A quickie before my next hip post…. Avoiding injury is the key to building bone

Sorry I have not posted in a while! Ive been deeply focused on the hip and pelvis at work. I still have to enter some pictures into my next hip blog before I post it. Until then here is a short statement to chew on…
When building bone through exercises one important thing to consider is avoiding injury. There is a fine balance between gradually increasing the difficulty (good stress) of an exercise on bone and too much stress causing “bad pain” and injury.
Listen to your body and focus on the following three components…
1) Alignment – the resistance you use should be at an amount where you maintain proper alignment. In general the spine should be elongated, the shoulders rolled back and the knees should point in the same direction as the toes. You want to try to lift a weight that is challenging enough where you can maintain good alignment yet fatigue after 8-12 repetitions.
2) Feel the burn in the muscles NOT pain in joints – The “burn” when lifting weights is the normal lactic acid by product in the muscles from an anaerobic energy state. The muscle burn is not necessary for building bone but a good sign you are working hard. The burn should occur after around 8 repetitions. If you feel the burn sooner try warming up more with a light weight or some cardio, then try lifting an appropriate weight where the burn occurs between 8-12 reps. A burn after 3-4 reps puts you at a higher chance of injury such as a muscle strain causing searing pain in the muscle (it could take 12 weeks to recover!) You should not feel sharp pain or pain in a joint. For example in the knee, a sharp pain could be from the patella (knee cap) rubbing on the femur (thigh bone.) this is not a pain to “work through,” stop, check your alignment, stretch and/or lighten the weight. Burning pain when not working out is a sign of an injury and could be due to a nerve impingement, this too is not a pain to work through.
3) Enjoy the workout – when you enjoy what you are doing, you will return for more! Consistency is key.

Spend time with your feet, fix and prevent ankle sprains…

It was the end of a full day and I was carrying many things when I stepped on the edge of the sidewalk, my foot twisted sideways over the edge and boom, down I went. So with a scraped bloody knee and throbbing pain in my ankle, I sat for a moment and was inspired to blog. Once the nausea eased up, I cleaned up and bandaged my knee and iced my ankle. After icing, I diagnosed myself with a lateral grade 1 ankle sprain. Phew, nothing major.

lateral sprain

An ankle sprain happens when you quickly over stretch the ligaments and tendons around your ankle. The most common ankle sprain is a lateral or inversion ankle sprain when one lands on the outside of the foot as I did. The classic ankle sprain involves the anterior talofibular ligament (ATFL) and sometimes the Calcaneaofibular ligament.


Ankle sprains are divided into three levels of injury:
Grade 1- Over stretched ligaments but not torn. People may be able to walk with out pain but it hurts to stretch or touch the area associated with minor swelling.
Grade 2 – Ligaments partially torn, swelling and pain to touch or stretch. People return to normal activity in 10-18 days depending on the activity.
Grade 3 –A fully torn ligament which could be combined with a fracture as well. Often people experience extreme pain and cannot walk. Often requires crutches and sometimes a boot. Medical intervention is recommended to rule out a dislocation, syndesmosis (injury to a ligament that connects the tibia and fibula) or a fracture.

If you have pain in the midfoot or bone tenderness at the fifth metatarsal (outside midfoot) or at the navicular bone (inside midfoot), or inability to bear weight for four steps, an x-ray is indicated.

Most people heal without medical intervention. The standard of care is to get rid of swelling with P.R.I.C.E. Protection, Rest, Ice, Compression and Elevation. This will greatly decrease the pain. Protection avoid hitting it or re injury to the ankle by using protective tape, bandage or brace. Rest the ankle and don’t perform anything that causes pain or puts the ankle at risk for re-injury. For example, If jogging doesn’t hurt start jogging short distances, use an ankle support and run on even surfaces or predictable routes you know well. Of course, if jogging does hurt, continue to rest and stick to walking or a non-painful activity. Ice with frozen veggies or a plastic bag with ice cubes and some water 15-20min. There are fancy ice packs out there but often not necessary. For Compression have a trainer or physical therapist tape your ankle or the local pharmacy probably has an ankle compression stocking. An old pair of tight hose or dress sock may do the trick if tight enough. Elevate by putting your foot up on a comfortable surface.

After PRICE if still painful and once the swelling is down, a medical practitioner will do ligament testing to make sure the ligaments are intact. There is much evidence to suggest that for lateral ankle sprains a short period of protection and early weight bearing should be followed by range of motion and neuromuscular training ASAP. Early functional treatment leads to the fastest recovery and least rate of reinjury.(2)
The risks for an ankle sprain are: a previous ankle sprain, weak ankles, shoes that are too small or worn down on one side, uneven sidewalks, sports that require side to side shifting (tennis, foot ball, basket ball…) and fatigue.
In order to prevent ankle sprains wear shoes that fit and aren’t worn out. The general rule of thumb is to replace sneakers every 6 months or alternate two different pairs over a years time. If you are very athletic you will need to replace your shoes more often or have more pairs, if you are less athletic or exercise bare foot (yoga, Pilates, GYROTONIC® exercise) then your shoes will last longer.
Keep in mind a previous ankle sprain puts you at risk for future sprains in the same ankle and in the other ankle. (1) It is important to re-train and strengthen your ankles.

Here is a program to prevent initial injury or to prevent re-injury. Many of these exercises will also be given in physical therapy to rehab an ankle sprain.

Ankle mobility:

Circles – For range and mobility put your foot up on a stool and circle the ankles in both directions. 5 slow large circles in each direction. Progress to circling your foot in a bucket of sand or rice.

Alphabet – For more of a challenge and to increase endurance draw the alphabet with your foot. Make big letters and perform exercise on both sides.

Retraining Balance – Stand on one foot, eyes open. Repeat with eyes closed make sure there is something to grab and prevent falling.

Repeat on pillow – To challenge your balance more, stand on pillow (uneven surface) first with your eyes open. Progress to closed eyes (make sure you are in a safe environment to prevent falls). Your ankle should fatigue with this above exercise. Your body is re-learning how to correct and weight shift to right your self and maintain balance.


Dynamic Balance-

Stand on the floor, on one foot and bend knee and hips to pick up an object from the floor.

To increase the challenge repeat on pillow. Make sure pillow is on a surface where it wont slide.

Repeat on thicker/higher pillow

Keep in mind a loss of balance is good for retraining the ankle and motor control centers to improve balance, falls are not. Choose an appropriate exercise to challenge your current level of coordination and balance.

Calf and ankle stretch and strength:

Eccentric Calf raises – On a step rise up to toes and slowly lower down, hold stretch, repeat rise up slowly lower down.

Theraband inversion and eversion – this is exercise is to strengthen the muscles and tendons around the ankle.


Wrap band around outside of working foot and under non working foot, hold band. Press working foot (in this picture the right foot) into band until muscle is felt on outside of ankle and shin. Start with 5 reps 2 sets and build to 10 reps until strength is restored.

eversion 2

This is a closer photo of the eversion exercise to strengthen peroneal muscles around were the ligaments were over stretched during the injury.

Directions wrap band around outside of working foot and under non working foot, Press top working foot into band until muscle is felt along inside of ankle and shin. start with 5 reps 2 sets and build to 10 reps until strength is restored.

Directions wrap band around outside of working foot and under non working foot, Press top working foot into band until muscle is felt along inside of ankle and shin. start with 5 reps 2 sets and build to 10 reps until strength is restored.

Myofasical release/massage:

Take care of your feet massage them with lotion or oil and wiggle your toes.

Take good care of your feet. They are important for many daily activities including balance! Your ankles have a direct link to areas of your central nervous system responsible for knowing where you are in space so keep them happy.


Dr. Justine
1) Int J Sports Phys Ther. 2014 Oct; 9(5): 583-95.

Injury risk is altered by previous injury a systematic review of the literature presentation of causative neuromusclar factors.

Fulton J, Wright K, Kelly M, Zebrosky B, Zanis M, Drvol C, Butler R

2) Ortho Rev (Pavia). Jan 2, 2012; 4(1):e5.

Diagnosis and Treatment of acute ankle injuries: development of an evidence-based algorithm

Polzer H, Kanz K, Prall W, Haasters F, Ockert B, Mutschler W, Grote S.


Exercise and improve your posture during your commute

I recently moved and now have a long commute to work. I’m not a person who likes sitting still for very long, so I thought I would share some exercises to keep you busy and improve your posture while sitting in the car.

These are isometric exercises, which are often used in posture training because postural muscles must work for extended periods of time. Thus, isometric endurance training is helpful to train your muscles to work while sitting at the computer, driving a car, washing dishes, etc.

For all the exercises, sit forward in your seat; do not lean back. (see last photo in this blog)

Start by exhaling and engaging core muscles then contract for the isometric exercise. Continue to breath normally. 

Note: Isometric exercises can raise blood pressure. For this reason I prefer to stick with short duration multiple repetitions: 3 sec hold and 15-20 reps.

Always listen to your body. Stop if you feel light headed or dizzy and of course pay attention to the road. The exercises should make you more alert and energized.



1) Sit forward in your seat. Inhale and lengthen your spine. Drop the chin and lengthen the back of your neck.

Exhale deeply and contract the core muscles (pelvic floor, transverse abdominals, obliques, diaphragm, back extensors – see previous blogs for details) by drawing in the tummy while continuing to lengthen the spine upright. 

Repeat, allow the belly to expand as you passively let the air rush in (inhale), exhale and contract the core muscles while maintaining a wonderful elongated spine.

Repeat 15-20 times


Upper body:

1) For pectorals, open elbows at a comfortable height press into the wheel. Inhale to prepare, exhale to engage core lengthen spine and press hands in.  Feel your long upright spine and a contraction of the front of your chest and shoulders.  Keep breathing normally and hold 3 sec. Relax and repeat 15-20 times.




2) For rear deltoid and peri-scapular muscles – hold wheel and pull elbows wide. Feel the muscles in your upper back and shoulders contract. Continue to maintain upright posture sitting forward in your seat.



3) Repeat 1st exercise with arms at a lower angle and push in and up into the wheel. Continue to exhale engage abdominals, inhale lengthen spine. Keep shoulders wide as you contract the chest muscles. 


4) Repeat 2nd exercise with arms at a lower angle like on a rowing machine. Feel muscles between the shoulder blades contract but do not pinch shoulders together feel upright and wide through the back and chest.




Repeat entire sequence from the top. This is a nice 10 min series that will help you improve your posture and feel accomplished when you arrive at your destination. 

Enjoy, and continue to lengthen, strengthen and move.





Diastasis Recti – the separation of “six pack abs”

Recently, Elements has seen an influx of women and men with diastasis recti, a separation of tissues in the abdomen, resulting in a protrusion or bulge running vertically down the center of the tummy. The two options for treatment are a conservative approach, exercise, and non-conservative approach, surgery. I highly recommend finding a trained physical therapist or personal trainer before considering the surgical option.

Diastasis (a separation of normally joined parts) recti (the “six pack” abs, see picture below) is a condition in which the recti separate by a pathological amount, usually as a result of thinning and stretching of the linea alba, the narrow band of tissue that runs down the midline between recti. This condition happens most frequently with pregnant women. However, it also occurs in men with over-training of the rectus abdominis without the underlying support of the internal obilques, external oblique, transverse abdominis, pelvic floor and diaphragm. People with a history of abdominal or inguinal hernia may develop diastasis recti; also, asthma can cause altered breathing patterns, thus altering the unique stability of “the core.” The core muscles are the transverse abdominis (TrA), internal oblique (IO) and external oblique (EO) muscles, and the diaphragm and pelvic floor muscles; see image below and previous blog [https://elementsjustine.wordpress.com/2014/01/19/stability-with-gyrotonicr-exercise/]


In the picture above the linea alba is the vertical line of connective tissue where the belly button is.


Do you have diastasis recti? If you do a “crunch” (sit up) and see a bump or ridge running up the center of your abdomen, you probably do. This bump is a result of the separation of the rectus abdominis at the linea alba with a protrusion of underlying tissues. When you are relaxed and lying down, the bump recedes and leaves a gap.

Physical therapists measure the gap by the number of fingers we can fit into the separation. The goal is to have no more than a 1-2 finger separation. We also look at the recruitment and timing of the muscle firing and where there is expansion in the body with an inhale. When you inhale, the lungs fill and there is a natural rise of the belly. When you exhale, the belly falls, and that is the optimal time to contract the core muscles to avoid the separation of the linea alba.

When you contract the core muscles on an exhale, the deep core stabilizers help support the abdominal wall. In addition to preventing or resolving diastase recti, this also stabilizes the spine. The action of the rectus abdominis muscle is to flex or bend the spine forward, it is not designed to stabilize the spine. Thus when training the rectus abdominis it is important to engage the, TrA, IO, EO, diaphragm and pelvic floor to protect the spine and avoid excessive sheer on the disks. Keep this in mind when training the six-pack for beautification, it is pretty but not very functional. In people with diastasis recti, the rectus is often overworked without the support of the core muscles underneath.

A wonderful exercise for diastasis recti is to sit upright, either on the floor or on a short stool, with your back against a wall. If you are sitting on the floor, you may cross your legs or put them out in front. Pregnant women usually find it more comfortable to cross their legs. Breathe in and feel the belly expand, then breathe out and feel the belly flatten. As you exhale again, gently draw in the abdomen. If your shoulders rise or you feel tension or your pelvis tucks under you, then you are working too hard. Try again with a little less effort. If it is too difficult to start against a wall, try lying down (see blog on true core [https://elementsjustine.wordpress.com/2013/07/01/the-deep-transverse-abdominal-muscle-just-breath/ ] ). In the supine position, lying flat, gravity is working with you thus it is an easier position. In sitting you have to hold your body upright against gravity so it can be a bit more challenging. Whether you are sitting or lying down for the exercise, it is important to remember that drawing in the abdomen during the exhale is just part of the picture. The exhale also helps recruit the diaphragm and gently draws up the pelvic floor, as if stopping the flow of urine. This exercise can safely be done during pregnancy and after (once cleared by MD). Remember exercise pre and postpartum has been proven to prevent diastasis recti (see reference number 2 below.)


To challenge the pelvic floor, it sometimes helps to feel the contraction by doing the draw-in exercise while in a deep squat position. Stand with your feet wide and squat all the way down, then exhale and draw abdomen in while contracting the pelvic floor. This position stretches the pelvic floor and makes contracting a little more difficult and challenging.

The goal is to be able to recruit the “core” muscles in everyday life. Try doing the draw-in exercise while standing, while reaching for a glass and then try drawing-in walking. Again, as you exhale, draw in the abdomen by contracting the muscles in the front (TrA), the sides (IO and EO), the back (multifidus), the top (diaphragm) and the bottom (pelvic floor picture below). Keep in mind the draw-in should not create tension, just a feeling of support.


Enjoy moving your beautiful body and remember the body does heal!

For more information, contact Elements Fitness and Wellness Center at 202-333-5252 or email frontdesk@elementscenter.com


Dr. Justine Bernard


1) Sharma G, Lobo T, Keller L. Postnatal exercise can reverse diastasis recti. Obstet Gynecol. 2014 May; 123 Suppl 1:171S. doi: 10.1097/01.AOG.0000447180.36758.7a.

“Conclusion: Women who started after delivery an exercise program aimed at reducing diastasis recti achieved the same reduction in diastasis recti as those who started the program during pregnancy. (N=63)”

2) Benjamin DR, van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar;100(1):1-8. doi: 10.1016/j.physio.2013.08.005. Epub 2013 Oct 5.

“Results: Eight studies totaling 336 women during the ante- and/or postnatal period were included. The study design ranged from case study to randomized controlled trial. All interventions included some form of exercise, mainly targeted abdominal/core strengthening. The available evidence showed that exercise during the antenatal period reduced the presence of DRAM by 35% (RR 0.65, 95% CI 0.46 to 0.92), and suggested that DRAM width may be reduced by exercising during the ante- and postnatal periods.”

3) pictures from wikipedia commons.

Stability with GYROTONIC(R) exercise

At Elements we have a monthly two hour “continuing education” teacher meeting. This last meeting was particularly inspiring. We discussed how Gyrotonic exercise addresses Lumbar and Pelvic stability.

Recently more and more people have walked through Elements Center’s door with a diagnosis of “hypermobility syndrome.” Some symptoms included back pain, torn capsules in hips and/or shoulders, achiness and fatigue similar to fibromyalgia. Hypermobile joints can be due to three primary reasons 1) a disease such as Ehlers-Danlos syndrome 2) Ligament laxity with certain body types often seen in dancers and gymnasts, you may be familiar with the “Gumby” type person 3) or compensatory hypermobility due to hypomobility elsewhere in the musculoskeletal system, for example if someone has a fused joint in the spine due to arthritis or surgery often the joints above and below the fusion are hypermobile to make up for the loss of range in the fused joints. In general hypermobile people present with excessive or extreme range of movement.

Of course we discussed the Gyrotonic principle of “Narrowing the Pelvis.” “Narrowing” consists of and isometric contraction of the core stabilizers such as the transversus abdominis, pelvic floor and multifidi to elongate the spine while supporting the pelvis. However, this very important and effective maneuver can take quite a long time to perfect before introducing movement safely to the hypermobile crowd. In a non-injured healthy body narrowing occurs naturally before movement. After an injury or altered mechanics narrowing needs to be re-learned. For more information on narrowing, please read my previous blog on the Transversus abdominis.


Above is a baby standing with a nice round belly and then below he naturally narrows, drawing in his abdominal stabilizers flat, as he prepares to go up on his toes.


Discussed next was the Gyrotonic concept of “stability through contrast.” Another wonderful principle in which one reaches through the spine or limbs in opposite directions to create stability just like a tightrope is stable in the middle because the two ends are pulled tight. This too is an effective way of creating stability so that movement can still occur. However, creating the sensation of internal traction for hypermobile people without hyperextending the knee or overstretching a capsule can be difficult for the beginner student to differentiate. In the beginning Gyrotonic students learn “leg pumps” by sliding the heel into the resistance of the weight while sitting on the floor. When done well the force goes right through the center of the bones through the heel, no pressure goes into the ligaments in the back of the knee.

Lastly and what we spent the most time on was “wrapping the sacrum” which goes along with “burying the sacrum.”  In physical therapy we teach creating stability in the sacroiliac joints through form closure and force closer of the sacrum. In form closure the bones of the sacrum fit into the bones of the ilium to create stability and in force closure the muscles, fascia and ligaments that connect to and over the ilium and sacrum create force on the sacrum into the pelvis. We all agreed many of the Gyrotonic exercises that involve wrapping the sacrum could be introduced to a beginner student or safely taught in a group class with a hypermobile student as long as the anterior labrum or psoas is not compromised/injured.  The “wrapping muscles”, deep external rotator muscles, also help stabilize the lumbar spine in closed chain movements such as standing phase of walking. Several people with instability of the lumbar spine present with weak gluteal muscles as well as weak deep abdominal muscles, if the ligaments are physiologically over stretched and the muscles are weak there is very little support for the pelvis, SI joints and lumbar spine.

Combining the narrowing with the wrapping of the sacrum allows for the anterior sheath connecting to the pubic bone (via external oblique, internal oblique and Transverse abdominus), the posterior diagonal sheath (gluteus maximus and biceps femoris), and the longitudinal sheath (multifidus, deep layer of thoracolumbar fascia and long head of biceps femoris in to the sacrotuberous ligament) to all support the low back and pelvis.

Some of the final ideas we drew from our meeting were:

-Limit the range until the concepts of narrowing, stability through contrast and wrapping the sacrum are practiced.

-Teach arch and curl series on the handle unit much later for the hypermobile clients. It was debatable if the benefits of moving the fascia, viscera and muscles through the arch and curl series seated on the handle unit out weight the risk of increasing range in the spine is even warranted in this population.  Begin with spinal motions on the stool maintaining a narrowed pelvis or even cat back series from Gyrokinesis until the student understands the range they can tolerate without loosing the strength to narrow and maintain an elongated spine through out the movement. Perhaps introduce arch and curl series facing the tower with resistance to help activate tone in the muscles or standing so the ligaments can stay elongated and the legs active to help maintain stability with movement, which is the ultimate goal.

– Use resistance to help create traction thorough hypermobile joints and strength through the muscles such as in traction series which consists of using heavier weights in a smaller range.

– Teach Psoas abdominals over simple curl ups to allow for less mobility and work to stabilize the spine against the pull of the psoas again if the hip labrum is not injured.

-Often at Elements we return to the homework series created by Paul Horvath for the scoliosis workshop. It requires stabilizing the pelvis with all of the above Gyrotonic stabilizing principles with emphasis on a slow three second exhale allowing the stabilizers including the diaphragm to coordinate and initiate prior to movement.

These ideas have worked in our practice but we only have antidotal evidence. I have heard many times that Gyrotonic exercise is too “stretchy” for my body, or Gyrotonic exercise doesn’t work for me I need more strength not more range. We at elements disagree, people with hypermobility are drawn to the Gyrotonic method because it feels good and works through out ones range. Hypermobile people can learn to stabilize with movement from an experienced instructor using the Gyrotonic method.

The staff’s conversation and practice went well beyond the 2 hours and continued via email. What we all agree on is that the body is an amazing creation with biodynamic, energetic and anatomical interrelationships that science has only begin to discover not to mention that 2 hours and a few emails just touch the surface of the benefits of the Gyrotonic method for people with hypermobility.

Lengthen, Strengthen, Move,


Osteoporosis-Keep moving

Women often come into my office wanting an exercise program to strengthen their bones. To see where the majority of bone loss is, and whether they have osteoporosis or osteopenia, I ask for is a copy of their Bone Density Scan (DXA scan).  Based on the results of the bone scan, the individual’s balance, posture and overall health we work together to design an enjoyable and effective program.

The three major components of an effective program are weight bearing exercise, resistance training and balance exercises. 

Weight bearing exercise, is exercise in which you hold your body weight; for example, in walking, stair climbing and running. Swimming and cycling, although wonderful cardiovascular non-impact exercise, are not weight bearing. To prevent bone loss an effective walking program must include fast pace walking for a minimum of 30 minutes, 4-5 times per week.

Resistance training includes exercise in which you use your body weight, exercise bands or weights to create a muscular contraction. There are several systems that include resistance training such as Pilates, Gyrotonic® exercise and Power Plate.  It is important that your trainer is knowledgeable about osteoporosis, which movements to include and which avoid; for example, bending your spine with resistance can lead to spinal injury. In addition, a known risk factor in falling is the actual fear of falling, so avoid instructors that make you fearful of moving.  Fear of movement is not helpful for your mind, body or bones. It is better to learn how to move your spine in a healthy way, rather than limit your movement.  Postural exercises should be incorporated into your resistance training as well. Strengthening your back muscles not only helps prevent bone loss, it also helps with your posture. Also, make sure to incorporate exercises that focus on the areas where you have the most bone loss.

Balance exercises can be easily incorporated into your daily life. Safely, brush your teeth while standing on one foot, or try to walk down the hall with one foot in front of the other as though you are walking on a tight rope. Also, massaging your feet and moving your ankles, brings awareness to your feet and, thus, increases balance.

I remind my patients of two things: 1)Your program must be enjoyable or you wont do it. Find a way to move that feels good, and that is convenient for you. 2) Challenge yourself enough to stimulate your bones to grow, but don’t push so hard that you get injured. In general, find a weight that you can lift with good form until you feel muscle fatigue (about 8 times). Listen to your body and what signals it’s giving you, or seek out a physical therapist or highly trained exercise coach to help develop a safe and effective program that works for you. 


For more information stop by our

Fall Osteoporosis support group:

Friday Nov 8th at 12 noon: Managing Osteoporosis with exercise

Winter Osteoporosis support group:

Wednesday Jan 8th at 7pm: Balance and fall prevention

Anterior Cruciate Ligament (ACL), Licorice of the knee

You may have torn your Anterior Cruciate Ligament (ACL) skiing or heard of a football or soccer player with a torn ACL or an ACL reconstruction?

Ligaments attach one bone to another bone, allowing movement while still keeping the bones together. This differs from tendons, which attach muscle to bone so that the muscles can move the bones. For example, the bicep tendon attaches the bicep muscle (Popeye the sailor man muscle) to the arm bone, enabling us to bend the elbow. The Anterior cruciate ligament is a piece of cartilage that attaches the shin-bone (tibia anterior medial side) to the thigh bone (femur posterior lateral side). The ACL prevents the tibia from moving too far forward on the thigh-bone. When I was in PT school over 10 years ago, we did an experiment separating the shin bone from the thigh bone and we watched the ACL rip, much like pulling two ends of a licorice rope until it starts to tear.

We have other ligaments in the knee: the posterior cruciate ligament (which forms an X with the ACL) and the medial and lateral collateral ligaments (that stabilize the sides of the knee) which keep the thigh and shin attached; however, without an ACL the extra sheer of the tibia sliding on the femur can lead to wearing out of the cartilage in the knee.  Approximately 1/3 of people without an ACL (someone who tore it an never got it reconstructed) will develop either a meniscus tear and/or arthritis from the sheering and wear and tear of the excessive movement at the knee. Most people opt to have the surgery, unless they choose to modify their activity.


View from the front of the knee. Photo from Wikimedia Commons

I currently have a patient who tore his ACL about 65 years ago. They didn’t repair ACLs back then. At this point his knee is pretty much bone on bone. He has decreased strength on the arthritic side and has developed scoliosis due to the limp he developed to take the weight off the injured side to avoid pain. Our bodies are smart, our bodies attempt to avoid pain through postural changes and changes in movement patterns, even though our brains don’t always agree.

For people who choose to get surgery, most postsurgical rehabilitation protocols enable them to return to sports-specific ac­tivities between 4 to 6 months post-ACL reconstruction with a full return to sports at 6 to 12 months. Approximately 60% of people return to their previous activity post-surgery depending on how active they were prior to surgery. (1)

Approxi­mately 70% of all ACL injuries are noncontact in nature, such as landing from a jump, and 30% are contact injuries, such as getting hit in the side of the leg. Noncontact ACL injuries are more common in sports that require multidirectional ac­tivities, like rapid deceleration, pivoting, cutting, and land­ing from jumps (e.g., basketball and soccer). (1)

Multiple studies have analyzed the biomechanics of jumps and which neuromuscular patterns are prone to injury. Athletes that land on a flat foot with their body weight (center of mass) falling behind where their foot lands (base of support) are more prone to ACL tears upon landing (3). In a static position, a person would fall over backward if their body weight were behind their feet, but in a dynamic movement people adjust by bending their hips and throwing their shoulders forward, causing excessive use of hip flexors and quadricep muscles (front of thigh). This adjustment puts increased stress on the ACL. Thus, trunk control and balance are important to practice and training to avoid injury for both weekend warriors and elite athletes alike.

Several sudies suggest that excessive use of the quadriceps muscle (front of thigh) without balanced activation of the hamstring muscle (back of thigh), especially during eccentric contractions such as landing from a jump may be a main factor in the injury risk to the ACL. The quadricep pulls on the front of the tibia and the hamstring pulls on the back; when working together they balance the force on the knee.

Female athletes are more prone to ACL tears. They also have higher levels of quadriceps activity and lower level of hamstring muscle activity and a slower hamstring activation, which combine to put increased stress on the ACL. (2) In athletes prone to ACL injury, the quadricep had a stronger contraction and the hamstring activation kicked in too late. Thus, the tibia was pulled forward by the quadricep, which altered the mechanics of the knee and ripped the licorice.

Other movement patterns that increase the risk of an ACL injury include a knock knee position (genu valgus), which can have structural causes or exist due to tight calves. Shimokochi and Shultz (1) performed a systematic review examining the mechanics of noncontact ACL injury, which included studies published through 2007. They concluded that noncontact ACL injuries are likely to happen during deceleration and acceleration motions (such as landing and taking off from a jump) with excessive quad­riceps contraction and reduced hamstring co-contraction at or near full knee extension (initial landing). ACL loading was higher during the application of a quadriceps force when combined with knee internal rotation (knee twisted in), a valgus load combined with knee in­ternal rotation (knee in, especially when thighbone is forward and tibia twists in), or excessive valgus knee loads (knee in) applied during weight-bearing, decelerating activities (landing from jump, slowing down from sprint). This again shows the importance of training and practicing lower leg alignment with activity.


incorrect alignment of knees coming together.

incorrect alignment of knees coming together.


notice good alignment of knees pointing over toes

notice good alignment of knees pointing over toes


As you can see, each segment of the lower extremity kinetic chain, from the ankle to the spine, play a role in injury of the ACL. If the ankles are not mobile, you may land on a flat foot or knock the knee, increasing risk of injury. If the knees are poorly aligned in landing or the quadriceps is overactive, your potential for injury is higher. If the trunk isn’t strong and your weight is back or not balanced over the feet, the risk of injury increases. Neuromuscular control from head to toe is extremely important to avoid injury. Luckily, alignment and dynamic posture can be trained and practiced; motor control is the most modifi­able risk factor.

There are a several other factors in predicting ACL injury including environment (e.g., type of shoe, type of surface) and hormones (for women, at what point during the menstrual cycle ligaments are more lax), and a high body mass index (BMI). Again, however, movement patters are the most modifiable, efficient and correctable ways to prevent an ACL tear.

A contact injury often occurs when someone plants the foot and is hit from the side. Contact injuries are more difficult to avoid; however, if one is flexible and mobile we can hope the ligament and tissues will bend instead of rip. The Medial meniscus is firmly attached to the medial collateral ligament as shown in the knee picture above. Triple triad is when three structures the ACL, medial meniscus and medial collateral sustain injury. This often happens when the foot is planted (stuck to the ground) and there is a forced hit from the side causing the knee to rotate and bend in while the thigh is still going forward. However, even repetitive strain of rotation to the leg with a planted foot can cause injury. We can see this in a golf swing if the ankle is planted and not mobile, the torque will enter the knee. Again, mobility, agility and dynamic alignment are key.

To test for injury to the ACL , physical therapists look for instability in the knee, especially forward instability (anterior) and rotary instability. In the Draw test, physical therapists pull the tibia anteriorly on the femur and measure how much movement is present. Six mm is normal, and if there is more, it is often indicates an injury to the ACL.

How to avoid injury: practice, practice, practice! Here are some suggestions…

1)    Practice articulation of the feet. 1. Start by bending your knees over your toes, 2. then straighten the knees and dorsi flex the foot by lifting the toes, 3. next rolling up articulating the ankle on to the toes and 4. roll back down to the heel. Coordinate this movement making it smooth. Try not to lean back keep your back upright and hips forward.

keep knee over toes, sit bones reaching for heels

keep knee over toes, sit bones reaching for heels

correct alignment, notice hip over knee over foot, also notice the hamstring muscle activity.

correct alignment, notice hip over knee over foot, also notice the hamstring muscle activity.

roll through ankle up to toes.

roll through ankle up to toes.


repeat straight leg through transition to increase foot articulation and propriception/ awareness.

repeat straight leg through transition to increase foot articulation and propriception/ awareness.

Notice the hyper extension of the knee, with no hamstring engagement and the weight behind the foot

incorrect flex: Notice the hyper extension of the knee, with no hamstring engagement and the weight placed behind the foot

In The Gyrotonic(R) method we practice “4 way feet” and articulating the hips, knees and ankles when rolling up through feet and down through heels.

2)   Once all the joints and surrounding muscle are coordinated, then practice jumping. Gyrotonic and Pilates equipment offers a safe and effective way to learn this. In the Gyrotonic method the Jump Stretch Board(R) can assist jumping and then gradually add resistance as the alignment, foot articulation, strength and coordination of the hamstring and quadriceps contraction develop. In Pilates the jump board also achieves these goals. If you do not have access to trained instructors or equipment, start with small jumps and gradually get bigger. Also practice single leg jumps. Then try to jump off a low object (small step stool) a “drop jump.”

3)    Stand on one leg while making an X with the other leg. Keep balance over foot. Watch for knee alignment with knee pointing towards second toe not inward. Change the speed and directions. Notice if the hamstring is co-contracting.


4)    Stand on one leg and lean forward to pick up a ball or shoe. Bend at ankle, knee and hip. Try to keep body upright as long as possible. Repeat on other legs at different speeds with different weighted objects. Keep hamstrings active.


Notice in above photo the left knee is starting to point in, practice keeping alignment all the way down and up.

Take good care of your knees.




1) Journal of Orthopaedic & sports physical therapy. April 2010, number 4 , volume 40 |

2) Lower Body Stiffness and Muscle Activity Differences Between Fmale Dancers and Basketball Players During Drop Jumps. Ambegankar, Shultz, Perrin et al. . Sport Health  Jan-Feb 2011  pp89-94

3) DYNAMIC SAGITTAL-PLANE TRUNK CONTROL DURING ANTERIOR CRUCIATE LIGAMENT INJURY. William Sipprell, BSE, Barry P Boden, MD, Frances T Sheehan, PhD. Am J Sports Med. 2012 May; 40(5): 1068–1074.

Published online 2012 March 1. doi:  10.1177/0363546512437850


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