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thorough evaluation of the muscular system

should include an assessment of the musclesfor over-activity, shortening, weakness, inhi-bition, and quality of motion. This is bestaccomplished by a skilled physician or thera-pist using muscle-length tests, strength tests,and tests for the efficiency of basic move-ment patterns and neuromuscular control. Athorough postural observation and video tap-ing of the athletes running gait will help inassessing and identifying any movementimbalances.

Preliminary stretches for shortened muscles

should include proprioceptive neuromuscularfacilitation (PNF) type or contract-relaxstretches that strive for isometric contraction,followed by end-range stretching. These areeffective techniques for maintaining musclelength and joint mobility. Active ReleaseTechniques (a specialised method for softtissue mobilisation) when used in conjunctionwith stretching techniques, have shown greatpromise in restoring muscle length and soft-tissue extensibility. Athletes can also do theirown self-mobilisation with use of a foam roll.

Proprioceptive: Relating to stimuli thatare produced and perceived by the body,

especially those connected with positionand movement.

Specific exercises for the runner shouldprogress from mobility to stability, to reflex-ive motor patterning, to acquiring the skills offundamental movement patterns, and finally,to progressive strengthening. These sequencesmay not be applicable to all athletes; there-fore, the key is to analyse the individual ineach exercise category and then to tailor an

exercise regimen that will best suit that run-ners needs. For example, it has been shownthat runners prone to iliotibialband syndromeoften have weakness in their hip abductorsthat predisposes them to increased stress onthe iliotibialband.5 Thus, a preventative train-ing programme for runners with this syn-drome must target the hip abductors, partic-ularly the posterior aspect of the gluteusmedius that assists external rotation or indecelerating internal rotation of the hip.

Other muscles that prove weak or inhibited on

evaluation should also be strengthened on acase-by-case basis.

The purpose of basic core stabilisation exer-cises is not only to increase stability, but moreimportantly it is to gain co-ordination andtiming of the deep abdominal-wall muscula-ture. It is extremely important to do thesebasic exercises correctly, as they are the foun-dation of all other core exercises and move-

ment patterns. These basic exercises empha-sise maintaining the lumbar spine in a neutralposition (which is the midrange position

between lumbar extension and flexion.),allowing for the natural curvature of thespine.

This first stage of core stability trainingbegins with the athlete learning to stabilisethe abdominal wall. Proper activation of thesemuscles is considered crucial in the firststages of a core stability programme, beforeprogressing to more dynamic and multi-pla-nar activities.

We recommend the technique as described

by McGill.6 This involves a sub-maximal iso-metric contraction of the three layers of theabdominal wall (rectus, obliques, and trans-verse) producing a true muscular girdlearound the spine to buttress against bucklingand shear instability.

Fundamental lumbo-pelvic stability

The exercise programme should progresssequentially through the fundamental move-ments as detailed below. The following exer-cises are to be performed three times per

week to maximise results. The athlete beginswith one to two sets of 15 repetitions andprogresses to three sets of 15-20 reptitions.These exercises are taught initially in either asupine, hook-lying position, or all-foursquadruped position. The athlete can progressto the more functional standing exercises, ascontrol is developed. Important conceptstaught at this stage include not tilting thepelvis or flattening the spine. We also empha-sise normal rhythmic breathing.

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Core stabilisation training for middle- and long-distance runners

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SUPINE BENT-KNEE RAISES

This is a fundamental exercise for recruitingthe deep abdominal muscles and for lumbo-pelvic control.

The athlete lies on her back, with knees bentand feet flat on the floor. She then braces theabdominal wall, holding the lumbar spine in aneutral position, and slowly raises one foot15-30cm off the ground with alternate legs.Common errors when performing this exerciseinclude rocking the pelvis, abdominal protru-

sion, or an inability to maintain the neutral(midrange) lumbar curve. If this happens, dis-continue the exercise for a rest period. Quali-ty more than quantity is stressed.

Progression: The exercise can progress toalternately extending the legs and lowering tothe ground. Once the athlete can maintainstability with alternate leg lifts. She can addalternate, overhead arm raises for greaterchallenge. The arm raises should be performedslowly, while maintaining lower abdominalbracing.

Figure 1: Supine Bent-Knee Raises

QUADRUPED WITH ALTERNATEARM/LEG RAISES

This exercise prepares the athlete for the pro-prioceptively more challenging, more dynamicexercises of the trunk. It specifically engagesthe multifidithe deep transverse spine sta-biliser and extensor of the lumbar spine.

The athlete should position herself on allfours. She then braces the abdominal wall as

described above. While maintaining a

midrange/neutral curve of the lumbar spine,the athlete should raise the right arm and theleft leg (opposite upper and lower limbs) intoa line with the trunk, while preventing anyrocking of the pelvis or spine (excessive trans-verse- or coronal-plane motion). If it helps tomaintain alignment, the athlete may use anobject, such as a foam roller or woodendowel, placed along the spine, for added tac-tile feedback. The leg should be raised only tothe height at which athlete can control anyexcessive motion of the lumbo-pelvic region.She then performs the exercise raising the left

arm with the right leg.

Progression: A Physioball underneath thetrunk can provide significantly more proprio-ceptive challenge owing to its unstable sur-face. The goal once again is for the athlete tomaintain lumbar stability while the oppositearm and leg are raised slowly.

Figure 2: Quadruped with Alternate Arm/Leg

Raises

BRIDGING

Bridging is a fundamental core-stabilityand gluteal-strengthening exercise.

The athlete begins the exercise on her back,in a hook-lying position, with arms resting ather sides. She activates the abdominals and

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squeezes the gluteal cheeks prior to initiating

the movement. The athlete lifts the pelvis andhips off the ground while maintaining neutrallumbar alignment. There should be no rota-tion of the pelvis. The hips should be alignedwith the knees and shoulders in a straightline. The athlete should hold the position for10sec and then slowly lower the pelvis to thefloor.

Progression: In the lifted-bridge position,while maintaining neutral lumbar and pelvicalignment, the athlete can lift one foot offthe ground and extend the leg. By placing her

arms across her chest, she can increase thechallenge of stabilising the lumbo-pelvicregion. To progress further, the athlete canraise both arms up to the ceiling and thenmove one arm out to the side. She shouldbring the arm back to the centre and repeatwith the other side.

Figure 3: Bridging

PRONE PLANK

This is a fundamental, static core-stabilityexercise.

The athlete supports herself with her fore-arms resting on the mat, elbows bent at 90,and the toes resting on the mat. The athletemaintains the spine in a neutral position,recruits the gluteal muscles, and keeps the

head level with the floor. She is instructed tobreath normally throughout the exercise, whilemaintaining the abdominal brace. We suggestholding the position for 20sec, working up toone minute for two to three repetitions. Nocompensatory motion, such as increased lum-bar lordosis or sag, should be seen.

Progression: In this position, the athletecan add leg lifts for more difficulty: one legcan be lifted off the mat, held for five sec-

onds, and then repeated on the opposite side.

Figure 4: Prone Plank

SIDE PLANK

This is a fundamental, static core-stabilityexercise designed to challenge the athletesbody against gravity in the coronal/frontal

plane and is an ideal exercise to train thequadratus lumborum.

The athlete is lying on her right side withthe right arm extended in a straight line upfrom the shoulder, with the forearm restingon the mat. She then raises the pelvis fromthe floor and holds it in a straight-line plankposition. The hips should not be allowed tosag toward the floor. We suggest holding theposition for 20sec, working up to one minuteholds for two to three repetitions.

Progression: The top foot can be raised toincreasingly challenge the core and glutealmusculature.

Figure 5: Side Plank

Advanced lumbo-pelvic stability

Once the athlete demonstrates good stabilitywith all static core exercises, they can bereplaced with more advanced exercises on thePhysioball detailed below. These exercisesshould be performed at least two times perweek to maximise results. The athlete progress-es to two sets of 10-15 repetitions. Quality ismore important than quantitiy; the athlete mustmaintain lumbar neutral and keep the spine inperfect alignment throughout the exercises.Ne

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blades should be supported on the ball. Knees

should be bent at a 90 angle, with feet onthe ground. While bracing the abdominalmuscles, the athlete raises the foot andextends the leg off the ground. The weightwill be shifted to one side, and the athleteshould focus on maintaining stability of thelumbo-pelvic region. The athlete should strivefor stability and balance, while holding thisposition for 10sec and alternating lowerlimbs.

Progression: The athlete lifts the arms up inthe air or out to the sides.

Figure 8: Alternate Leg Bridge with Shoulderson Ball

LEG CURLS ON A PHYSIOBALL

The purpose of this dynamic exercise is torecruit both actions of the hamstringshipextension and knee flexionwhile maintain-ing dynamic stability of the lumbar spine.

In a supine position on the floor, the ath-

lete places both feet on the Physioball.(Shoes should be removed to allow increasedproprioception from the exteroceptors of thefeet.) The athlete keeps her arms on the floorat the sides of the body for balance and rais-es the hips off the ground until the knees,hips, and shoulders create a straight line.She should focus on holding the spine in aneutral midrange position. In this position,the athlete then pushes the ball forwardwith the feet while maintaining the bridge.

The goal is to keep the pelvis elevated (hip

extension) as both legs extend and flex atthe knees. While the knees extend and flexfrom this elevated bridge position, the ath-lete focuses on maintaining lumbo-pelvicstability.

Progression: The athlete can continue withsingle leg hamstring curls in the same posi-tion (see Figure 9b).

(a)

(b)

Figure 9: Leg Curls on a Physioball

Exteroceptor: A sensory receptorthat receives external stiumuli.

ABDOMINAL ROLLOUT

The athlete kneels behind the ball, withboth hands on the ball. Keeping the abdomi-nal muscles braced and lower back in a neu-

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tral position, she then rolls the ball away from

her body a short distance until there is astraight line from the shoulder to hips. Whilemaintaining alignment, she pulls the ball backta short distance, then pushes it away again.The movement should occur only at theshoulders, not the back.

Progression: The athlete can graduallystraighten the body until she is up on hertoes. There should be a straight line fromthe back of the head to the knees. Now shecan again move the ball away and backtoward the body a short distance with the

arms.

Figure 10: Abdominal Rollout

SQUAT BALL THRUST

Keeping the abdominal muscles braced and

lower back and shoulder blades in a neutralposition, he athlete uses her abdominal con-traction to move the ball forward and back.Keep the spine in neutral alignment through-out the movement. If the exercise shown istoo challenging, start with the shins insteadof the toes on the ball.

Progression: The athlete can perform theexercise with only one foot on the ball (seeFigure 11b).

(a)

(b)

Figure 11: Squat Ball Thrust

Development of balance and motorcontrol

The following movements require reflexivecontrol. The athlete can establish this controlusing an unstable surface and taking advantageof the numerous proprioceptors in the soles ofthe feet, and by activating the neck muscles,which contribute greatly to postural regulation.This sensory-motor training is an attempt toprovide the sub-cortex with a basis for move-

ment that is progressively more challenging. Itinvolves exercises that stimulate balance, coor-dination, precision and skill acquisition.

Various devices are useful to progressivelychallenge balance, including a balance boardwith a whole sphere underneath the board(which creates multi-planar instability) or arocker-board with a curved surface underneaththe board (which allows single-plane motion).Dynamic foam rollers are an inexpensive alter-

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native to the boards that also can be used to

challenge balance, proprioception, and stabili-ty. These include half-rollers and full-sizedrollers. Two other items that are invaluable tochallenge balance and core stability and aidproprioceptive training in the standing positionare the Bosu Balance Trainer and the Dyna Disk(these can be used interchangeably.) The Bosuhas two functional surfaces that integratedynamic balance with sports-specific or func-tional training: the domed surface is convex,the other side is flat and can be used for lesschallenge. The Dyna Disk is an air-filled plasticdisc that can be firmly inflated. It has a small-

er diameter than the Bosu and can be used likethe Bosu Trainer, as it creates an increased pro-prioceptive challenge to the athlete whilestanding on it. The Dyna Disk is unstable anddoes not have a base like the Bosu trainer.

FORWARD/BACKWARD ROCKING

In this exercise, a rocker-board is used tochallenge balance in the frontal plane ofmotion. Standing on the rocker-board withboth feet in perfect postural alignment, the

athlete gently rocks forward and backward.(To maintain ideal posture, the athlete cancreate an imaginary line through the joints ofthe ankle, knee, hip, and shoulder. The earshould align in a straight line with these

joints, with no excessive extension [swayback]of the lumbar spine or anterior pelvic rota-tion.) While rocking, there should be no excessbody movement in the coronal or transverseplanes. This exercise should be performed forseveral minutes. The goal is to optimally alignthe spinal curves and lower extremities.

Progression: The athlete canprogress to a slight flexed-kneeposition, with fast and slow move-ments to stimulate the rightingreflexes and balance reactions.She also can progress the steppingmotion to the three axes ofmotion.

Figure 12: Forward/BackwardRocking

SINGLE-LEG BALANCE3 PLANES

This next exercise progresses the athlete toa single-leg stance. The rocker-board is usedin the three planes of motion. This exercisealso can be performed with a balance board,which is more demanding as it incorporatesall planes of motion simultaneously.

The athlete takes one step forward whilemaintaining alignment and balance, control-ling aberrant motion, mimicking a forwardrunning motion. The goal is to maintain

lumbo-pelvic alignment. The athlete controlsmovement in the three planes of motions byplacing her feet in various positions on theboard. The athlete then alternately steps for-ward and backward onto the rocker-board.

Progression: Once the athlete achievesstatic stability and can remain stable whilestanding on the rocker board, she can add anaccessory motion. The athlete can swing thearm and the non-weight-bearing opposite leg(as though mimicking running). No excessivemotion in the pelvis or lumbar spine should

occur during the swing phase.

Figure 13: Single-leg Balance3 Planes

WEIGHT TRANSFERS WITHPROPER ALIGNMENT

The preceding exercise progresses tofalling onto an unstable surface. Figure 14shows a rocker-board and falling onto acircular balance board. Again, the emphasis ison spinal alignment from the head to thesacrum. The athlete steps forward quickly

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and catches herself from falling over with a

quick forward movement of the leg onto theboard.

Figure 14: Weight Transfers with ProperAlignment

Functional Movement Training

Functional movements require acceleration,deceleration, and dynamic stabilisation. Afunctional exercise regimen specific to thedemands of running includes single-leg drills,three-dimensional lunges, resistive diagonalpatterns of the upper and lower extremities,and tri-planar movement sequences. Athletescan progress through the three planes ofmotion by performing similar exercises on

balance boards, the Dyna Disk or Bosu typetrainers, as static trunk and core stabilityhave been mastered. Once these exercises areperformed at a high level, the coach can beassured the athlete has the necessary corestability to start plyometric drills.

SINGLE-LEG BALANCE WITHHIP FLEXION

This exercise provides a functional move-ment pattern that is similar to running. The

exercise seeks to increase stability of thelower abdominal muscles while using a for-ward motion at the hip. The exercise isdesigned to develop sagittal-plane control.

While balancing on one leg, the athleteimitates a running motion. As the upper thighis lifted forward in a running motion, she con-centrates on maintaining the abdominalbrace and lumbo-pelvic stability while avoid-ing excessive anterior or posterior pelvic rota-

tion. The athlete raises the opposite arm

simultaneously into flexion, while maintain-ing postural alignment with an erect spine,allowing only the extremities to move.

Progression: Once the athlete can maintainlumbar spine stability without effort, she canattach a pulley or resistive cord to the ankleto increase the challenge to the hip flexors

Figure 15: Single-leg Balance with Hip Flexion

MULTI-DIRECTIONAL LUNGES

The athlete begins this exercise with a for-ward lunge. Again, the emphasis is on main-

taining a neutral spine position and abdomi-nal brace throughout the entire movement.As the athlete steps forward, knee flexion ofthe forward leg is limited to 90. The knee

joint should be over the ankle joint and thepatella aligned with the second toe. The lowerpart of the leg should be perpendicular to theground, as shown in Figure 16.

Progression: Once strength and stability inthe forward (sagittal) plane have beenachieved, the athlete can begin stepping outat oblique angles, creating a narrower lunge

or a wider lunge in the coronal or transverse

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Figure 16: Multi-directional Lunges

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planes. The athlete can also step out onto an

unstable surface such as a Bosu Trainer orDyna Disk, which vastly increase the proprio-ceptive and dynamic core-stability challenge.

RESISTED ALTERNATE ARM/LEGSTEP-UPS

This exercise is a continued progression ofmulti-directional lunges and must not bestarted until strength and stability in thatexercise has been achieved.

This exercise utilises a sports cord to resistshoulder and hip flexion while doing Step-ups. The movement pattern is similar to therunning gait. The athletes opposite arm andleg are resisted simultaneously to increase thestrength and co-ordination of this movementpattern.

Figure 17: Resisted Alternate Arm/Leg Step-ups

MULTI-DIRECTIONAL RESISTEDALTERNATE ARM/LEG STEP-UPS

This is a continued progression of the pre-vious exercise. Once strength and stability is

achieved in the frontal plane of motion, the

athlete can begin stepping up at a 45.

STANDING PULLEY OR MEDICINE BALLROTATION

This resistive, dynamic trunk pattern chal-lenges the core with a rotational movementpattern while the athlete maintains stabili-ty in the hips and pelvis. It requires strictbracing of the abdominal muscles and lock-ing the rib cage and pelvis together to avoidunnecessary stress from torsion on the

spine.

The athlete stands with feet about shoul-der-width apart and knees slightly bent. Sheactivates the abdominal brace prior to themovement. It is important to emphasisepostural alignment, with the scapulaeretracted and depressed. The athlete shouldmaintain neutral spinal angles throughoutthe movement. Holding a straight-arm posi-tion (elbows extended) while grasping thepulley handle or medicine ball with bothhands, the athlete rotates the trunk by acti-

vating the abdominal obliques and spinalrotators. She concentrates on keeping thearms extended in front of the chest. It isimportant that the pelvis remains stable inthe movement. Resistance is perpendicularto the body.

This exercise can be done in the same man-ner using a 2.0 to 4.0kg medicine ball.

Progression: The athlete can add diagonalmotions with the pulley or medicine ball.

Figure 19: Standing Pulley or Medicine BallRotation

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Figure 18: Multi-directional Resisted Alter-nate Arm/Leg Step-ups

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FORWARD LUNGE WITH A MEDICINEBALL WITH TRUNK ROTATION

The purpose of this exercise is to challengethe trunk muscles with appropriate weightshift, balance, and control on one leg. It usesa resistive movement of the trunk with alunge that demands a high level of lumbo-pelvic and lower extremity stability as theathlete moves the ball in a diagonal patternacross the body.

The athlete will need approximately 30m

to complete this exercise. She standsupright, holding onto a 2.0 to 4.0kg medi-cine ball, with arms outstretched, perpendi-

cular to the body. She steps forward with the

medicine ball in front of her chest with thearms extended. Once the lunge portion iscompleted, she rotates the trunk by bringingthe ball across her body towards the sameside as the front leg and then returns theball to midline as the next step is made. It isimportant that the knee joint on the step-ping limb does not come forward past thevertical angle relative to the ankle joint. Thesecond toe is aligned perpendicular with thepatella.

STANDING REVERSE WOOD-CHOPWITH A MEDICINE BALL

This exercise is a resistive diagonal pat-tern of the trunk that demands a high levelof lumbo-pelvic stability and combinesupper- and lower-chain integration as theball is moved in a diagonal pattern acrossthe body.

The athlete stands, holding onto a 2.0 to4.0kg medicine ball with both hands, withthe feet approximately shoulder-width

apart. While holding the arms in front of thebody with elbows extended, the athlete

Sample Programme

Summer/FallBase Training/General Preparation(3 x /week, 2 sets of 15-20 reptitions for each exercise)

Restore mobility/address any muscle imbalances

Fundamental core stability exercises

Sensory-motor stimulation

WinterSpecific Preparation(2-3 x /week, 2 sets of 10-15 reptitions for each exercise)

Advanced core stability exercises

Functional movement training

Spring/SummerCompetition(1-2 x /week. 1-2 sets of 8-12 repetitions for each exercise)

Similar to specific preparation training with the addition of plyometric exercises

Figure 20: Forward Lunge with a MedicineBall with Trunk Rotation

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moves the ball from a lower position at the

hip, raising it across the body to the oppositeshoulder, simulating a wood-choppingmotion. The motion is then reversed by start-ing at the lower knee position and bringingthe ball diagonally across the body, endingoverhead at the opposite shoulder. This exer-cise also can be performed with resistivecords or a pulley system simulating the samemotions.

Progression: The athlete can progress tostanding on one leg, using the opposite armto complete the motion.

Figure 21: Standing Reverse Wood-chop witha Medicine Ball

Conclusion

This article is intended to provide an under-standing of the importance of core muscula-ture to middle- and long-distance runnersand to offer exercises that will help themachieve desired stability, balance, and neuro-muscular control. It is highly recommended,however, that athletes consult a skilled prac-titioner to address individual needs and max-imise results from a programme of thisnature.

Please send all correspondence to:

Michael Fredericson, MDE-mail: [email protected]

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REFERENCES

RICHARDSON, C.; JULL, G.; HODGES, P.; HIDE, J.:Therapeutic exercise for spinal stabilization andlow back pain: Scientific basis and clinicalapproach. Edinburgh: Churchill Livingstone, 1999.

COMERFORD, M.J.; MOTTRAM, S.L.; Movement andstability dysfunction. Contemporary developments.Manual Therapy. 2001; 6(1): 15-26.

HODGES, T.W.; RICHARDSON, C.A .: Inefficient muscu-lar stabilization of the lumbar spine associatedwith low back pain: A motor evaluation of trans-verse abdominus. Spine. 1996; 21(22): 2640-2650.

HODGES, T.W.; RICHARDSON, C.A: Altered trunk mus-cle recruitment in people with low back pain withupper limb movement at different speeds. Archiveof Physical Medical Rehabilitation. 1999 Sep;80(9): 1005-1012.

FREDERICSON, M.; COOKINGHAM, C.L.; CHAUDHARI,A.M.; DOWDELL, B.C.; OESTREICHER, N,;SAHRMANN, S.A.: Hip abductor weakness in dis-tance runners with iliotibial band syndrome. Clin-ical Journal of Sport Medicine. 2000 July; 10(3):169-175.

McGILL, S.; Ultimate back fitness and performance.Wabuno Publishers, 2004.

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