It was minus twenty outside, but there was nothing frosty about the way this group of intelligent Icelanders engaged with the Rehab Essentials at the end of last year.  

Although more than half the cohort were successful Physios in their own right, each one with their own knowledge base about injuries, the spirit was collaborative and generous.  We had loads of fascinating discussions about how to rehabilitate injuries... particularly muscle imbalances... and everyone learned some valuable stuff, including me.  

Many many thanks to Einar and Stefan for an incredible job of hosting, culminating in an incredible experience on the glaciers snow-scootering!

Of all the soft-tissue injuries the athlete can suffer, groin injuries are potentially the most debilitating and frustrating of all, especially in terms of time lost from competition and return to full competitive fitness.

The co-existence of multiple pathologies is the most plausible explanation for this observed difficulty in management. It is common for athletes to shop around seeking different medical opinions for their ongoing groin pain, and to receive varying medical suggestions as to where the problem originates.

It is important to remember that groin problems often have more than one possible pathology existing. Groin injuries are notorious for ‘co-existing pathologies’.

The ‘big three’ when considering ongoing chronic groin pain are adductor tendinopathy, osteitis pubis and inguinal (sportsman’s) hernia.

It is not uncommon to see two or even all three of these conditions co-existing at the same time. However, there still exists a myriad of other pathological conditions affecting the groin area. This post will limit its focus to tears/strains of the adductor muscles.

Adductor muscles are more commonly strained in sports involving twisting, turning, stepping and kicking, such as all codes of football. They are less commonly injured in straight-line sprinting, with acceleration being the dominant mechanism of injury with this sort of running. Similarly with hamstring injuries, adductor muscle injuries come about because of excessively strong contraction or excessive stretch.

One school of thought suggests that a muscle must have pre-existing increased tone in order to tear/strain. This rationale maintains that an increase in tone due to some sort of altered afferent input brings a normally healthy muscle closer to its tensile breaking point. Any excessive stretch or contraction may possibly cause the muscle to tear. This reasoning gains some weight in support when one considers how often a pre-existing pathology such as osteitis pubis or an inguinal hernia is soon followed by an adductor muscle tear or vice versa.

Another interesting consideration is the neurology of the ilioinguinal nerve. It is novel to suggest that irritation of the ilioinguinal nerve (which innervates the motor component of the transversus abdominus and lower abdominals, and sensory component of the groin area) may in fact be a precursor to the general groin syndromes we know as adductor tendinopathy/osteitis pubis/inguinal hernia.

Repetitive sprinting, turning and kicking may excessively load and stretch the psoas and abdominal muscles. This may generate an interface problem with the ilioinguinal nerve so that irritation of the nerve develops and, as a cause and effect consequence, the groin becomes irritated and poor muscle control leads to weakening of the abdominal wall, poor stability of the symphysis pubis and altered adductor-abdominal synergy during ballistic movement. As a result, breakdown of the groin area ensues. This may then be a plausible explanation as to why pathologies very often co-exist with ongoing groin pain. If any reader has the time or inclination to research such a topic it would make for some ground-breaking and innovative material.

An athlete presenting with an adductor strain/tear will usually remember a definite episode leading to the injury, whether caused by sprinting, turning, stepping or kicking. Usually immediate pain is felt in the adductor attachment or in the two to three centimetres below the attachment. The athlete will demonstrate some degree of functional difficulty, whether it be inability to sprint or kick, and even walking may be hindered.

Often the adductor episode is preceded by abdominal or groin pain in the weeks leading up to the injury. For example, a posterior abdominal wall weakness may cause initial pain in the lower abdominal and/or referred into the groin. As mentioned above, due to possible reflex pathways the abdominal pain may then cause spasm and increased tone in the adductor group, leading to tightness and subsequent tearing.

The most common diagnostic tests for groin injuries include: strength testing, palpation, associated joins (hip joint) (sacroiliac joins), lumbar spine and abdominal control.

Post by Chris Mallac

Hamstring injuries can be one of the most debilitating and frustrating of all muscle injuries for athletes involved in sports requiring top-end speed. The difficulty with managing hamstrings is particularly evident in minor ‘Grade 1’-type strains. Is it true muscle pathology or is it a ‘neural hamstring’ mimicking muscle pathology?

Differentiating the cause of posterior thigh pain can be an overwhelming clinical challenge. Furthermore, there is a wide practical gap between clinical treatment and a full return of the athlete to sport. In short, therapists must ask themselves, first, are they treating the right thing, and second, are they letting the athletes come back too early?

To put this into perspective, recent statistical studies in Australia on injury types and injury frequencies have shown that 25% of hamstring injuries will recur in the first four weeks. To the optimist, this means that 75% of hamstrings you think are right to return to sport will do well. To the pessimist, this means that there is a 25% chance of re-injury and going back to square one.

In the first instance, it’s important to differentiation between true muscle injuries and ‘neural hamstring’ problems.

Hamstring pain or ‘posterior thigh’ pain can present in many different ways. On one end of the spectrum, we have true tears involving local muscle pathology. These are usually sudden onset and involve a definite grabbing or tearing sensation with associated moderate to severe pain. Strong Grade 2 and Grade 3 strains will be functionally limiting, with walking often painful. The grading nomenclature is well covered in most sports medicine textbooks, and I am assuming that most readers will be familiar with these.

Acute ‘cramping’ or ‘spasm’ of the hamstring may also cause sudden onsets of pain. These are commonly referred to as ‘neural hamstrings’. That is, an increase in hamstring tone is the cause of the cramping pain. However, the causative factors for the increase in muscle tone are very often much more difficult to determine. The tone increase may be a response to referred pain from the lumbar spine, sacroiliac joint, neuromeningeal structures or local myofascial trigger points.

Patients who present with ‘niggling’ recurrent cramping, spasm and minor aches and pains may appear to have minor Grade 1 strains. However, although these types of neural hamstrings are not limited in performance other than top-end speed, they are often the more frustrating and difficult to manage. They are the ones who never miss a game, but are never at 100% either. A better understanding of referred pain, lumbar spine involvement and neuromeningeal dynamics will help differentiate true muscle pathology from ‘neural hamstrings’.

In presentation and diagnosis, both ‘muscle’ hamstrings and ‘neural’ hamstrings may exhibit weakness and pain on strength testing. One distinguishing clinical feature is that if the hamstring is weak but not painful, then the problem is more than likely a neural hamstring. Muscle injuries more often than not present with weakness AND pain on contraction, irrespective of the grade of the tear. However, a neural hamstring with no local muscle involvement may still be painful on testing and on palpation due to peripheral sensitisation.

Pain, inhibition and weakness with a true muscle tear are a result of the pulling of the disrupted fibres. Weakness and inhibition with a neural hamstring may be caused by nerve root compression, active myofascial trigger points in the gluteals and/or hamstrings or pain inhibition caused by a lumbar disc problem.

A number of useful strength tests exist to help the diagnosis of injury, evaluating response to treatment and determining progression and recovery including; functional bridging, resisted knee flexion, range of motion, straight leg raises, passive knee extension, neural mechanics, lumbar spine, abdominal control and pelvic balance.

Posted by Chris Mallac

We all know that gross shoulder instability in the form of a dislocated shoulder is a common occurrence in high risk sports such as motocross, downhill mountain biking and all of the contact sports such as rugby, wrestling and MMA.

The direct blows to the back of the shoulder that commonly occur in these sports, as well as having the arm caught in the ‘stop sign’ position can fulcrum the head of the humerus out of the glenoid socket.

As the head of the humerus contacts the neurovascular bundle at the front of the shoulder the patient will experience severe pain and most likely a numb arm. Ouch!

Some people experiencing this injury may spontaneously relocate their shoulder. Often, if this is the first time this particular injury has occured, they will need to have it relocated under anaesthetic in a hospital ward.

Treatment most commonly involves a full shoulder reconstruction and many months of rehab.

But in my opinion it’s subtle shoulder instabilities are the interesting ones. Those constantly present, niggly anterior or posterior shoulder pains that just won’t budge.

These subtle should instabilities are commonly associated with overhead activities such as swimming and tennis, or exercises such as the deep bench press and behind neck shoulder press/pulldowns.

What invariably happens in the shoulders is that for some reason (which I will attempt to explain shortly), the humeral head sits too far anteriorly in the glenoid. This places a strain on the anterior stabilising ligaments and muscles.

The most likely cause of a subtle shoulder instability is an imbalance between the posterior infraspinatus muscle and the anterior subscapularis muscle. The two muscles create opposing external and internal rotation. They both work during arm movements to stabilise and centralise the humeral head in the glenoid socket, so that sheer force does not occur and the movement at the ball and socket is all a pure rotation.

A nice analogy is to think of the glenohumeral joint as a golf ball on a tee. The head of the humerus is bigger than the socket (not quite to the dimensions of the ball versus tee). Because the head is bigger, the subscapularis and infraspinstus which are flat triangular muscles starting on the scapular surface (subscap is anterior, infraspinatus is posterior) have to curve around the head of the humerus on their way to their respective humeral attachments. If both muscles contract with the same degree of force, then the head is forced into the glenoid and no rotation occurs – the ball sits firmly in the tee.

What commonly occurs though is that the infraspinatus dominates and thus creates a rotational force imbalance. If it was only these two muscles working, then the head of the humerus would start to externally rotate in the glenoid – this actually happens as we lift our arm up – the head of the humerus needs to externally rotate to clear the greater tubercle away from the acromian process as we lift our arm up (abduct our arm).

People experiencing these injuries should absolutely avoid performing external rotation strengthening work as they already have an overactive infraspinatus, and there is no need to make it even more active.

During movement, the infraspinatus also pushes the head of the humerus forwards (anteriorly). Conceptually this is similar to the ‘hammock’ analogy. Imagine someone is lying in a hammock and you grab one end and pull it towards you. The hammock becomes taut and the person will lift upwards. In this instance the person is the humeral head, the hammock is the tendon of the infraspinatus wrapping around the humeral head and the person pulling the hammock is the infraspinatus muscle.

The result is that an overactive infraspinatus, if unchecked by the opposing subscapularis, will create a sheer force and force the head of the humerus anteriorly. This stretches the anterior structures and creates a what we call a subtle shoulder instablity.

For those involved in clinical assessment and diagnosis, these patients will present with reduced glenohumeral internal rotation (as the infraspinatus tightness stops this) and also a positive relocation sign.

Management techniques for subtle shoulder instabilities should focus on direct loosening and deactivation of the overactive and dominant infraspinatus. This is best done through direct trigger point releases and also stretching.

Trigger point releases can be done effectively with a tennis ball or POCKET PHYSIO. Hold each tender spot for about 1 minute and find 5 key target spots through the muscle.

Many years ago in my role as Head Physiotherapist for the Queensland Reds Rugby, we would do ‘The Plank Challenge’ as part of our pre-gym prehab routine.



Basically, the players would have to hold ‘the plank’ for as long as they could. Those who could hold for 3+ minutes were considered Spartans, between 2-3 minutes and they were considered worthy of Spartan status but needing some work, between 1-2 mins and they were peasants sent back to the remedial abdominal class, and below 1 min, well…they didn’t really last that long. And in all honesty, the ones with the best abs and no back pain are the ones who could generally hold the plank for 3mins+ without losing pelvic position. Losing pelvic position incidentally (more on this later) was the criteria for being booted out of the challenge.

So does mean that the plank is the best Abdominal Strength Exercise?

Well, it’s horses for courses really. If you weigh 120kg and do nothing but collect stamps and play chess all day then it will represent possibly the worst abdominal exercise you could embark on.

If you are an elite level Rugby player, then it may represent a higher level abdominal challenge.

What does the plank actually do? It is what Stuart McGill, the Canadian back-pain super-trainer refers to as a ‘super stiffness exercise’. It generates stiffness in all the abdominal wall muscles to create a rigid core between the rib cage and the pelvis. In doing so the spine is supported by muscle stiffness with minimal damaging compressive forces associated with sit ups and hanging leg raises.

The biomechanics of the exercise are quite obvious. Without some ‘stiffness’ in the muscles at the front of the body (as in abdominals) the body would sag under its own weight between the pivot and support points being the elbows and the feet. It thus requires a considerable degree of holding capacity in these muscles to generate the stiffness to prevent the spine arching into extension. But is that all it trains?

Many other muscles are also trained in this exercise and as a result, many other muscles can ‘cheat’ and compensate for weaker abdominals. If this occurs, then you are simply training those muscles with ability and neglecting the dysfunctional weal muscles. Before describing how other muscles work in this exercise (especially in cheating), let’s firstly describe the ‘perfect’ plank exercise.

In a perfect plank, the elbows are placed directly under the shoulders and the ankles are kept at 90 degrees bend. You can draw a straight line from the shoulders, through the hips, through the knees and through the ankles. This line will clearly slope downwards considering that the ankles are lower than the shoulders. But there should be any ‘breaks’ in this straight line. The most important pre-requisite however is that the pelvis is kept in ‘neutral tilt’. This means that the natural curve of the lumbar spine is maintained. It neither over-arches or as commonly seen, is not overly flat or even rounded (flexed or posterior tilt of the pelvis).



Cheat Number 1: Push the wrists into the ground and really dig your toes in and push with your calves. This creates an artificial ‘stiffness’ scenario. The triceps contract to try and extend the elbow, in doing so the body is pushed towards the feet. At the same time the calves contract to plantarflex the ankles, or to put it another way, push the body away from the feet. The 2 forces meet in the middle and les work is needed by the abdominals as the body has already artificially compressed itself. Solution. Do this on a timber floor with a tea towel under the elbows and under the feet. If you push too much with the arms or feet, they will slide due to that force.

Cheat Number 2: Resting the head on top of the hands whilst pushing with the feet. This does the same as above however now the head forms a block to movement. Push with the feet (as in calves), the body wants to move upwards but the head stops the movement. Result. Again artificial compression is generated. Solution. Head must be in line with the shoulders.

Cheat Number 3: Spine sagging and associated anterior pelvic tilting. This happens as the abdominals fatigue. You will see it in someone because their butt starts to stick out more and the arch becomes exaggerated in the spine. The reason this happens is that the hip flexors and the abdominals are trying to find a new physiological length-tension advantage. The anterior hip flexors will force the pelvis to anterior tilt and as a result the abdominals become slightly stretched, a more favourable position to continue to produce holding force. What can also happen is that the psoas major muscle will also start to kick in to support the spine from the front. What you will feel is a low back ache as the facet joints are compressed under the load of muscle contraction whilst locked into spine extension. Solution. Don’t lose neutral spine or neutral pelvis.

Cheat Number 4: Knees bend. Again as fatigue sets in, the body will look for ways to cheat. We ere born to cheat so the body will look for the most economical way to maintain a task with minimal effort. By allowing the knees to bend, the long rectus femoris muscle uses its physiological length-tension advantage. Because it also crosses the front of the hip, it is another muscle which is used to help ‘hold’ the hip in neutral so it does not sag into extension.

So therefore, what are the other muscles that can be trained in a ‘plank’ exercise. The list includes but is not limited to; triceps, anterior deltoid, clavicular head of pec, serratus anterior, TFL, rectus femoris, anterior adductors, soleus and gastrocnemius.

If performed incorrectly, then the ‘plank’ may possibly recruit as many muscles as the deadlift.

The only difference is that the deadlift is a good rehab exercise whereas a poorly performed plank is not a good rehab exercise.

That’s the warning that comes with this fabulous two minute video from the Rehab Trainer Masterclass at the Functional Training Insititute in Singapore, held last month.

It’s some awesome, slightly crazy footage of the group getting their groove on – and going a bit loco – at the end of the two-day Masterclass delivered by Chris Mallac. And for those who have always wanted to see a Rehab Educator boogie – Chris is in the middle of the front row at the start of the clip. Worth a look.



And if you’re ever in Singapore, the FTI is WELL WORTH a visit. Both Ulrik and Chris agree that they are some of the best Fitness Professionals they have come across in the world, with a team spirit that is second to none.

Love it, guys. Well done.

Rehab Trainer launched its Essentials course in Auckland over this past fortnight.  Hosted by the superstar Trainers at Netfit, Ulrik delivered the course to a room full of motivated and enthusiastic Kiwis over two weekends, with a two-week break in the middle.

And what did he do during that time off?

That's right, he took his family around the North Island in a motorhome. What fun! Here's their home-on-wheels parked outside Netfit...



Calling it an "Essentials" tour – they took in all the major sights: the caves at Waitomo, snow at Ruapehu, geothermal mud, geysers and steam at Rotarua, and beaches with hot water at Coromandel. It was brilliant, and, being Winter, pretty chilly!

So while Auckland's Personal Trainers were practicing the Essentials of working with the Upper Limbs (and loving it, by all accounts), the Larsen family were diving into the essential North Island experiences – and loving it, too.



Thanks Netfit, and thank-you, New Zealand. What a place you are. We will most certainly be back.

Rehab Trainer Educator, Wayne Rodgers, compares how the Gym Experience has changed since the Eighties, and why we have it so much better today, with Fitness Professionals who are educated in, and committed to, functional training.

(This is the last of four posts in this series.)



1985 - Follow These Instructions

Gym instructors have become recognized as people with some expertise in exercise prescription and training advice.

Many of these “experts” have developed long lists of instructions for clients hoping to achieve fitness goals.

There are the top 10 ten things you must do to lose weight and the top 20 things you must do to gain muscle and the lists go on. However, humans value their freedom and autonomy far too much and the lists simply don’t work. Very few people are motivated by someone else’s must-do lists.

2011 - The Evolution of Coaching

Many personal trainers still have there lists of instructions for clients but the well informed trainer is keeping a close eye on motivational psychology research and is aware that coaching is a more successful approach to helping a client reach his or her goals.

In coaching the client actively participates in decision making regarding change and strategies for success. Questions such as “How do you think you think you can best lose weight?” and “How will your life be different in 6 months when you have achieved this goal?” are typically of a coaching approach. As many fitness coaches often say, “We simply wait for the client to tell us what we are dying to tell them.” The psychology of motivation suggests that when the client “creates and owns” their strategies for change they are much more likely to achieve positive results.

Rehab Trainer Educator, Wayne Rodgers, compares how the Gym Experience has changed since the Eighties, and why we have it so much better today, with Fitness Professionals who are educated in, and committed to, functional training.

(This is the third of four posts in this series.)

1985 – Body Part Training Rules

“Body Builders” have ruled the gyms for the past 30 years and only in the past ten years have athletes and fitness enthusiasts started to join gyms and consider weight-training as an important component of a balanced exercise program.

With a strong desire to pack on muscle at precise locations, the body builders have devised exercises and a huge array of machines to help isolate every muscle in the body. There is no real thought about exploring the natural movement patterns of the body and a reductionist approach to anatomy sees the body as a conveniently arranged array of individual muscles. Split training programs are the norm and everybody knows that Monday is “chest day”.



2011 – The Evolution of Functional Training

Functional training has become a buzz-word and programming trend in the fitness industry over the past decade. In gyms, personal training studios and physiotherapy clinics throughout the country all manner of exercises with athletic, therapeutic and performance enhancing benefits, are being taught under the banner of “Functional Training”.

“Functional” is defined as “having a practical application or serving a useful purpose”.

“Functional Training” can be best defined as any training modality aimed at improving functional capacity – the ability to perform daily physical tasks, occupational or sports specific tasks, simple and/or complex motor activities with ease, efficiency, strength and control.

Typically, a functional training program will demonstrate a comprehensive approach to conditioning that addresses all the performance components necessary to achieve success in any target activity. Such training is commonly, but not limited to, multi-joint, multi-plane, multi-tempo exercises with moderate to high complexity (or neurological demand), requiring coordinated dynamic peripheral control and core stability. Training often mimics common movement patterns or sporting activities, often using body weight or external loads as resistance whilst respecting the kinetic link principle.

The body is programmed to use the Kinetic Link Principle. A series of interrelated links or a series of sequentially activated body segments – from toes to finger tips. Movement at one segment affects adjacent segments in a positive manner – generation of greater force, greater speed or a more biomechanically advantageous body position. Commonly proximal to distal sequencing promotes proximal stability for distal mobility. Rotational forces through the trunk may also aid distal strength and power generation. For example in throwing: the hip and trunk accelerate the entire system and sequentially transfer momentum to the next distal segment, along the upper limb to accelerate the hand for ball release.

Biomechanics research has confirmed that force transfer between lower and upper limbs must occur through a controlled core with adequate dynamic stability. In athletic function, core stability is not about maximal stability and definitely not about rigidity, but more-so about optimal motion control at each spinal segment provided by the co-ordination of muscular, ligamentous and bony structures. The amount of dynamic control required in any sporting activity is determined by the load, variability of motion and unpredictability of the activity.

The personal trainer, taking a functional training approach, thinks and talks in movements not muscles.