Alignment for the Endurance Athlete

What does it mean to be “out of alignment?” Are joints ever truly “out of joint?” For the most part, no.

There are some special cases such as costochondral (rib-cartilage) and other costal (rib) joints, and impingement from things like menisci and loose bodies, but in most
alignmentfortheenduranceathlete
Christine Fletcher at the Ironman World Championships, Kona, Hawaii, demonstrating proper alignment.
cases, it is highly unlikely that you are out of joint. Believing that malalignment means your joints are outside their physiological range is an oversimplification. Instead, it is a complex pattern of muscle imbalance, involving muscle length, strength, activation, etc., which can arise from either structural asymmetries or, more often, learned postures and movement patterns, which in turn can be a result of poor technique or muscle inhibition due to pain or injury. There are some typical patterns of imbalance and malalignment that we see clinically, but individual mechanics can differ greatly. Our body can hold itself in certain positions (secondary to muscle tension, shortness, pain, etc.), and certain joints can be held outside of their available range, but never truly out of joint.

These asymmetries or alignment problems can lead to problems such as direct sacroiliac (SI) joint dysfunction, patellar pain syndrome (PPS), Ilio-tibial band (ITB) friction syndrome, rotator cuff injury (often supraspinatus, but subscapularis and infraspinatus as well), muscle strain (often hamstrings), tendonopathies (especially Achilles), and the list goes on. These conditions are all very prevalent in the athletic population and cause much trouble and time for the athlete, but instead of retroactively treating these injuries, treating the underlying malalignment, muscle imbalances, and movement patterns is far more effective than dealing with the acute injuries.

When working with elite athletes at the world-class and Olympic level, it’s not so much injuries we deal with, but correction of minute imbalances and weakness, like fine tuning. Two recent Ironman triathletes were perfect examples of this approach. In both cases we addressed full body alignment, one preventatively, and the other following a foot injury that altered the mechanics in her foot and consequently her gait. Due to the training schedule and sport demands, the management will likely be more difficult in the competitive season.

Why is alignment more important for the endurance athlete?

Alignment is especially important for endurance events as opposed to shorter distances due to the shear repetition of movement. Many studies have shown that although there seems to be a relationship between static and dynamic misalignment and certain injuries amongst various athletes, the relationships are much more evident in distance and ultra-distance athletes. Beyond the mere duration of the activity, certain activities are simply more repetitive with respect to movement patterns than others. For a soccer player, it is also not optimal to have alignment issues as they can lead to injury, but due to the variation of movement undergone by a soccer player, they don’t fall victim to repetition injuries or friction injuries (i.e., ITB or various tendonopathies) as readily as runners.

There is another way in which alignment indirectly helps athletes stay injury free through aiding stability. For most sports or activities, stabilization of the lumbopelvic region is critical in the prevention of injury. Some argument exists in the manner in how we train this stability, but many studies show a relationship between it (especially in the case of gluteus medius) and minimizing the unnecessary jarring forces through various joints. Pelvic obliquity (malalignment) can drastically alter the ability to stabilize the lumbopelvic region. Upsetting this balance can put some fibres of certain muscles in either a shortened or lengthened position (i.e., creating a suboptimal length-tension relationship), thereby decreasing the force production of the muscles in question.

How do we address this?

The best way to deal with malalignment is a full functional exam, looking at static and dynamic alignment, mobility, muscle length, tension, and strength and movement patterning. Special attention needs to be given to the axial skeleton (spine and pelvis) and the lower extremity, but even para-scapular and shoulder imbalances can affect dynamic alignment. This is why we need to assess the whole body to do this properly.

One important consideration in solving alignment issues is whether there is a leg length discrepancy (LLD). The first step is finding the cause of the discrepancy, whether it’s true (actual) or functional (i.e., from rotation, side flexion of the low back/pelvis). In the case of functional LLDs, the important step is discovering the exact root of the malalignment. The combined movements of the lower lumbar spine, SI joints, and hips can be quite complex and exist on all three planes of movement. The main goal of treatment here is to normalize the alignment of the axial skeleton. This also applies in the case of true LLDs; however, there is some dispute over the degree to which we should correct for actual leg length. The size of the lift for the shorter leg is decided upon differently by different practitioners and different sports. Care must be taken not to overcorrect.

If the assessment is incomplete, (i.e., positional tests from bony landmarks only), and if treatment is too  brief (i.e., the “quick fix”), your correction and relief will likely not last, as the underlying cause was not discovered. As mentioned earlier, many things can cause misalignments. What’s holding the pelvis rotated? Is it a chronic hip flexor injury? An asymmetry in the spinal musculature? An old abdominal surgery leading to decreased stabilization of the core abdominal muscles (i.e., transversus abdominis)? Etc.

Once you have had a full functional scan by your sports physiotherapist or other qualified health professional, the first part of the treatment should focus on the internal factors. The treatment may include correcting alignment by manual techniques, movement pattern re-education, activating inhibited muscles, stretching, active release techniques, etc.

External factors can be addressed by biomechanical correction through footwear, possible use of orthotics, correction of training errors (such as unvaried road camber for runners), etc. There are no quick fixes, and individual biomechanics can vary greatly. Regardless of who you see, the most important thing is to learn about the root causes of your own body’s malalignment. Various forms of treatment to help correct the problem can be sought, but be eager to learn ways in which you can avoid falling back into faulty patterns and positions.

Why is this especially important in the off-season?

Athletes have an increased vulnerability to injury during certain periods of the training cycle: when adding volume, when increasing intensity, when adding new movement patterns, and when returning from an absence of training. The off-season, therefore, is associated with less vulnerability to injury and provides an excellent opportunity to deal with malalignment issues for many other reasons. It provides ample time to work through connective-tissue shortening of muscle/tendon. Connective-tissue changes (i.e., lengthening) can take many weeks to appropriately adapt. It provides time for re-patterning of faulty movement. Altering biomechanics can initially affect performance adversely, making the competitive season less than ideal for this.

If in need of external fixes, such as a change of footwear or orthotics, time should be taken to “break them in.”

Cross-training can be an effective part of the off-season, so long as the activity or sport chosen does not perpetuate asymmetries and imbalances.

All athletes need to address alignment for optimal performance, and especially in the case of the endurance athlete. There is no better time than right now to address those concerns.

About the Author

Harminder (Harry) Toor is a Sports Physiotherapist and part owner of Envision Physiotherapy in Vancouver, BC. (envisionphysio.com). He is the creator of vancouversportsphysio.com, and was the part of the medical team for Torino 2006, and has been selected for Vancouver 2010.
 

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