Rewind: Foundational Leg Strength in Rehab

I am reviewing things for a new project and this blog post from April 2020 has some things I want to keep in mind. Thought I would share it again. Might prompt some good reflection for the physio crowd.

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Last week Donie Fox had a great article for HMMRMedia -- "Using Foundational Legs Exercises as the Cornerstone of Rehabilitation." Check it out if you haven't already. Donie's article is important in my mind because it addresses a critical issue in the rehab world. There is a serious lack of appreciation for and mastery of the use of basic movements (squats, lunges, step ups) to build foundational lower extremity strength.

Donie and I have decided to go into more depth on this topic in our next few podcasts. We will also hopefully touch on return to running programming criteria.

Here are some barriers, in my opinion, to rehab professionals adopting a "foundational legs" approach. I'm not trying to be overly critical or a curmudgeon here. I am simply trying to share my observations after 20 years of working at all points on the rehab and performance spectrum.

Ok, here goes.

1.  "Protection" mindset vs "performance" mindset. "Can't do vs can do" says Vern G. Medical model vs performance model as often discussed by Bill Knowles. This is important.

2.  The "protection" mindset is compounded by facility space configuration and professional dress standards that do not promote movement. There is no space to move and the physio is in dress shoes and dress pants. The shackles of the khaki pants. Potential sweat and stink aren't considered professional. All movement is on table, bike or maybe elliptical / treadmill. The environment is geared for manual work and stillness, or very controlled, machine-based movement. It is all very tidy and clinical.

3. The "Cult of Stillness and Stability." It is easy to measure stillness (time). When you don't have any space in which to move, it becomes the thing to do. This stems from the whole "core stability" idea --- and for LE injuries, morphs into the an obsession with "balance and proprioception" tasks. You know, stand on one leg (on an unstable surface) while you and the physio toss a ball back and forth. Doesn't take up much space and seems like you are doing something productive. I've been there and done that. I know the challenge of moving past that -- and I am determined to help others do so.

4. Special exercise toolbox / language to "activate" it all after we have mastered "stability." Ideas about lower extremity strength are not rooted in elements of physical literacy, with foundations of gait and progressive gait-related function (running, jumping). They are based in protocols for each diagnosis and more often than not, isolation of particular joints / muscles; and the movement prescription is simply a collection of exercises pulled from some software (used to be from cards and physical handouts) with standard sets and reps. Furthermore, these exercises are not connected to higher level "gym" based "strength" work. A wall sit is for your quads. Bridges are for your glutes. And so on. There is not a coherent relationship or synergy among the movements and the more complex, emergent property of "athletic leg function" is lost because it is reduced to isolated elements of balance, agility, strength, proprioception along with ill-informed ideas of "activation." Meanwhile, experts in the field argue about "quad index" and "quad/ham ratios" or the value of OKC vs CKC while a majority of practitioners cannot adequately teach, program or progress basic movement. It doesn't seem like we are addressing the root cause of the issue here.

5. Which brings us to the mindset of "movement in and of itself is not enough." Gravity, amplitude, tempo, direction, management of ground reaction forces are not "special" enough. Dumbbells and medballs? Lunges, squats and basic step ups? Not special enough. There has to be some kind of special, and often very expensive, gadget: BFR, some type of tubing, Alter G, Shuttle Leg Press. I'm not saying these are never useful in early rehab. I am suggesting we, as a profession, struggle to let go of these things and appreciate the complexity and necessity of working with humans moving in gravity alone.

6. And finally, the lack of understanding of sport demands and what the human body is physically capable of in sport. Many rehab professionals only see patients who have below-normal fitness and function in their training and early careers. They tend to work with and see early post-surgical rehab and rarely get to see the end-stages of a full RTS case. This is a problem because we quickly forget -- or may never ever realize -- what is possible and necessary. I'll never forget watching my boss back in 1998, 2x Olympian Derrick Crass, FLOAT up on to a 42" box -- like a cat -- at 40 years old and about 190 lbs. And easily squat over 350 lbs. And deadlift over 400 lbs. And still do a 9 ft + standing long jump. Being around that level of athleticism and being encouraged to explore my own athleticism was an important part of my acceptance of Vern's "can do vs can't do" approach in my own practice. I learned to put the "physical" back into physical therapy because I saw, felt and worked in an environment that allowed for physicality.