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Tibialis Anterior – The missing link to pain free legs and performance?

Tibialis Anterior – The missing link to pain free legs and performance?

by | May 16, 2023 | Ankle and Foot, Return to Sport, Running Injuries

Shin splints? Painful knee with jumping? Recurrent ankle sprains? These are the types of injuries we fix day in and day out at Praxis Physio. There are number of recommended paths for rehabilitation in theses injuries backed by the research and our clinical experience, but has the evidence been missing something? There is some social media traction in the fitness and exercise world recently around tibialis anterior (TA) loading as a ‘cure all’ for every lower limb injury. Being the physio nerds that we are, we looked in to it for you!

The tibialis anterior is located on the front (anterior) portion of the shin (tibia) – hence the name. Its role is to lift the foot (dorsiflex) the ankle as well as provide some stability for the outside of the ankle . This action is key for movements in walking and running especially in negotiating steps and hills as the foot needs to clear a certain height before landing. It is also very important in landing from a height and changing directions rapidly, as it acts as shock absorber for the knee and ankle joints (reference).

Like any muscle or joint in the body, the TA is not without its problems. Physios are regularly confronted with patients who complain of pain and stiffness around the muscles of the shin. Such conditions may include shin splints, compartment syndrome, patellofemoral pain syndrome (aka runner’s knee) and general ankle joint pain and stiffness post ankle sprain.

As mentioned, there has been a lot of discussion lately in the strength and conditioning community about whether training this muscle can prevent or treat musculoskeletal conditions, such as the ones mentioned above. Anecdotally, training of the TA has been described several benefits. Specific athletes have explained that they have seen improvements in vertical jump height, running speed, running stamina and squat depth. From a prevention and treatment point of view, it has been said that training the TA has helped improve symptoms associated with knee pain, ankle pain and shin splints. Also let us not forget, that from an aesthetics point of view, a strong and bulky looking TA does make our legs look more attractive, as bodybuilders would argue.

Unfortunately, the scientific community has not provided strong evidence that training the TA can aid in affecting the above musculoskeletal pathologies, or attain the performance benefits. So what do we know from previous scientific literature? Well, Munoz et al (2015) describes the tibialis anterior as key during an efficient gait cycle as well as being critical for balance control. Furthermore, an increase in strength of the TA helps greatly reduce the risk of falling. Maharaj et al (2019) confirms that during walking and running , TA’s tendinous tissue absorbs energy during contact and controls foot position during swing.

The proposed mechanisms to aid in athletic performance include:

  1. Increased ankle stability: Strong tibialis anterior muscles provide better stability to the ankle joint during jumping movements. This stability allows for improved force transmission from the lower leg to the foot, enabling athletes to generate greater power and maintain proper alignment during takeoff and landing.
  2. Enhanced dorsiflexion range of motion: Adequate dorsiflexion range of motion is essential for optimal jumping performance. Strengthening the tibialis anterior helps to improve flexibility and mobility in the ankle joint, allowing athletes to achieve a greater degree of dorsiflexion during the pre-jump phase. This increased range of motion enables a longer and more powerful push-off, resulting in higher jumps.
  3. Improved jump height and explosive power: The tibialis anterior plays a significant role in generating propulsive force during the takeoff phase of a jump. By strengthening this muscle, athletes can produce a more forceful and efficient push-off, leading to increased jump height and explosive power. The ability to generate greater force through dorsiflexion contributes to a more powerful and effective jump.
  4. Injury prevention: Weak tibialis anterior muscles can contribute to imbalances in the lower leg, potentially leading to various conditions such as shin splints or ankle sprains. Strengthening this muscle group helps to maintain proper muscle balance around the ankle joint, reducing the risk of injuries that could hinder jumping performance.

So if we are to believe TA holds the key to athletic performance and injury mitigation, how do we unlock it?

To strengthen the tibialis anterior, physiotherapists often prescribe specific exercises that target this muscle, such as toe raises, resisted dorsiflexion exercises, or using resistance bands to provide resistance during dorsiflexion movements. These exercises should be performed in a controlled manner and progressively increased in intensity to promote muscle strength and endurance. Below you see variations on how you can load the TA and progress and regress it respectively. Remember that we need to treat the TA like any other muscle we are wanting to train – progressively overloading it!

As Physiotherapists, we greatly value and adhere to evidence-based practice, however one could argue that this particular muscle has not received the scientific study treatment it rightly deserves. So if you are having some lower leg issues, or haven’t quite got that bounce you are wanting, come and chat to one of our friendly and knowledgeable staff. We can do a full assessment and put the spring back in your step!

Until next time, Praxis what you preach!

Prevent. Prepare. Perform

References:

Maharaj JN, Cresswell AG, Lichtwark GA. Tibialis anterior tendinous tissue plays a key role in energy absorption during human walking. J Exp Biol. 2019 Jun 4;222(Pt 11):jeb191247. doi: 10.1242/jeb.191247. PMID: 31064856.

Ruiz Muñoz, M., González-Sánchez, M. & Cuesta-Vargas, A.I. Tibialis anterior analysis from functional and architectural perspective during isometric foot dorsiflexion: a cross-sectional study of repeated measures. J Foot Ankle Res 8, 74 (2015). https://doi.org/10.1186/s13047-015-0132-3

Fact or Fiction Friday – Lower back Pain and MRI’s

Fact or Fiction Friday – Lower back Pain and MRI’s

by | Nov 8, 2022 | Lower Back, Pain

I need to get an MRI to help with the management of my lower back pain

Answer – FICTION

In a recent narrative review, Wang and colleagues (2018) concluded that MRI imaging in the early stages of lower back pain can have detrimental effects including more pain, less improvement, higher risk of surgery and worse overall health status. In fact, one study reported that patients that received an MRI within the first month had an 8x greater risk for surgery and 5x more medical costs!

If you do NOT present with severe neurological deficits, signs of a serious or specific underlying condition or have persistent pain >6 weeks which is unresponsive to conservative treatment then there likely isn’t a need for further investigation!

To get help with your long standing back pain or even that acute flare up, give us a call on (07) 3102 3337 or book online  so we can sort you out.

#praxiswhatyoupreach #praxisphysio #factorfictionfriday #physioeducation #preventprepareperform #pain #backpain #lowerbackpain #MRI #patienteducation

Wang Y, et al. Informed appropriate imaging for low back pain management: A narrative review. Journal of Orthopaedic Translation. 2018.

Blood Flow Restriction – more than just a gimmick?

Blood Flow Restriction – more than just a gimmick?

by | Oct 11, 2022 | ACL, Gym and Strength, Knee, Reformer Pilates, Return to Sport

Summary:

  • Restriction of blood flow purportedly creates an internal environment of greater stress, thus greater adaptation
  • Importantly, the greater adaptation can occur with less absolute load to damaged or painful tissues
  • Started in healthy population to build muscles but the principles are transferable to rehabilitation
  • Best suited persons who are unable to tolerate normal load
  • Post surgery, tendinopathies and people needing to arrest atrophy or build muscle fast are best candidates

Blood flow restriction (BFR) training is becoming increasingly popular in rehabilitation and conditioning settings. As the name suggests, BFR training incorporates a restriction of blood to an area paired with low resistance training (20-50% of 1 rep maximum). The principle is to achieve greater muscle strength and hypertrophy gains for healthy and load-compromised populations with the same or less load than without a cuff. Essentially – more bang for your buck in the early phases of rehabilitation!

Benefits of BFR include; prevention of muscle mass in early post-operative periods, similar benefits of muscle mass and strength as heavier resistance training in achilles tendinopathies (>70% 1RM) (Centner et al, 2019), and improvement in maximum voluntary torque.

 

Whilst research is still being developed, multiple studies have been conducted recently showing the benefits of BFR training in post-operative populations ie. ACLR, patella / achilles tendinopathies, as well as knee osteoarthritis and patellofemoral pain syndrome.

Here at Praxis Physiotherapy, we have used a BFR cuff paired with low-resistance training on the reformer pilates and in the gym to optimise the distal quadriceps strength post ACL surgery. As you can see we are putting to the distal quadriceps to fatigue under a small amount of load, thus preventing muscle loss (Prue, et al. 2022) which can be common postoperatively.

General prescription guidelines according to the Australian Institute of Sport recommend that “the application of BFR should be limited to less than 20 minutes for lower limb, and 15 minutes for upper limb, before allowing adequate time for reperfusion of tissues (3 min).” (AIS, 2022).

In summary, this is an exciting new area of research that we are investigating clinically. Anecdotally, we hear from patients that they fatigue earlier in the desired muscle groups. We as a Praxis Team are embarking on some in clinic research in the area and hoping to provide feedback on our experiences so keep your eyes peeled. In the meantime, if you are pre or post your operation and are looking to maximise your recovery, come and have a chat with us about whether BFR is suitable for you!

Until next time,

Prevent | Prepare | Perform

Team Praxis

Jumper’s Knee (Patellar Tendinopathy)

Jumper’s Knee (Patellar Tendinopathy)

by | May 17, 2022 | Knee, Return to Sport, Sports Injury, Tendon

Do you play a jumping sport such as volleyball, basketball or AFL? Have pain in the front of your knee when jumping, landing or changing direction? Have you lost some jumping power recently? Well read on friends as you may have a grumbly knee tendon.

Summary:

  • Patellar tendinopathy is summarised clinically as pain and dysfunction in the patellar tendon
  • Most commonly affects jumping athletes from adolescence to early middle age.
  • Return to sport can be slow with physio useful as a front line management tool
  • Often requires prolonged rehabilitation centred around education, strength training and load management

Jumper’s knee (or patellar tendinopathy) as its name suggest predominantly affects athletes who engage in sports which require large volumes of jumping. Jumping dynamically loads the knee and places large loads on the patellar tendons due the large and repeated requirements of the thigh muscles (quadriceps). These include sports that require repeat jump / landing efforts and/or high volumes of load during training and competition. Elite adolescent male athletes tend to be at a higher risk, especially if you play volleyball.

Mid Potion Achilles Tendinopathy Location

Like most injuries, patellar tendinopathy reflects an overload of the tissue and a failed healing response. Tendons tend to most susceptible to long periods of dynamic loading given their role in storing and releasing energy like a spring. The stiffer the spring, the more effective the spring and the more punishment it can take before the function deteriorates.

This injury is one that can be mild or moderate in nature and as such allow playing to some degree. As such, player’s tend to not to miss a lot of games like more “traditional” injuries such as ankle sprains or hamstring tears. It can typically slowly present and have a “warm up phenomena” (as in it can get better during a game), however aches after activity and the next morning. The pain is often at the very bottom of the knee cap, and on the space between the kneecap and the top of the shin bone where the tendon lies.

Key management strategies include ensuring the correct diagnosis and an understanding of tendon pathology (for more on tendon pathology, check out this blog). From there, pain management strategies and workload management is a key tenant to rehabilitation. Above and beyond workload management and good patient education, we at Praxis Physio also test the strength and range of the hip, knee and ankle musculature as well as jumping / landing biomechanics to understand where the likely reasons are for your knee pain.

After a comprehensive assessment, targeted and graduated strengthening is provided. The premise of these early phases are to reduce pain, improve strength, improve function, increase power (specifically the energy storage potential of the tendon) then finally sports specific training and management on symptoms.

As someone who has had an 18 month history of patellar tendinopathy, I personally can attest to the frustration this injury provides. I made many mistakes along my rehabilitation journey – though this was before I was a physiotherapist and took a clinical interest in tendinopathies. Thankfully, the research has come a long way in the last decade, so if you are having ongoing knee pain that you suspect is jumper’s knee, book in with us so we can get you jumping back to your best.

Until next time, Praxis what you Preach.

Stephen Timms

Peri-Menopause and injury – your guide to the most common issues

Peri-Menopause and injury – your guide to the most common issues

by | Mar 17, 2022 | Gym and Strength, Reformer Pilates

  • Menopause alters hormones and results in physical changes
  • These changes typically result in increased injury risk or activity reduction
  • The most common injuries affect structures such as the plantar fascia, tendons of the hip and shoulder
  • Appropriate exercise and judicious hands on therapy should be cornerstones of management
Betty Friedan said it best when she said “Aging is not lost youth but a new stage of opportunity and strength.” If only our bodies would play the game and come along for the ride as Betty wishfully thought. Age related transitions such as menopause often results in physiological changes (as outlined in other blogs) is an increase in weight, a loss of muscle and bone mass and a drop in physical activity. Not something anyone would wait in line for. A spiral of further activity loss, deconditioning and ultimately, injury can easily occur as a result. As a physiotherapist who looks after everyone from elite athletes, to weekend warriors to desk jockeys, I see the frustration injuries cause my patients (and myself!). So, in the interests of helping you enter the chapter of “opportunity and strength”, these are the most common injuries I see on a daily basis in perimenopausal women and what to do about them.

Heel pain – Plantar fasciopathy (the injury formerly known as plantar fasciitis)

Heel pain can be a number of things. The heel pain that I tend to see the most of is the one that feels like you are walking on glass the first thing in the morning or after you have been sitting down for a while. It makes you walk like your Grandma used to for those first few steps and the thought of doing a long walk, or heaven forbid wearing heels, gives you the sweats.

This pain is usually characterized by a condition called plantar fasciopathy. The plantar fascia is designed to help to absorb, store and transfer force during walking, running and jumping activities. Collagen (the main protein based building blocks of the body) is a non contractile tissue that sits on the underside of your foot. The attachment point for this tissue, is you guessed it, on the bottom of your heel where that “burning glass” feeling .

Plantar fasciopathy loves the status quo. It likes loading the same way, at the same intensity, at the same volume day in day out. Pain and dysfunction is brought about typically in a sudden increase in dynamic loading, whether that is walking, running or jumping. This often happens with women hell bent on a health kick to lose those extra kilos. With the shoelaces tied, lycra on and the world your oyster, some women start at where they remember they left their exercise behind, often several years (and children) ago. The resultant spike in load, particularly dynamic loading coupled with musculoskeletal detraining, is what kicks off the pain as the plantar fascia gets overloaded more easily and grizzles about it.

Key tip – Start slow with walks – not running – if it has been a while since you last exercised. Progress to jogging with some walk intervals in there (e.g 30s jog, 90s walk). Do calf raises (eg. 3 sets to a feeling of semi-fatigue) to get more calf strength as this can help deload the plantar fascia.

Outside / Lateral hip pain (Gluteus medius tendinopathy)

The muscles on the outside of your hips are designed to help keep your pelvis level when you are walking or running. This area is a particular passion of mine given my masters thesis was based on the single leg squat. Similar to the plantar fasciopathy, gluteal tendinopathies tend to be an injury that I see when people go too hard, too quickly. This results in outside hip pain that hurts rising from a chair, walking up stairs or even lying on that side at night.

The human instinct is to rest, but tendinopathies don’t work that way, in fact it is the opposite. The only way to adequately address issues such as gluteal tendinopathy is getting on top of your workload. Ensure you are graduating whatever activity you are re-engaging in appropriately, and you have the strength to do so. I typically use a hand held dynamometer in my clinic to assess someone’s strength to give me accurate numbers to work with. However, a rough guide is that if you can do a side plank for 30 seconds, you need some more hip strength.

Key tip – Workload management and pain management are paramount. If in pain, reduce loading and focus on strength. Lying hip lifts (e.g. 10 x 10 sec holds) are good when pain is acute. If not sore (just weak), side plank with top leg lifts are a good option to start. 3 x semi-fatigue each side. We employ reformer pilates often in this space but gym based activities are also appropriate.

Shoulder Pain – “Rotator Cuff” tears / tendinopathy

Do you have a ‘good’ and ‘bad’ shoulder? Have you been putting up with that grumbly shoulder for weeks, months or even years? Shoulder pain can put a real dampener on activities where repetitive overhead dynamic loading is common (e.g weights, tennis, golf or boxing).

The “rotator cuff” is a group of four muscles that help provide stability and control of the shoulder joint through range, particularly overhead. Rotator cuff tears are common in individuals over the age of 40 with linear increase in incidence as we get older. The most common reason for rotator cuff tears are due to overactivity of the shoulder joint coupled with deconditioning of the shoulder complex. Pain with movement and function is one of the biggest symptoms of a rotator cuff pathology.

Key Tip – Look at how much overhead activity you are doing and adequately prepare for it. This is best achieved in my experience with something like a banded Y Press hold (10x10s holds daily for a month) then progressing to more dynamic activities.

All in all, changes associated with menopause can leave you open to more injuries. However, if you can appropriately navigate, and most importantly graduate, your return to physical activity, then your body will certainly pay you dividends down the line. The evidence is overwhelming for the positive influences physical has on the human body. So do yourself (and your future self) a favour and ensure you aren’t retreating from your physical activity goals due to injury. It’s not what Betty would want.

If you have some of the above aches and pains, feel free to reach out or book in with one of our expert therapists.

Until next time, Praxis what you Preach.

Stephen Timms

All information is general in nature and it is always best to see your local physiotherapist, who uses exercise as the cornerstone of your rehabilitation.