still a good idea to also mentally prepare for the possibility that the injury may rear it's head half way through, leaving you with the potential choice of dropping out or limping it in. This is always a possibility with racing.

Tom Robertson Photography

• Use your non-running time to visualize your race Just because the hard training is done, doesn't mean you can let up on your mental efforts for success. See yourself at the start and in the first few miles feeling good but not going out too fast. Imagine how you will likely feel in the last 1/3 of the race- tired and like you want to slow down but pushing through and staying strong, relaxed, calm and confident. Visualize yourself catching that second wind and kicking it into the finish line with your goal time displayed overhead. At this point, your physical training is pretty much over, but it is the crucial time for mental preparation.

I hope some of these thoughts help you be as ready as you can be for race day.  

GOOD LUCK MISSOULA MARATHON PARTICIPANTS!!!

Anya Gue, DPT

Endurance Physio Sponsorships

At Endurance Physio, we’re lucky to be able to support some amazing local organizations and events. We are taking this opportunity to share them with you and why we think each is so valuable in our community.

MTB Missoula  

MTB Missoula’s mission is to promote the development and sustainability of mountain biking in the Missoula area.They ensure the sustainability of existing trail resources, provide sustainable trail building expertise, and serve as a unifying voice for the mountain bike community in the Missoula area. They work towards this mission through community outreach and events, and through rider and youth education.

Some recent milestones that MTB Missoula has accomplished include: Maintaining over 80 miles of singletrack for the benefit of all user groups; building bike-optimized trails within riding distance of town; collaborating with wilderness groups to protect access to beloved alpine rides; and promoting the Missoula XC and the Western Montana Trail Series, popular events that cater to a wide range of riders

Endurance Physio understands and appreciates the time, hard work, and financial resources that it takes to open, build, and maintain trails. The board and staff of MTB Missoula have an inspiring passion for creating mountain biking opportunities in Missoula and work tirelessly towards their mission. We’re honored to be able to support the great work of MTB Missoula and look forward to seeing what they accomplish next!

Find out more about MTB Missoula, their mission and events here: http://www.mtbmissoula.org/

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RATPOD

The annual Ride Around The Pioneers in One Day is a highly anticipated fundraiser comprised of 126 miles of cycling through the beautiful Big Hole valley in Southwest MT.

RATPOD is the single largest fundraiser for Camp Mak-A-Dream, a cost-free camp in western Montana for children, young adults and families affected by cancer. Their mission is to provide cost-free Montana experiences, in an intimate community setting for children, teens, young adults, women and families affected by cancer, as well as programs for children who have a sibling or a parent with cancer.  Since opening its doors, Camp Mak-A-Dream has welcomed thousands of participants from across the United States, Canada, and several other countries.

Talk about a great cause! The RATPOD team wants to make sure every dollar possible benefits Camp Mak-A-Dream. To help with that goal, Endurance Physio is excited to help cover race-day expenses this year. We’re also inspired to complete the ride ourselves. You’ll see Anya there this year - give her a shout!

Follow this link to learn or about or register for RATPOD: https://ratpod.org/

To learn more about the great work and mission of Camp Mak-A-Dream, click here: http://www.campdream.org/

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MT Alpha

MT Alpha Cycling Team is the region’s first premier women’s mountain bike race team. Through trail maintenance, skills clinics, event volunteering and racing, they support the growth and development of mountain biking in our community, creating lifelong friendships along the way.

MT Alpha is equally as dedicated to developing young riders. The MT Alpha Junior Development Team is a safe place where young girls can go to develop new skills, practice as a team and travel to races around the state. The annual MT Alpha skills clinic is open to ladies and junior boys and girls. The MT Alpha team leads lessons in everything from bike comfort and braking to downhill riding and cornering and wraps up with an afternoon group ride.

Endurance Physio loves the passion these women share for mountain biking, youth development, mentorship, and creating more opportunities for everyone to enjoy the great trails around Missoula! We are proud to support the team, doing our part to keep them healthy and rippin’ trail!

To learn more about MT Alpha, join the team, or learn more about their skills clinics, visit their webpage here: http://www.mtalphacycling.org/

Success Story: Sarah!

Congrats to Sarah on completing her first Spartan Race! Sarah has worked extremely hard to overcome both the physical and mental hurdles of battling running injuries. When they come at you one right after another, it takes a lot of patience and persistence to stick with the process of rehabilitation and cross training, even when it feels like there is no light at the end of the tunnel.

My motto for Sarah is:

"If you run to get fit, you are tempting injury. If you get fit to run, you feel better, run faster, and finish badass spartan races!"

Way to go Sarah! Your hard work has paid off!

What makes Endurance Physio unique?

By Jamie Terry, DPT, SCS, CSCS

I often get asked, “What makes Endurance Physio different from every other physical therapy clinic in Missoula?” I think a few wonderful things make us unique and set us apart in this amazing community full of great physical therapists. The first thing is size. The clinic is small. You will see Anya or myself for your care, and the entirety of your care. This is our quality control. We are strong believers in continuing education, evidence based practice and providing the best possible care to our patients. This is our passion. Being a small clinic, we are also able understand our patients’ insurance plans and educate them on their coverage to help keep their costs down. Anya and I know what it’s like to be injured and not able to do the things we love. We would never want cost to get in the way of getting you back to what you love. So we don’t let it.  

Our approach to patient care is unique. We teach our patients how to activate the right muscles, apply that activation to movement and load that movement to improve strength. All too often I see patients who have missed a piece of the puzzle. Sometimes the right muscle wasn't firing at the right time. Sometimes the correct way to move through the correct joint was misunderstood. Occasionally the tissue wasn't loaded enough to cause strength changes. My goal is for my patients is to feel changed when they finish their care here and have all the pieces to the puzzle-- stronger, more knowledgeable about why they had their pain, and how to avoid getting into the same situation again. Recovery from injury takes commitment and hard work with proper guidance. We are fortunate to help guide this process.

Another unique aspect of our clinic is that we refer-out when appropriate. If I think my patient would benefit from a 3D running analysis at the University Movement Science Lab, I’ll send him/her over. If my patient is suffering from vertigo, lymphedema, or another area I don’t specialize in, I will send them to a physical therapist with advanced training in that area of treatment. We keep our patients' best interest at the forefront of our care. Missoula has so many amazing services to offer, and we believe that helping our patients find these services to facilitate their plan of care is a big part of our job.

Anya is unique. Her resume in the running world is impressive to say the least. She was a collegiate pole vaulter and has evolved into one of Missoula’s best female trail runners. She is as passionate about her patients as she is about running and that’s why she is the only one I want to work beside. I have had the opportunity to work and learn from many amazing therapists over the years, but Anya has inspired me the most. Anya has applied herself to physical therapy for runners and gait mechanics at a level that supersedes any other therapist in this community. If running is your jam and you are hurting, this is your girl. Hands down.

The main thing that sets us apart from other clinics in Missoula is we are sports specialists. Many clinics are afraid to declare a specialty at the risk of turning away potential patients. I know through specializing we can provide better care. You wouldn’t go to a orthopedic surgeon if you had a stomach ulcer. You wouldn’t go to a dermatologist if you had a neurology problem. The medical field supports specialization to provide patients with the best possible care. Physical therapy is no different. I am one of 3 board certified sports specialist in Missoula and the only one that is residency trained. This means I went to an additional year of school to focus on sports physical therapy and specialize my care. I also am a certified strength and conditioning specialist.

I grew up competitively ski racing, playing volleyball, and playing basketball. I continue to bike race, run, practice yoga, practice pilates and lift weights. I practice what I preach. I understand your sport from personal experience and advanced education. I am also a mom. I know how hard it is to get back in the game after having a baby. I think that makes me unique and all the hard work helps me relate to my patients. Anya and I are both athletes and specialize in helping people return to their active lifestyle. This is the main thing that sets us apart from other clinics in this amazing community. We are so lucky to live and work here and proud to be specialists in helping athletes get back to the things they love.

Photo Credit: John Sieber Photography

Photo Credit: Tom Robertson Photography

Photo Credit: Vo von Schlen

Photo Credit: Owen Gue

How to Safely Increase Your Running Mileage

One of the primary causes of running injury is increasing mileage too quickly. Although it's not even February, some folks are beginning to think about ramping up mileage whether it's training for Boston Marathon or an early season 50k (anyone else signed up for Chuckanut 50k on March 19th?). I am sharing a useful, evidence-based guideline for safely increasing your running mileage. Feel free to email me with any questions regarding this article at endurancephysioanya@gmail.com.

Sorry about the small print. I have re-typed the smaller print below if you are having difficulty reading.

New insights

Although runners, coaches, and health care providers commonly use the 10% rule, more science is needed to understand its role in injury prevention. Researchers followed 873 new runners for 1 year; during this period, 202 runners had a running-related injury. The researchers compared runner injuries based on each participant’s weekly increase in running distance: less than 10%, 10% to 30%, and more than 30% in the

2 weeks prior to injury. Runners who increased their mileage by more than 30% had a higher injury rate than those who increased their mileage by less than 10%. Runners who ran farther faster were at higher risk for patellofemoral pain (runner’s knee), iliotibial band syndrome, medial tibial stress syndrome (shin splints), patellar tendinopathy (jumper’s knee), greater trochanteric bursitis, and injury to the gluteus medius or tensor fascia latae (see illustration). However, other types of injuries were not linked to the 10% rule, such as plantar fasciitis, Achilles tendinopathy, calf injuries, hamstring injuries, tibial stress fractures, and hip flexor strains. The authors suggest that these injuries may be related to other training errors. 

Practical advice

A sudden increase in weekly running distance by more than 30% over a 2-week period may put runners at increased risk for developing running-related injuries. The lowest injury rates were found in new runners who increased their weekly mileage by less than 10% over 2 weeks. However, other running injuries may be linked to running pace, increasing running speed, sprint training, or other training errors. If you are starting a running program, your physical therapist can help customize a safe running progression to meet your needs. For more information on a personalized running program, contact your physical therapist specializing in musculoskeletal disorders and running-related injuries. 

Running Injury Prevention Tip for the Weekend

You should not run to get fit, you have to be fit to run.

Ask yourself, is your body "fit" for the daily recreational tasks you ask it to perform? January-March is a great month to get yourself fit to tolerate the mileage and racing you may have planned for the warmer months. Here are two scenarios that I implore you to avoid:

1. Neglect to perform additional strengthening and cross training during the off-season and find yourself disappointed in your performance at your first race in May. You could tell that you lacked the power to get up those hills as quickly as your fellow racer and you decide you had better start doing some extra strengthening in order to "get your butt in gear" for your next race in June. So, you hit the high intensity strength workouts at your local fitness center. Your body's tissues can't take the additional loads from strength training in addition to continued increase your weekly mileage, and you end up with muscle strain or tendonitis, forcing you to take weeks off of running.

2. Decide that you want to "get fit" as a new years resolution and start running off-the-couch as your method to do so. After 3 weeks of running for 30 minutes every day on your lunch break, your knee starts to hurt, and you give up on running. I'm not saying you shouldn't start running, just make sure your progression is gradual (10-20% increase in weakly mileage) and assure you are performing some routine strengthening routine in addition to a gradual increase in your running mileage. Strengthening should focus on core and hip stability exercises as well as dynamic single leg balance and squatting.

Feel free to email me with questions at endurancephysioanya@gmail.com.

Thanks for reading! 

Christmas Vacation Recap from Endurance Physio - Missoula Physical Therapy

Endurance Physio took a few days off for the Holidays to celebrate family and play in the snow. We hope you all got to spend a few days celebrating with loved ones and doing whatever it is that makes you happy!

                     Hilary and her husband John took advantage of a powder day at Big Mountain Resort

Anya got to skate ski with her Dad and Sister. Blue sky, and good company made the 10 degree temps and 40 mph winds tolerable and fun! Photo credit: Owen Gue (who was keeping the pace up in order to keep our lungs burning and toes warm)

Anya and her Dad -  A wood chopping family affair. Photo credit: Owen Gue (who was the master wood-chopper when not taking photos)

                  Jamie skate skis with her husband Doug on the pristine Whitefish nordic trails.

                    Jamie hit the slopes with Sabine

Followed by enough hot chocolate to make anyone loopy!

Like mother-like-daughter. Sabine is quickly turning into a little ripper and is totally loving it!

Happy Holidays!!!