Fact or Fiction – Strength Training

Fact or Fiction – Strength Training

I’ve been doing my exercises for two weeks religiously and I’m no stronger! This will never work!

ANSWER: Fiction

How Long Does It Actually Take?

How long does it take to have strength gains? The answer is actually in two parts. Increasing muscle size (hypertrophy) takes a minimum of 6 weeks, and repetitive exposures to fatiguing loads. BUT, neural adaptations can occur over the first 1-2 weeks.

What Are Neural Adaptations?

What the heck is neural adaptations? Imaging you have a small car battery trying to start a truck. It will struggle to do a good job again and again and fade easily. Now try using 10 of those same smaller batteries, which makes the engine start easier. A similar type of thing happens with our nervous system as we train. We become much more efficient with our neural firing to the muscle.

As you can see in the picture below, you have a long way to go in your strengthening after those first two weeks. That is often why we often need to see beyond when the pain goes away as we know that there is so much more work to be done!

If you have been troubled by niggles and pains, don’t hesitate to contact us to ensure we can help you prevent prepare perform! Book online or call us on (07) 3102 3337.

#factorfictionfriday #praxisphysio #physioeducation #knowledgeiskey

Sale, D. G. (1988). Neural adaptation to resistance training. Med Sci Sports Exerc, 20(5 Suppl), S135-145. doi:10.1249/00005768-198810001-00009

Until next time, Praxis What You Preach

📍 Clinics in Teneriffe, Buranda, and Carseldine

💪 Trusted by athletes. Backed by evidence. Here for everyone.

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Chronic Groin Pain (Athletic Pubalgia)

Chronic Groin Pain (Athletic Pubalgia)

GROIN PAIN

Groin pain, referred to also as athletic pubalgia, is a common problem for a number of athletes, particularly those who engage in sports that require specific use (or overuse) of lower abdominal muscles and the proximal muscles of the thigh. Predominantly, these activities centre around kicking sports such as AFL and soccer, as well as long distance running. Ice hockey is also a well renowned sport in which chronic groin pain occurs. All these sports involve repetitive energetic kicking, twisting, turning or cutting movements, which are all risk factors for causing pubalgia.

SUMMARY:

  • Four structures are commonly implicated in the causes of groin pain
  • Adductor muscles
  • Pubic bone
  • Abdominal wall
  • Iliopsoas
  • Understanding which of these four structures is causing your pain is key in effective management
  • Exercise therapy and activity modifications should be the mainstay of treatment
  • Absolute rest has been shown to be ineffective
  • Steady gradual progressions through strength and function, tailored to your goals, is key to successful management
Mid Potion Achilles Tendinopathy Location

ROLE OF HIP ADDUCTORS (groin muscles)

Similar to other joints in the body, the hip relies on muscular control for stability and movement. At the hip, there are five key planes of movement; flexion, extension, abduction, adduction and rotation.

The adductor muscles are a large group of muscles located on the inner side of the thigh, attaching from below the knee, along the shaft of the femur and into the pubic bone of the pelvis.

While acute tears of the adductor muscle is common, more long standing pain is usually the result of an overload of the adductor tendon that attach to the pelvis. This is called an adductor tendinopathy. Adductor enthesopathy is common disorder which effects the bony attachment point of the tendon, with a slight structural difference from tendinopathy, however, management is similar in both cases

MANAGEMENT OPTIONS

Exercise:

Strength and functional based exercise are the core management strategies for adductor tendinopathy, and have been shown to increase function, decrease pain and reduce likelihood of injury [4].

Activity Modification:

Activity modification, especially in the acute phase or when symptoms are significantly affecting function, is key in reducing load on the affected structures and allowing tissues to adapt. [1]

Rest:

While activity modification is important, absolute rest has been shown to be ineffective in the management of adductor tendinopathy, and does not promote adequate tissue repair. [1,2]

Other:

Other conservative measures such as manual therapy, electrotherapy and stretching have been [1] explored, with reduced effect compared exercise prescription. Surgical management is also a potential option, with some positive results emerging for groin pain, though specific evidence [10] around adductor tendinopathy is limited. [10]

Photo from the Praxis Physiotherapy article: Chronic Groin Pain (Athletic Pubalgia)

WHY IS EXERCISE IMPORTANT?

Exercise has been shown to increase tendon turnover, meaning in the first 24-36 hours there is a reduction in tendon integrity, but after that there is an overall increase in integrity and strength. Other benefits include: increased blood flow, increase in growth factors, and a reduction in altered pain processes in the brain [14].

WHAT’S THE BEST EXERCISE?

Isometric exercise has been shown to be effective in short term pain relief. Current evidence is unclear as to the best long term exercise strategies, with evidence supporting both eccentric and heavy-slow isotonic exercise. [12]

Photo from the Praxis Physiotherapy article: Chronic Groin Pain (Athletic Pubalgia)

EXERCISE PLAN

The Copenhagen Adductor Program [9], with the below dosage, has been shown to significantly improve adductor strength, as well as being effective in groin injury prevention. It is important to note that though the program is eight weeks long, most effective tendon[12] adaptations take ≥ 12 weeks, and a tailored dosage should be discussed with your physiotherapist towards the end stage of rehabilitation.

Depending on how the symptoms affect your function, a reduction in training, running and kicking may also be required. Example progressions are noted below in the running program, in order of loading on adductors.

Photo from the Praxis Physiotherapy article: Chronic Groin Pain (Athletic Pubalgia)

ADDITIONAL STRENGTH AND PROGRAMS

While targeted strengthening to the adductors is key, global strengthening around the hip may also aid in a reduction of loading to the tendon. Thorough assessment of your strength through all five movements noted previously is needed, as well as a tailored training program to resolve any discrepancies.

As symptoms reduce and function improves, part practice of painful activities, can be beneficial to reload structures, for example, banded kicking movements in preparation for return to soccer.

Photo from the Praxis Physiotherapy article: Chronic Groin Pain (Athletic Pubalgia)
Photo from the Praxis Physiotherapy article: Chronic Groin Pain (Athletic Pubalgia)

SUMMARY

In chronic adductor tendinopathy, tendon adaptations take time. It is important to understand this as you begin your rehab journey and not progress more than your body can tolerate. Steady gradual progressions through strength and function, tailored to your goals, is key to successful management.

As always, if you have a history of groin pain or are concerned about performance in your chosen sport, contact us today and chat to one of our friendly and knowledgeable physiotherapist to ensure you can Prevent. Prepare. Perform. Alternatively you can book online here

Till next time, Praxis what you Preach

📍 Clinics in Teneriffe, Buranda, and Carseldine

💪 Trusted by athletes. Backed by evidence. Here for everyone.

References: 

  1.  Almeida, M.O., et al., Conservative interventions for treating exercise‐related musculotendinous, ligamentous and osseous groin pain. Cochrane Database of Systematic Reviews, 2013(6).
  2. Bohm, S., F. Mersmann, and A. Arampatzis, Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults. Sports Medicine – Open, 2015. 1(1): p. 7.
  3.  Brukner, P., Brukner & Khan’s clinical sports medicine / Peter Brukner … [et al.]. Sports medicine series, ed. K. Khan. 2012, North Ryde, N.S.W: McGraw-Hill Australia.
  4. Charlton, P.C., et al., Exercise Interventions for the Prevention and Treatment of Groin Pain and Injury in Athletes: A Critical and Systematic Review. Sports Med, 2017. 47(10): p. 2011-2026.
  5. Frizziero, A., et al., The role of eccentric exercise in sport injuries rehabilitation. Br Med Bull, 2014. 110(1): p. 47-75.
  6. Griffin, V.C., T. Everett, and I.G. Horsley, A comparison of hip adduction to abduction strength ratios, in the dominant and non-dominant limb, of elite academy football players. Journal of Biomedical Engineering and Informatics, 2015. 2(1): p. 109.
  7. Haroy, J., et al., The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial. Br J Sports Med, 2019. 53(3): p. 150-157.
  8. Harøy, J., et al., Infographic. The Adductor Strengthening Programme prevents groin problems among male football players. British Journal of Sports Medicine, 2019. 53(1): p. 45.
  9. Haroy, J., et al., Including the Copenhagen Adduction Exercise in the FIFA 11+ Provides Missing Eccentric Hip Adduction Strength Effect in Male Soccer Players: A Randomized Controlled Trial. Am J Sports Med, 2017. 45(13): p. 3052-3059.
  10. Jorgensen, S.G., S. Oberg, and J. Rosenberg, Treatment of longstanding groin pain: a systematic review. Hernia, 2019.
  11. Kohavi, B., et al., Effectiveness of Field-Based Resistance Training Protocols on Hip Muscle Strength Among Young Elite Football Players. Clin J Sport Med, 2018.
  12. Lim, H.Y. and S.H. Wong, Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review. Physiother Res Int, 2018. 23(4): p. e1721.
  13. Machotka, Z., S. Kumar, and L.G. Perraton, A systematic review of the literature on the effectiveness of exercise therapy for groin pain in athletes. Sports Med Arthrosc Rehabil Ther Technol, 2009. 1(1): p. 5.
  14. Magnusson, S.P., H. Langberg, and M. Kjaer, The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol, 2010. 6(5): p. 262-8.
  15. Rio, E., et al., Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British Journal of Sports Medicine, 2016. 50(4): p. 209.
  16. Thorborg, K., et al., The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. Br J Sports Med, 2011. 45(6): p. 478-91.
  17. Wei, A.S., et al., The effect of corticosteroid on collagen expression in injured rotator cuff tendon. The Journal of bone and joint surgery. American volume, 2006. 88(6): p. 1331-1338.

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Pilates: Mat vs Reformer Pilates (Part 2 of 3)

Pilates: Mat vs Reformer Pilates (Part 2 of 3)

In part one, we unearthed that pilates has a role to play in reducing the severity of chronic lower back pain. In part two, we tackle a common question from our patients and delve further into the research to see if there is a difference between mat and reformer pilates.

Photo from the Praxis Physiotherapy article: Pilates: Mat vs Reformer Pilates (Part 2 of 3)

SUMMARY:

  • A reformer is a large piece of pilates equipment that utilises a spring mechanism to apply load in various positions and degrees of loading from gravity.
  • Both forms of exercise are better than the ‘wait and see’ or pharmacological approach with respect to chronic lower back pain
  • The use of reformers may provide a larger stimuli to the sensory system which facilitates proper performance due to better stabilisation
  • Pilates promotes the restoration of the function of muscles involved in lumbopelvic stabilisation, that is, transversus abdominis, multifidus, diaphragm and pelvic floor muscles (the “core”)
  • Reformer pilates provides more options for strengthening, ideal for those recovering from injury, pregnancy or surgery
Photo from the Praxis Physiotherapy article: Pilates: Mat vs Reformer Pilates (Part 2 of 3)

As a general rule, the aim of pilates is to restore or sustain the motor control of the lumbar spine and proper body posture. Joseph Pilates (the founder of pilates) believed beginning exercise in the horizontal plane was important to relieve the stress and strain on the joints, and to align the body before adding additional gravitational forces while standing, sitting or kneeling.

Both mat and reformer are popular types of pilates which both focus on strengthening. Mat pilates, as its names suggests is a floor based method that tends to use bodyweight as the chief form of resistance.

Reformer, is the most popular equipment of Pilates. The design of Reformer utilises a spring mechanism that the person works to control while moving in various planes (Bulguroglu et al 2017). Reformer pilates allows more exercises compared to a mat and it provides the option of performing exercises numerous body positions – from your back, side, stomach and being seated — and also on your feet or knees.

COMPARE THE PAIR

Not a great deal of research has been conducted on differentiating the two forms of pilates. What studies do exist tend poorly define what equipment was used or whether individual tailoring of the sessions occurred.

Luz et al compared the effectiveness of Pilates mat and equipment-based Pilates exercises (with the use of Reformer) in a group of 86 individuals with chronic lower back pain. The 6-week routine included individual, 1-hour sessions performed twice a week and supervised by a Pilates-experienced physical therapist. The outcome measures were: pain intensity, disability, global perceived effect, patient’s specific disability and fear of movement, known as kinesiophobia (Luz et al 2014). The assessment was recorded after 6-week intervention and 6 months. A significant difference was noted in both groups after a 6-week programme in all of the areas evaluated. After 6 months however, a significant difference was found in disability, specific disability and kinesiophobia in favour of equipment-based Pilates exercises (Luz et al 2014; Eilks et al 2019).

Photo from the Praxis Physiotherapy article: Pilates: Mat vs Reformer Pilates (Part 2 of 3)
In the study by Cruz-Diaz et al, the influence of Pilates mat exercises and equipment-based Pilates exercises (with reformer) on pain, disability, kinesiophobia and activation of transversus abdominis (expressed as a change in muscle thickness and assessed by real-time ultrasound examination) was assessed. The trial involved 98 patients with chronic lower back pan (CLBP) allocated to three groups: Pilates mat exercises, Pilates apparatus or the control group. The programme was conducted in groups of four participants during 12 weeks with 50 min sessions (twice a week). The evaluation was carried out during intervention (6 weeks after baseline) and after 12 weeks. As with Luz et al, significant improvement were shown in both groups for all outcome measures after 6 and 12 weeks. However, in the comparison between groups, the superiority of equipment-based Pilates was noted (Cruz-Diaz et al 2017). In both studies, it was suggested that the finding may be an effect of the use of apparatus in exercises that provides larger stimuli to the sensory system, resulting in larger feedback, which facilitates proper performance due to better stabilisation (Eilks et al 2019). According to da Luz et al, this result may also be caused by a placebo effect inherent for the application of equipment. As noted earlier however, reformer pilates offers a larger scope of exercises to draw upon for those who are limited by pain, weakness or fear of movement. So there you have it. What little research there is suggests that any pilates is good for your rehabilitation or as a part of your ongoing strength program. However, it appears that reformer pilates is more effective, and allows a greater degree of variability of training. For more about what makes Praxis Pilates special, check out our website here. Join us for part 3 next week where we look at what the research suggests regarding the frequency of pilates. Is more actually better?

Until next time, Praxis What You Preach

📍 Clinics in Teneriffe, Buranda, and Carseldine

💪 Trusted by athletes. Backed by evidence. Here for everyone.

References:

  1. Eliks, M., Zgorzalewicz-Stachowiak, M., & Zeńczak-Praga, K. (2019). Application of Pilates-based exercises in the treatment of chronic non-specific low back pain: state of the art. Postgraduate medical journal, 95(1119), 41-45.
  2. da Luz Jr, M. A., Costa, L. O. P., Fuhro, F. F., Manzoni, A. C. T., Oliveira, N. T. B., & Cabral, C. M. N. (2014). Effectiveness of mat Pilates or equipment-based Pilates exercises in patients with chronic nonspecific low back pain: a randomized controlled trial. Physical therapy, 94(5), 623-631.
  3. Bulguroglu, I., Guclu-Gunduz, A., Yazici, G., Ozkul, C., Irkec, C., Nazliel, B., & Batur-Caglayan, H. Z. (2017). The effects of Mat Pilates and Reformer Pilates in patients with Multiple Sclerosis: A randomized controlled study. NeuroRehabilitation, 41(2), 413-422.
  4. Cruz-Díaz, D., Bergamin, M., Gobbo, S., Martínez-Amat, A., & Hita-Contreras, F. (2017). Comparative effects of 12 weeks of equipment based and mat Pilates in patients with Chronic Low Back Pain on pain, function and transversus abdominis activation. A randomized controlled trial. Complementary therapies in medicine, 33, 72-77.

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Pilates: Reforming our back pain rehabilitation (Part 1 of 3)

Pilates: Reforming our back pain rehabilitation (Part 1 of 3)

With our 30 day pilates challenge starting today, we thought we would take a look at why we love pilates so much for our patients, and what some of the benefits are. Part 1 looks at how pilates affect those with chronic lower back pain. Part 2 looks at the difference between mat and reformer pilates and part 3 looks at how often is required to see the benefit of pilates.

SUMMARY:

  • Back pain is extremely common, multifactorial, and often reoccurs
  • Strengthening interventions appear better for long term suffers of lower back pain
  • Pilates has been shown to improve muscular strength and endurance of key pelvic and postural musculature associated with lower back pain
  • Specifically, pilates promotes the restoration of the function of muscles involved in lumbopelvic stabilisation, that is, transversus abdominis, multifidus, diaphragm and pelvic floor muscles
  • As little as 2 sessions per week for 6 weeks has been shown to see improvements in pain and function for those with longstanding lower back pain, even after stopping pilates

Chronic low back pain (CLBP) is one of the commonest musculoskeletal problems in modern society (Anderson 1999) and is a highly prevalent in both the sporting and general public. CLBP is experienced by 70%–80% of adults at some time in their lives (Crombez et al 1999) and as such, the costs associated with LBP and related disability are enormous, causing a major economic burden for patients, governments and health insurance companies (Dagenais 2008).

Lower back pain has been one of the most extensively studied musculoskeletal conditions as a result of the prevalence and debilitation nature. Its management comprises a range of different intervention strategies including surgery, drug therapy and non-medical intervention like rehabilitation (Paolucci et al 2018). Within Physiotherapy, exercise therapy is probably the most commonly used intervention for the treatment of patients with chronic non-specific LBP due to its plausible biological rationale and low cost.

Whilst general conditioning programs to train strength and endurance of the spine musculature have been shown to reduce pain intensity and disability (Rainville et al 2004), the popularity of pilates (both mat and reformer) has helped provide an accessible and supervised form of therapeutic exercise.

Photo from the Praxis Physiotherapy article: Pilates: Reforming our back pain rehabilitation (Part 1 of 3)

EVIDENCE FOR PILATES

The Pilates method, using functional exercises aims to improve muscular strength and endurance. Specifically, the pilates method have promotes the restoration of the function of muscles involved in lumbopelvic stabilisation, that is, transversus abdominis, multifidus, diaphragm and pelvic floor muscles. Using the principles of progressive overload, your body adapts to the incremental loading week after week and consequently results important postural control improvement. In 2009, Curnow and colleagues showed that the Pilates method improves load transfer through the pelvis, something that intuitively helps those with CLBP.

However, a systematic review (Patti et al 2015) reported evidence that Pilates method-based exercises are more effective than no treatment or minimal physical exercise interventions in the management of chronic nonspecific LBP. Further, they pointed out that the effects of the Pilates method are only proven for patients with chronic nonspecific LBP in the short term.

A recent study by Natour and colleagues (2015) showed that the group of participants that were practicing Pilates method resulted statistically better compared with the a non exercising group who only used inflammatory medication. Those who were in the pilates group used less pain medication at 45, 90 (conclusion of the Pilates method), and 180 days, 90 days after the conclusion of the exercise program.

In conclusion, Pilates as an exercise choice is more effective than minimal physical exercise or drug based interventions in reducing pain and disability in the short-term period. There is agreement that exercise “helps” in the treatment of chronic pain, but it is still not clear exactly which factors or particular kind of exercises may be responsible of such improvements (Natour et al 2015; Patti et al 2015). Praxis Physiotherapy has always been a strong proponent of movement and loading early in rehabilitation (more on this in later blogs!).

In the next instalment, we discuss the difference between mat and reformer pilates and perhaps find some more answers regarding which exercise regime reigns supreme!

Check out all our other reformer pilates services on our website

Until next time,

Until next time, Praxis What You Preach

📍 Clinics in Teneriffe, Buranda, and Carseldine

💪 Trusted by athletes. Backed by evidence. Here for everyone.

References:

  1. Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999;354(91789178):581–585.
  2. Crombez G, Vlaeyen JW, Heuts PH, Lysens R, Crombez G. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80(1-2):329–339.
  3. Dagenais DC, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. The Spine Journal 2008;8(1):8‐20.
  4. Paolucci, T., Attanasi, C., Cecchini, W., Marazzi, A., Capobianco, S. V., & Santilli, V. (2019). Chronic low back pain and postural rehabilitation exercise: a literature review. Journal of pain research, 12, 95.
  5. Rainville J, Hartigan C, Martinez E, Limke J, Jouve C, Finno M. Exercise as a treatment for chronic low back pain. Spine J. 2004;4:106-115
  6. Patti, A., Bianco, A., Paoli, A., Messina, G., Montalto, M. A., Bellafiore, M., … & Palma, A. (2015). Effects of Pilates exercise programs in people with chronic low back pain: a systematic review. Medicine, 94(4).
  7. Curnow, D., Cobbin, D., Wyndham, J., & Choy, S. B. (2009). Altered motor control, posture and the Pilates method of exercise prescription. Journal of bodywork and movement therapies, 13(1), 104-111.
  8. Natour, J., Cazotti, L. D. A., Ribeiro, L. H., Baptista, A. S., & Jones, A. (2015). Pilates improves pain, function and quality of life in patients with chronic low back pain: a randomized controlled trial. Clinical rehabilitation, 29(1), 59-68.

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The Single Leg Squat

The Single Leg Squat

For those of you who have ever read a research article and thought it was a tough read, i’d like to let you in on a little secret. Doing the research is far worse! If only memes were a thing when I started my Masters of Applied Science thesis, I’d have changed my background to remind myself that conducting research was even drier than every dish an apprentice has cooked for Gordon Ramsey.

My mentor at the time, who was the manager of the sports science and sports medicine devision of Cricket Australia and later the head of the AIS human movements department, Dr Marc Portus, enlightened me with something quite profound. He said, “There are two outcomes from a thesis. Either you live it for the rest of you academic days or it sits on a bookshelf for years collecting dust.” Given I completed my thesis and went straight onto my graduate entry physiotherapy masters, it is fair to say i’m in the later camp. Quite a few years have passed now however, so I’d thought i’d dust off the cover and summarise my thesis for all of you playing at home!

So not to degrade my self entirely, I thought I found some pretty good stuff that has affected the way I assess and treat today. I haven’t shared it all today as it was more than 140 pages long and ‘ain’t nobody got time for that’. More importantly though, my thesis reminded me of the passion I have for lower limb biomechanics and that physiotherapy (as opposed to research) was always meant to be on the cards for me. My thesis, “The 3D Kinematics of the Single Leg Flat and Decline Squats” boiled down to looking at how the ankle position changed the joint angles single leg squat, how hip strength affected the squat as well as few other things that aren’t worth mentioning here.

BACKGROUND:

The single leg squat (SLS) replicates an athletic position commonly assumed in sport such as cutting (powerful change in direction while running made from one leg), jumping and balancing which all require the control of the trunk and pelvis on the weight bearing femur in all three planes of movement [1-5].

Photo from the Praxis Physiotherapy article: The Single Leg Squat
Photo from the Praxis Physiotherapy article: The Single Leg Squat

As such, the SLS is commonly used by clinicians as a functional measure of dynamic lumbo-pelvic stability [6-8]. Abnormal movement within the SLS tend to be characterised by the commonly described “medial collapse” or “dynamic valgus”. Specifically, there is excessive femoral internal rotation, femoral adduction, knee valgus, tibial internal rotation and foot pronation of the weight-bearing limb with resultant excursion of the contralateral non weight bearing Ilium and excessive lateral flexion of the trunk [3, 6-8].

The reason why this tends to be perceived as a big deal is that this position tends to be argued as a lack of lumbopelvic stability and results in increased loading of the knee. Moreover, pelvis weakness tends to be ascribed to the absence of stability ultimately resulting in a position in which many acute and overuse injuries of the lower limb may occur. These ailments include, ACL / MCL ruptures, patellofemoral pain syndrome (PFPS), illiotibial band friction syndrome (ITBFS) and shin splints to name a few. That is why the SLS appears to be a valuable rough screening tool in clinical practice.

Photo from the Praxis Physiotherapy article: The Single Leg Squat

MY FINDINGS:

As mentioned, I looked at how a decline board of 20 degrees changed the angles of the lower limb during the squat. I also looked at if any strength measures of the hip related to how someone squatted between conditions. Finally, I looked at if the decline board altered how someone was scored by experienced physiotherapist as a competent or not at the squat

Photo from the Praxis Physiotherapy article: The Single Leg Squat

JOINT ANGLES (KINEMATICS:)

A picture tells a thousand words so in the interests of brevity, the stick squat figure is essentially a summary of two years of work.

So what this means, when someone performs a SLS on a flat surface, relative to a decline surface they tend to have:

  • A more upright torso
  • More rotation of the pelvis toward the weigh bearing (WB) limb
  • Reduced flexion but more adduction and internal rotation of the thigh on the WB hip (pelvic close to femur)
  • Less flexion of the knee but the same position relative to the foot as you look from the front (known as frontal plane knee excursion) at the bottom of range
  • Reduced internal rotation of the shin
  • Reduced ankle flexion

Essentially, in a flat squat you tend to ‘corkscrew’ your pelvis and adopt the medial collapse position much more easily than in the decline squat position. This may because of ankle range of motion issues as well as the ability to adequately recruit pelvic musculature. Yep – two years to get that!

REVISITING THE DATA (2026 RE-ANALYSIS):

Since I first wrote this piece, I have gone back to the original 3D motion capture dataset from my Masters and re-analysed it using more rigorous statistics than I had access to at the time. This work is unpublished and currently being prepared for peer review, so treat it as “watch this space” rather than settled science, but it is a meaningful sharpening of the original findings and, in one respect, a genuine correction to what I wrote above.

The original analysis compared single joint angles at one point in the squat. The re-analysis instead used a multivariate test (Hotelling’s T²) across five hip and pelvis variables together, a false-discovery-rate corrected sweep across eleven segments of the entire kinetic chain (ankle to thorax), and a continuous waveform comparison across the full 0-100% squat cycle rather than a single snapshot.

Two things held up, and one thing did not.

What held up: hip adduction and hip external rotation were consistently greater on the flat squat than the decline squat, by roughly 2-4 degrees on average, and this was robust to the multivariate correction, not just a single-variable finding. Of the eleven segments tested across the whole kinetic chain, only the weight-bearing ankle and the weight-bearing hip reliably differed between conditions (both p<0.001 after FDR correction) - the pelvis, lumbar spine and thorax did not differ. The continuous waveform data also showed that this divergence is not constant through the squat - it emerges gradually through descent and peaks near the deepest point, then closes again on the way up, which matters if you are assessing someone visually and only glance at the very bottom of the movement.

What did not hold up: the “medial collapse” / frontal-plane knee position I described above, comparing flat to decline squat, was not significantly different between the two conditions in this more rigorous analysis. The knee did move differently between the two squat variations, but the difference was in the sagittal (flexion) and transverse (rotation) planes, not the frontal plane. In plain terms, if you are judging flat-versus-decline squat technique by eye and using “does the knee cave in” as your marker, this data suggests that is not actually a variable that distinguishes the two techniques, even though the knee genuinely is moving differently between them in other planes.

Two figures below summarise this: continuous waveform plots (mean ± 1 SD) across the squat cycle for hip adduction, hip external rotation, hip flexion, pelvic obliquity, frontal-plane knee position and knee flexion, for both the dominant and non-dominant limb.

Cohort-averaged 3D kinematic waveform plots across the squat cycle for the dominant limb: hip adduction, hip external rotation, hip flexion, pelvic obliquity, frontal-plane knee position and knee flexion, comparing single leg flat squat and single leg decline squat

Figure 1: Dominant leg, n=19.

Cohort-averaged 3D kinematic waveform plots across the squat cycle for the non-dominant limb: hip adduction, hip external rotation, hip flexion, pelvic obliquity, frontal-plane knee position and knee flexion, comparing single leg flat squat and single leg decline squat

Figure 2: Non-dominant leg, n=19.

A couple of honest caveats: this dataset has no force plate data, so none of this is a statement about joint torque, only joint angle. Limb dominance was self-reported (kicking leg), not independently tested, and squat depth and tempo were self-selected rather than standardised between conditions. I’d treat this as a more careful re-reading of the same movement pattern, not a wholesale rewrite of the original conclusion – the ankle-hip relationship I originally described still stands up, it’s just the frontal-plane knee story that needs dropping.

STRENGTH AND MOVEMENT:

My results demonstrated a tendency for the pelvis to remain increasingly level with greater hip abduction strength. However, the relationship between strength and the pelvis was observed in the decline condition but not the flat condition. This may be due to hip abduction was shown to be significantly less (more neutral) in the SLDS which seemingly promoted greater muscle activation and subsequent control of pelvis. The self selection of squat depth may have also been a critical factor in finding as those with weak hips may have squatted deep to adopt maladaptive positions. Previous research has indicated that the hip abductors and external rotators play an important role in lower extremity alignment as they assist in the maintenance of a level pelvis [9] and are capable in balancing a number of biomechanical forces in the body [10].

Interestingly, there were no significant relationships observed between hip abduction strength and knee valgus (knee falling in) for both squatting conditions. There was however a trend between hip abduction strength and knee valgus which supported previous research. It is keeping with the assumption that increased knee valgus might also be associated with reduced hip abduction and external rotation strength [11].

SUMMARY:

  • To maximise athletic function, particularly in sports such as soccer, netball and AFL, stability through the pelvis and hips, proximal lower limb, spine and abdominal structures is required [12].
  • The importance of pelvis stabilisation for lower extremity injury prevention [13] particularly the knee [14-17] has been well documented in the literature.
  • Adequate lumbopelvic-femur strength and muscle function may conceivably reduce exposure to other intrinsic risk factors such as inefficient force attenuation, unstable movement patterns and lower limb malalignments during activity [18, 19].
  • Ankle flexibility may also be a factor in lower limb physical resilience and injury prevention.
  • Support for the previous statements has been demonstrated in the relationships between hip strength measures and kinematics within selected results of my study.

There you have it. Two years of my life summarised to a few paragraphs. From a personal perspective, I took away from my research experience to be always questioning why we do things and see if there is someone out there who has answered the questions we seek. Finally, don’t overcook chicken – Ramsay doesn’t like it.

Until next time, Praxis What You Preach

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