A Better Way To Stretch?

By: Kim Kranz, PT, DScPT, SCS

As PTs, we often preach the basic rule of stretching:  If you want to improve length in a muscle, you have to consistently perform static stretching, doing 3 sets of each stretch and holding each stretch for at least 30 seconds.  Not a bad place to start; but, maybe we have something to learn from the other disciplines that promote flexibility:  Yoga and Pilates.  After studying Anatomy Trains by Thomas Myers, it’s become clear that yoga practitioners really do have a leg up on us.  Anatomy Trains shows us that the fascial lines (connective tissue that is interwoven throughout our bodies) are more connected than we once thought and that to truly improve fascial mobility, and thereby muscle length, it’s important to stretch through the whole fascial line.  If we take the hamstrings, for example, we could stretch like this and target only the hamstring muscle:

Hamstring Stretch

The Hamstring Group








Or we could stretch like this and stretch the whole superficial back line of fascia:

Standing Forward Fold

Superficial Back Line

Superficial Back Line









If you doubt the role of fascia in “hamstring flexibility”, here’s a simple test.  Stand up and bend forward as far as you can.  Make a mental note of how far you can bend forward and then stand up.  Now, take a tennis ball (or other firm ball) and roll the ball on the bottom of your foot for one minute on each side.  Remove the ball and bend forward again.  Did you go farther?  Most likely, yes.  You released the fascia in part of the superficial back line (in this case, the fascia on the bottom of your foot) and as a result, you had better mobility throughout the fascial line, including the hamstrings.

Another thing that Yoga and Pilates have on us is the use of breath with stretching.  When you get stressed or frustrated and you take a few deep breaths, you feel a little more relaxed, right?  Well, the body uses deep breathing as a way to help your muscles relax, too.  By coordinating our breathing with our stretching, we can make stretching more effective.  Pilates is well-known for using rhythmic, controlled and low-intensity movements to gain flexibility.  In their book Stretch to Win, Ann and Chris Frederick (Chris Frederick is a Physical Therapist) postulate that a stretch should be undulating or wave-like, timing the stretch to your breath.  Inhale and then exhale as you move into the stretch, release the stretch as you inhale again.  Anyone who has ever taken a Pilates class will be familiar with those instructions.

The third thing to keep in mind is that the “no pain, no gain” mentality should never be used with stretching.  Our body has multiple protective mechanisms in place to try to keep us from hurting ourselves and the stretch reflex is one of those.  This reflex causes a muscle to tighten up or shorten in response to either a quick stretch or a prolonged, high-intensity stretch.  So, if your leg is “shaking” while you’re trying to stretch, that’s a sign that your stretch reflex is kicking in and you need to back off a little until that stops.

Lastly, we need to remember that most muscles work in many planes and across joints.  So, when you’re stretching, don’t just stretch in one plane of movement.  Thorough stretching of the hamstrings, for example, requires you to extend your knee and flex your hip (sagittal plane), rotate your leg in and out (transverse plane) and vary the position of the leg side to side (frontal plane) to stretch all of the fibers.  A good example is shown in this video:  https://www.youtube.com/watch?v=oDpuNRznih8

If you have any pain with any activity, including stretching, consult your physician or a physical therapist for a personalized assessment and guidance in the best way to rehabilitate the injury.

CHKD’s Sports Medicine program is a comprehensive sports medicine program with services provided solely for athletes under the age of 21.  Call 757-668-PLAY (7529) or visit our website at www.chkd.org/sportsmed.

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Known dangers, hidden risks to teenagers using performance enhancing drugs

CHKD’s Dr. Joel Brenner recently contributed to this piece from our local ABC station.

Known dangers, hidden risks to teenagers using performance enhancing drugs.

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Pilates For Kids

By: Ashley deLalla, DPT, PMA®-CPT

“I’m a dancer and these exercises you are teaching me in therapy don’t really apply to me. Can I do some Pilates for my rehab?”

“How little is too little for Pilates training?”

“How is working on the reformer going to teach me to jump higher…I’m a basketball player?”

“What is Pilates anyway?”

Every day, hundreds of adults practice Pilates in gyms, on the mat, in the studio on equipment, in classes, and one-on-one. But, how young is too young? What are the benefits to the young population?  Recently, the Pilates Method Alliance (PMA) published a book called Pilates for Children and Adolescents: A manual of Guidelines and Curriculum. They also hosted a conference “PMA’s Pilates 4 Youth initiative” which is a grassroots program offering children the experience of Pilates. This program was taught at their educational level so they could understand the mental, physical, and emotional benefits of Pilates.  In learning about the program and developing an exercise regimen here at CHKD, I began to look at the differences in Pilates for adults and children as well as the things to keep in mind when working with young children and adolescents.

Male Pilates

As an adult who has been trained in the Pilates method, I have learned first-hand the benefits of Joseph Pilates “Contrology” method including an integrated body and mind.  His teachings sought to undo and “correct wrong postures, restore physical vitality, invigorate the mind and elevate the spirit”.  He did this through his 3 guiding Pilates principles: whole body health, whole body commitment, and breath.  Through practicing Pilates, one is able to override the body’s physiological response to stress, initiate relaxation response (through improved ability to concentrate and focus on proper breathing techniques), exercise multiple muscle groups to become energized (coordination), increase self-awareness and self-confidence, strengthen muscles (including the core or powerhouse),   improve posture, and enhance quality of life. The best news is that all of these benefits apply to Pilates training in young children and adolescents!1

In teaching Pilates to youth, the PMA breaks down the exercise programming to 3 different groups (with different goals and precautions based on the child’s development).  The three age groups are: 5-8 years old (the inquisitive learner), 9-13 years old (the “magic window” when a structured exercise program can be followed at this appropriate level of motor and cognitive development), and 12-18 years old (the adolescent).  The following are important areas to be aware of when teaching children and how Pilates is different in the younger population:

  1. Bone growth and open growth plates/flexibility: Since children’s bones are still growing, the teacher must be aware of muscle imbalances secondary to the bones growing faster than the muscle-tendon complex. The teacher must also be aware that young children’s bones are more flexible and may fracture easier than adults.
  2. Body Temperature and Regulation: A child’s body does not regulate temperature the same as adults secondary to smaller stature and less storage volume of fluids lost. Thus it is important to allow children water breaks and observe their reaction to exercise much more closely.
  3. Breathing: Since a child’s lungs are still developing up to adolescence it is important to recognize that children breathe differently than adults. Thus in teaching youth Pilates and focusing on Joseph Pilates’ principle of breath one must seek to educate the child on good breathing techniques and improved awareness of breath with movement.
  4. Posture: When teaching Pilates to youth, one must understand the development of children.  For example as children grow so do the arches of the feet.  A 12 year old may have a defined arch whereas a 5 year old may have a flat foot, so don’t expect them to have the same posture in standing.

The following are different injuries in children that you don’t see in adults that can have an effect on teaching Pilates to children:

  1. Growth Plate Injuries: Another important Growth Plate Cross Sectioncomponent in teaching Pilates to youth is the different injuries that are present in the growing population. One of these being growth plate injuries.  Occasionally inflammation can occur at the growth plate (especially the knees) resulting in point tenderness and pain.  It is important to be aware of this and to not “push the client through the pain” but address the issue and refer to the right professional for treatment.
  2. The Spine:
    1. Spondylolysis: This term refers to a defect in the spine which can range from a stress fracture to complete separation involving nervous system involvement. It is important to avoid all spine extension based exercises with this population.
    2. Scoliosis: This term refers to an abnormal curvature of the spine found in imaging the spine in the frontal plane. It is important to address the growing spine in this population to avoid further injury while improving muscle imbalances and improving posture.
    3. According to the PMA’s guidelines, the spinal growth plates are not completed until 20-25 years old. It is their recommendation that inversion exercises be avoided in the youth population.
  3. ACL Tears: These occur from a dynamic knee valgus and twisting position to the knee. The ACL is responsible for stability of the knee.  Following a tear, focus is on quad strengthening/stability with conservative treatment before repair. After surgical intervention, a protocol must be followed to allow for proper graft healing and save strengthening.

The following is an example of how the exercises can be modified for each age group to safely be successful with the movement:

The Hundred Table

Criss Cross TableSwimming TablePictures in table ©CHKD Sports Medicine Physical Therapy and may not be copied or used without permission.

I encourage children and adolescents interested in participating in Pilates to find a teacher who is knowledgeable about working with this population since children are not just little adults.  Keep checking back to the blog here at CHKD for information on weekly mat classes and private reformer classes coming soon to a clinic near you!


  1. Corey-Zopich C, Howard B, and Ickes D. (2014).  Pilates for Children and Adolescents: Manual of Guidelines and Curriculum.  United Kingdom: Handspring Publishing Limited.





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What is an Athletic Trainer?

By: Oscar Mallory, ATC

Many times in my career I have heard questions from the general public that usually sound like this: “What exactly do you do?”; “Are you like a Personal Trainer?”; “Are you like a Sports Medicine Doctor?”; ” Are you like a coach?”; “Are you one of those guys that run on the field or court when the athletes get hurt?”

These questions arise a few times a year and many of you are asking this as well; the answers are simple.

First, we need to define a Certified Athletic Trainer (ATC).  An ATC is a skilled allied health professional that specializes in prevention, recognition, assessment, and management of athletic injuries. He or she is also trained in therapeutic exercise (rehabilitation) and the use of modalities, such as electrical stimulation, ultrasound, heat, ice, along with various others.¹ The ATC works closely with licensed medical professionals to provide care for various athletic populations such as local middle and high schools, as well as colleges and universities. He or she will occasionally refer athletes to physicians or collaborate with team physicians in order to manage injured athletes.

As for Personal Trainers, their primary job is to guide their client’s through exercise routines that they create for them to reach their fitness goals. They also perform routine fitness assessments to help determine how their clients can move forward and increase physical fitness.² We are not Personal Trainers, although our athletes could benefit from their skills in pre- and post-season exercise programs.  After explaining the difference, the reply I commonly get is “Aw man, I was hoping you could show me how to lose some weight!” Even though we have the capability to help people lose weight, we usually focus those efforts on the athletic population.

Although we are often referred to as “Doc”, we are not Sports Medicine Doctors.  After residency, doctors interested in sports medicine complete a fellowship program which allows them to further their interests in either general practice in sports medicine or orthopedic surgery.  Sports medicine doctors in general practice treat patients with athletic injuries.  Depending on the nature of the injury, the doctor will either refer the patient to an orthopedic surgeon for corrective measures or to a physical therapist or athletic trainer for rehabilitation.  As athletic trainers, we work under their supervision most of the time. On many occasions, the doctors are present at games, and some practices, to follow up on past patients.  This increases their accessibility should a medical emergency arise or if an on the spot diagnosis is needed. If their expertise is not needed at that time, the Athletic Trainer will handle all situations that present themselves.

Coaches and Athletic Trainers have one key thing in common; both want their athletes to be healthy and prepared to play.  That is where the similarity ends.  Coaches are responsible for training athletes in proper game play and conditioning athletes for strength and endurance.  They also organize practices and plan for games.  Most coaches are former athletes and they build on their knowledge through seminars or clinics.  There are also many coaches that have earned degrees in physical education and have completed course work in coaching and officiating. Though most coaches have first aid training, they do not take care of injuries unless an ATC is not available.

To address the final question, we are those guys and gals who run on the field when people are hurt.  However the unseen portion of our job is just as important. We perform concussion testing at each of our home schools, coordinating with the school’s athletic director to ensure all athletes have a baseline test.  We are in constant contact with the athletic directors to stay informed of game and practice schedule changes, along with severe weather alerts. Another unseen duty is coordinating with the school’s Principals, Teachers, and Nursing staff to ensure that injured athletes receive any necessary accommodations to aid them throughout the school day. Injuries that may require accommodations can range from joint injuries to concussions.  Of course, athletes can also get sick from a number of things, just like everyone else. As ATCs we are on the lookout for other conditions such as blood disorders, heart conditions and asthma, most of which are revealed during pre-participation physicals.

So as you can see, Certified Athletic Trainers are a specialized medical care group, primarily serving the athletic community, with the ability to administer preventative, acute and rehabilitative care. ATCs also use a lot of the same manual testing methods that sports medicine doctors use in the field and the athletic training room. These tests help determine the nature of an injury and help the ATC come up with a plan of action that may involve taping, bracing, rehabilitating, or referring to a physician for diagnosis. The athletic trainers at CHKD are a dedicated group of people that enjoy working with young athletes, as well as the many sporting events we cover in the community.


NATA, board of directors, (2013, January). Terminology. nata.org/athletic training/terminology

Earl, Roger (2004). NCSA’s Essentials of Personal Training. NCSA Certification Commission.  pp. 162, 617.

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Core Exercises for Runners

By: Tim McDonald, PT, ATC

The Oregon Project Stability Routine

Key exercises that keep some of the world’s best runners healthy.

Here is an article from Running Times magazine written by Matt McCue regarding exercises done by Oregon Project runners.  The Oregon Project is a distance running team coached by Alberto Salazar, former Boston Marathon winner and American record holder.  Two of his runners, Mo Farah and Galen Rupp, medaled in the 2012 Olympics; Farah with a gold in the 5K and 10K, Rupp with a silver in the 10K. As the strength coach for the Oregon Project, David McHenry, PT, is tasked with keeping 2012 Olympians Mo Farah, Galen Rupp, Dathan Ritzenhein, and Matthew Centrowitz healthy.  For each movement, do 2 sets of 20 repetitions, 3 times per week.

Hot Salsa

Step into a wide lunge and reach a weighted ball as far out in front of you toward the ground as you can. Keep your back as straight as possible. Shift your weight forward on your front foot. While keeping the ball forward, lift your back leg off the ground and rise up to a perfect running position.

Runner Touch

Strike a pose in perfect running position with one leg in high knee position. Balancing on the one leg, bend at the hip and touch the toe that’s on the ground with the opposite hand while the leg in the air rotates under and back. Make sure the standing leg remains stable and as straight as possible while enabling you to touch the ground. Be sure to prevent the moving knee from crossing midline while that leg straightens out behind you. Come back up to running position quickly without losing balance, pause for a second or two, and repeat. Switch legs and repeat.

Side Plank Knee to ChestBegin in a side plank. Let your shins rest on a BOSU ball and balance on the ground using your lower arm. Keeping your body level to the ground, drive your top knee toward your chest while moving your upper arm back in a running motion. If your left elbow is on the ground, your right knee will move forward in a “high knee” position and the right arm will swing behind, parallel to the ground. The motion recruits the core, scapular stabilizers and muscles down the leg. Repeat on the opposite side.

The Clamshell

Lie on your back and bend your knees to 90 degrees, keeping your feet on the ground. Then hold that position and roll onto your side. Keeping your feet together and your femurs slightly in front of the midline of your body, lift the top knee away from the bottom knee using the glutes to drive the action. The upper foot will turn down to “stand” on the other foot and the motion will engage the external hip rotators.

Reverse Clamshell

These may feel like they’re the same as the clamshell, but they control the hip in a different way. Whereas the clamshell opens on the front side of the body, this exercise opens on the backside. Lie on one side with your knees bent and your lower legs behind you at a 90-degree angle. While keeping your knees together, lift your top foot away from the bottom foot as high as you can, hold it for a two-count and then bring it back down slowly. The target muscle is the deep internal hip rotators.

Mountain ClimbersDrop to a plank position with your forearms on a medium-sized stability ball. Keeping your core tight, bring a knee to the ball. Try to keep the ball and torso as steady as possible. Alternate knees to the ball throughout the exercise. The movements integrate muscles used during a stride.

The Jane Fonda

Lie on your side and place your bottom hand behind your head. Put your top hand on your upper hip, pressing your pelvis forward to make sure it does not rotate back during the exercise. Use your core muscles to stay steady. Keeping the top leg straight, lift it up and then back using your glutes to lift the leg. By keeping the outside of your foot level to the ground, you should feel the fatigue in your gluteus medius.

Runner Pulls

Balance on one leg and grab a pulley system or elastic band in front of you with the opposite hand. Raise the free knee up toward your waist while simultaneously pulling the weight down 90 degrees and rotating toward your opposite leg. These should only be undertaken after you have mastered the previous drills, as any lingering hip or core weakness or control deficiency will reinforce the wrong movements here.

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