Runner's Knee

One type of knee pain is patellofemoral joint pain. This occurs when the tissues on the underside of the patella ( the knee cap) is inflamed causing pain. It plagues many runners limiting their training and sidelining them from racing. When the area is really aggravated, it can hurt to sit and negotiate stars.  The patella and the femur (thigh bone) make up the patellofemoral joint. When the knee bends, the patella slides up and down in a groove of the femur. There are several ways the patellofemoral joint can be aggravated. There can be compression from the quadriceps (which can also lead to patella tendonitis),  lateral compression from the illiotibial band (ITB) and poor mechanics.

Causes

Quadriceps Compression 

The patella 'floats' in the connective tissue of the quadriceps. The quadriceps transitions into the quadriceps tendon then attaches to the patella then becomes the patella tendon. When the quadriceps are over worked, it puts an increase pull to the tendons. The tension from the tendons compresses the patella into the femoral groove resulting in grinding. The grinding causes degeneration of the tissue  behind the patella leading to pain and arthritis.

http://physioworks.com.au/injuries-conditions-1/chondromalacia-patella

Lateral compression 

Due to imbalance of muscles, the tissue on the lateral (outside) of the thigh can get stiff pulling on the the patella. This structure is known as the ITB. The ITB has fibers which attach to the patella. Cadaver studies have shown a variation in how much of the ITB tissue attaches to the patella. You can't stretch the ITB because it is not a muscle, it is fascia. There is no elastic tissue to stretch.  This is why foam rolling is so important ( we'll get to that in a minute). When the ITB pulls on the knee cap it cause pain on the either side of the knee cap.  The lateral tissue pull the kneecap to the outside which can  stretch the medial structures causing pain on the inside. On the other hand, the pull of the ITB can cause the knee cap to rub again the femur causing pain on the outside of the knee. Stiffness of the ITB can be a result of poor muscle activation.

Biomechanics

"The knee is a stupid joint."- Gary Gray. It is influenced by the hip from the top down and the ankle from the bottom up. The knee comprises of the tibia (shin) and femur. These bones make up the ankle and hip respectively. Any biomechanical deviations above and below has a direct affect on the knee.

Pronation of the foot is normal in the stance phase. However, excessive or prolonged pronation leads to injury. When the foot over-pronates, the foot rolls towards the ground bringing ankle joint in. The tibia (shin bone) follows along. Since the tibia makes up the knee, the knee follows along and collapses inward. This is called the valgus position and causes abnormal stress to the knee. 

http://www.fixflatfeet.com/hip-weakness/

From the top down, the gluteal muscles can play a role in knee pain. The gluteals originate from the pelvis and attaches to the thigh bone. When the glute muscles contracts, the femur (thigh) bone rotates keeping the knee forward. Activation of this muscle keeps the femur aligned forward and the knee in a good line of pull. However, when there is weakness of the gluteals, the femur is allowed to drift inward. This causes the knee to fall inward, again, causing increase stress to the knee.

Treatment

What to do now?

Foam rolling is a type of myofascial release. The science is unclear on it's exact mechanism. My belief is the compression provided restores fluid ( think about squeezing a kitchen sponge) between the connective tissues which improves the ability for the tissues to slide. It is good at managing symptoms but will not get to the root source. There is a reason why the muscles and tissues get unusually tight. Foam rolling  is still beneficial because you want the muscles and connective tissue slide better. For quadriceps compression roll over the quadriceps and for lateral compression roll over the ITB.
*** For the optimal benefits make sure you are hydrated when foam rolling. 

Long term

Exercises 

Research has shown glute strength has a direct affect on knee pain. Due to the attachment of the gluteals, it has direct control of the femur.  Proper glute strength and activation keeps the femur in a forward position. This aligns the femur the the patella can stay within it's groove. This leads to less strain in the knee joint. However, when the glutes are weak, the femur is allowed to roll inward which leads to mis-aligned position increasing stress to the knee. Also, energy absorption from ground forces is more evenly dispersed to the glutes and away from the knees. I have written posts on glute strengthening exercises.

Limited ankle dorsiflexion is a contributing factor in foot pronation which can impact knee position. Dorsiflexion is the ability to pull the foot towards your body. While you are running, as your foot hits the ground, your shin moves over the ankle as the knee bents. This movement is also ankle dorsiflexion. If there is inadequate ankle dorsiflexion, the foot will pronate to compensate for the loss of movement. In a tight ankle the tibia comes forward but there is a stop in the ankle. Momentum will carry that energy forward in the form of foot pronation. Due to the bony structure of the ankle, when the foot pronates the ankle with rotate along with the tibia. This will result in knee valgus (see above picture) leading to increase stress to the knee. In order to resolve the mechanics from the ground up you have to perform ankle mobilizations to loosen up the joint then restrengthen the foot. Here is a video to demonstrate ankle exercises.



Form  

Running form has a big influence on injuries. Over striding places a bigger emphasis on using the quadriceps for propulsion. This leads over use injuries  of the quadriceps.  Over-striding brings the ground reaction forces in front of the knee creating more strain in that joint. People who over stride tend to be heel strikers. Research has shown that heel strikers have more knee pain then forefoot strikers. By heel striking, the ground reaction forces goes anteriorly placing more stress on shin, knees and quadriceps. However, forefoot running brings the body over the ground reaction forces which allows the energy to be disperse through the entire leg. This occurs because the body mass is over the foot. Meanwhile in heel strike the body is behind the knee, which makes the quadriceps work harder to propel the body over the foot.

Proper forefoot strike also works the muscles (tibialis posterior) that hold up the arch limiting the amount of pronation. This leads to better knee alignment. BUT beware, if there is weakness of the muscles you can get aches and pains in the lower leg in the transition. Having good core strength takes the pressure off the lower leg.

My recent post discusses the benefits of forefoot running.

Our body is all connected. The regions above and below the pain typically contributes to injury.

Please contact me if you have any questions.




Kulmala JP, Avela J, Pasanen K, Parkkari J. Forefoot strikers exhibit lower running-induced 

knee loading than rearfoot strikers. Med Sci Sports Exerc. 2013 Dec;45(12):2306-13.

Daoud, Adam I., et al. "Foot strike and injury rates in endurance runners: a retrospective study." Med Sci Sports Exerc 44.7 (2012): 1325-34.

30 day 3D Exercise Challenge

While I'm working on my next post, I'm going to do a 30 day 3D exercise challenge on my Instagram starting 3/13/15 (3drunner, also link located on the right). 

What  is 3D? Our body moves in 3 main planes of motion - sagittal, frontal and transverse ( forward/back, R/L and twist). And our muscles, joints, bones are 3 dimensional! Unfortunately a majority of us assess, treat and train primarily in the sagittal plane while the frontal and transverse planes are under utilized. In running (and walking), we move in the sagittal plane, but the other planes work to support forward movement. I think weakness of frontal and transverse planes leads to early fatigue and even injury. Performing exercises with the 3 dimensions in mind strengthens more muscle fibers!

Exercises to Transition to Forefoot

Did I convince you to try forefoot running? Have patience, this transition should take several months. You have been landing on your heels for years, it's not going to change in a couple minutes. It takes time for your brain to change the firing patterns of the nerves, your muscles to build strength and the movement to become natural.

If you're not already walking at home barefoot, DO IT every day. Actually, think about landing on your forefoot while you walk.

Core

Good core strength and stability is the most important aspect in maintaining a forefoot strike running pattern. Due to the inherent forward lean of this running style, the core is always engaged. The onset of fatigue leads to poor form. The chest starts to hutch over (as oppose to forward pelvis over the foot) and hips shift backwards which leads to heel striking.



For clams, side lying leg lifts, fire hydrants and bridges:

stage 1 - perform 3 sets x 12 reps
            - hold plank 10 x 10 sec

stage 2 - hold 10 reps for 10 seconds
            - hold plank 3 x 30 sec

stage 3 - add band repeat stage 1
            - progress to single leg bridges
            - add squats and lunges: use push knee back cue
            - add plank - add knee bent plank and rotation 10 each side

stage 4  - repeat 2 with band
             - continue single leg bridges, squats, lunges and plank (lunges and squat add weight or            bend knees more)

*** Perform stage 1 every day. Stages 2-4 perform 3-4 x week.
*** Do not progress stage until the current stage feels easy.
*** You should have glute soreness after each session.
This should take a minimum of 8 weeks!!! Spend about 2 weeks per stage. 
           

Ankle Strength and Drills

To land on your forefoot you have to have excellent calf strength. Forefoot strike puts extra stress to the calf muscles and Achilles tendon. You are performing an eccentric heel raise with each stride! These drills help with proper form and getting the neurologic input to land on your forefoot.



Calf Raises - With a twist! By turning left and right as you come up, different muscle fibers are being used. In running, the twisting motions occur when your foot lands and when it lifts off the ground. It happens so fast you can't feel it. Start with double leg 2-3 sets of 10, then at stage 3 of core, try single leg 3 sets of 10 reps.

Wall Falls - Forefoot running requires eccentric strength of the calves. Eccentric strength is when the muscle is working while it's stretching. This strength is required during the time the forefoot hits the ground and when the heel lands. 2-3 sets of 10 reps

Falls Into Strides - This takes wall falls to the next step. Fall forward until you can't hold yourself up, then stride for about 20 yards. Keep your back straight and core tight. Please don't fall on your face!

High Knees - This works on front side form. Bring your knee up to your chest without leaning backwards and land on your forefoot. Keep your feet under your body and don't reach forward. This drill is about speed not distance of each step. 10-20 yards

Butt Kicks - This works on back side form. Kick your heel towards your glutes. The tendency is to arch your back because of tightness in the quadriceps and hip flexors. Keep your core tight and back in neutral. Land on your forefoot. Again, this is about quick feet and not distance. 10 - 20 yards

Running Program

Start slow and forefoot run for a 2-3 minutes then return to your normal form for 5 minutes to allow the new working muscles to rest. Repeat until you reach 30 minutes. Increase the amount of time you forefoot running by 1 minute each week as long on there is no pain. So forefoot run 3-4 minutes then walk 5 minute.


Week 1
Barefoot walking in the house using a forefoot pattern.
Week 2
2-3 minutes forefoot running 5 minutes running normal x 3 - 4 for 30 minutes total 2-3 times a week
Week 3
3-4 minutes forefoot running 5 minute running normal x 3 - 4 for 30 minutes total 2-3 times a week
Week 4
4-5 minute forefoot running 5 minute running normal x 3  for 30 minutes total 2-3 times a week
Week 5
5-6 minute forefoot running 4 minute running normal x 3  for 30 minutes total 2-3 times a week
Week 6-12
6-7 minute forefoot running 3 minute running normal x 3  for 30 minutes total 2-3 times a week
Repeat until you reach 3 x 10 minutes of running forefoot
Then transition
15 minutes of forefoot running 3 x week
18 minutes of forefoot running 3 x week
add 3 minutes to each run each week until you reach 30 minutes.

Do not move forward if you have pain. You should be able to comfortably run forefoot for 30 minutes without discomfort before incorporating it into harder runs.


There are a lot of different core and ankle exercises, as well as, running drills. However, I believe these are the fundamentals which build a good base for forefoot running. Remember this takes time to transition!

Look out for a future post on how footwear ( heel drop) can change your strike pattern.

References

The core exercises are a modified version of Dr. Chris Powers's Course Evaluation and Treatment of the Injured Runner: A Biomechanical Approach

The running program is a modified version from Dr. Irene Davis's running lecture Spaulding National
Running Center - Barefoot running Training.

Why Forefoot Strike

In recent years, there has been significant increase in the media about forefoot strike. Is forefoot running good for you? Will it lead to injury? Is it just a fad? Research seems to show forefoot strike decreases injury and improve running performance.
I was already adjusting my stride to manage my own injury. I've tried shifting my hips side to side to load my hips, but that just gave me a bunion. I tried kicking my leg to the side as it went behind my body, but that didn't work. My recent glute activation cue of "push the knee back"while running seems to be alleviating my symptoms. I also notice this cue made me strike more forward on my foot. So I decided to investigate. Here are the benefits I learned about forefoot running.

TO BE CLEAR
*** Forefoot strike is not running on tip toes. Forefoot running is landing on your forefoot then allowing the foot to come down.

Why Forefoot Strike? 

Decrease Forces

For every action there is an equal and opposite reaction. That is Newton's 3rd law of motion. How does this relate to running? When looking studies using force plates, there's a big difference in  forefoot strike vs. heel strike. During forefoot strike there is 1 smooth peak of force. However, in heel strike there are 2 peaks of force. This means there is more force when you heel strike.  Your muscles work harder have to absorb extra force. It doesn't seem like that extra force is a lot but if you multiple how many steps you take per minute ( ideally 180 steps) that is over 5,400 steps over 30 minutes multiplied by that extra force. By forefoot striking, you use less energy because there is less force.

This chart shows the double peak vs single peak
difference in heel strike vs forefoot strike.

Better Body Position 

Proper running form is having foot under you as your body moves over your leg with a slight forward lean from the hips. Foot placement under the body is critical because it allows smooth transition of force. The ankle is used and a spring. In heel strike, there is a "braking" involved when the foot hits the ground. Landing on your forefoot helps to bring the body forward into slight forward lean. A forward lean helps to activate your core muscles to stabilize your body while running.

In heel strike the body trails behind the leg, this causes increase demand in quadriceps. However, during a forefoot strike the body is over the leg which allows improve loading of the whole lower extremity. Clinically this is important because many injuries arise from over use of the quadriceps and under-utilization of the gluteals. Forefoot striking improve posterior chain activation.

Forefoot strike The upper torso is  over
the ankle. This allows force to smoothly
transition over the foot.

Heel strike  The upper torso trails behind the
contact leg which increases the work load.

*** TRY this: 1) In standing shift your weight towards your heels. What do you feel? I feel my quadriceps engage. Now shift your wight into your toes. What do you feel? I feel glute and core activation . 2) Walk with the forefoot hitting the ground first. What do you feel? I feel my body lean forward and my abs are activated. Now, walk exaggerating a heel strike. What do you feel? I feel my body leaning back Or my chest comes forward and my hips move back ( this creates lumbar lordosis which leads to low back pain).

Preserving  Forward Momentum 

Heel Strike - red line demonstrates gravity pushing
down at the shoulder. The line falls behind the foot.
This means your body weight is you and
your muscles has to work harder to
push you forward.

Forefoot Strike - red line shows gravity pushing
down through the foot. This gets your weight
forward which is easier for your muscles
to propel. 

To run with proper forefoot strike, you have to lean forward at your pelvis. This moves your center of mass forward over your base of support. This allows gravity to work in your favor by pushing your body forward. When you heel strike, typically, your center of mass is behind your base. You are fighting ground reaction forces and gravity to move forward. Gravity is actually pushing you backwards. It's hard to land heel strike while maintaining a forward pelvic lean. When you forefoot strike, you lean forward at your pelvis allowing gravity to help which makes you more efficient while running.

Tips

Lean forward at pelvis

When you bring your pelvis over your feet you bring your center of mass over your base. This helps to keep your feet under your body which allows you to forefoot strike. At the same time, as mentioned above, you allow momentum to carry you forward.  Make sure to keep your core tight by bring your pelvis under your body.

180 steps per min

Research has shown 180 -190 stride rate is most effective. To establish this frequency you have to take shorter strides which help with landing forefoot. When you heel strike, the length of your stride is longer making it difficult to increase frequency. A quick Google search shows Play list for songs with 180 beats per minute.

Be light on your feet

This seems obvious. But when you're landing light and soft, it's  hard to land on your heel. Landing light also decreases the time your foot spends on the ground. This will help decrease the forces your body has to absorb.

Conclusion

My conclusion is running with a forefoot strike is better for body alignment and efficiency. This can in turn decrease injury and improve performance. However, it requires A LOT of ankle and core strength. FOREFOOT RUNNING ISN'T FOR EVERYONE. It takes time to get your body moving in a different pattern! In order to transition to forefoot strike safety, you be have patience and have good strength. I recommend forefoot strike only if you have a GOOD core stabilization program and calf strength. It is my personal belief that some one who has pain while attempting to forefoot strike is not  strong enough to maintain this pattern.

Please have your form evaluated by a professional. It is critical that you get feedback on your form.

I am working to transition myself to forefoot running. Those who know me know I have been battling a 6 year injury from a fall. I've had numerous imaging and injections without answers or resolution. Through the past 6 years I have been able to run but always with some symptoms. Recently, I have been focusing on REALLY improving my core and glute strength because of the possibility of a hip labral tear. I have been incorporating fore foot strike into my runs focusing on proper form. I have not had ANY symptoms. As soon as I can't maintain my form my quadriceps symptoms return.

"PEOPLE RUN TO GET FIT BUT YOU HAVE TO BE FIT TO RUN" - Chris Powers, PhD, PT, FACSM, FAPTA

STAY TUNED FOR MY NEXT POST ON STRENGTH EXERCISES AND DRILLS TO SAFELY BEGIN FOREFOOT RUNNING



----
References

Altman, A.R.  Davis, I.R. Barefoot Running: Biomechanics and Implications for Running Injuries. Current Sports Medicine Reports. Am. J. Sports Med. Volume 11 & Number 5 & September/October. 2012 (244-50).

Davis, Irene.  Lecture Foot Strike, Footwear, Treatment of the Foot- An Evolution of Thought.

Divert, C. et al. Mechanical Comparison of Barefoot and Shod Running. Int J Sports Med 2005; 26: 593 – 598.

Powers, C.M. Functional Biomechanics of the Lower Quarter Lecture.

Rooney, B.D. Joint contact loading in forefoot and rearfoot strike patterns during running. J Biom,V46, 13.  September 2013, Pages 2201–2206.

STOP Stretching Your Iliopsoas

It's all over the internet. You've read about it on numerous blogs. I've even talked about it. There's stretches. There's lacrosse ball rolling. There are standing desks.  It's all to resolve tight hip flexors (Illiopsoas). "The tightness is killing you!" You're doing everything you can ... But WHY is it still tight?

When we roll, stretch and use a standing desk,  are we REALLY solving the issue?  There has to be more to the story then hip flexors contractures from sitting.

Yes, sitting can contribute to tight hip flexors. However, instability of the core and back can also cause the hip flexor to be tight. The hip flexor originates from the lumbar spine. It is a massive muscle in the center of our body. When the core is unstable the hip flexor compensates by tightening to provide the stability needed. Our body wants to be stable. Could it be that our hip flexor doesn't get tight because of the position itself? Or does it tighten because the way we sit causes or back stabilizers to shut off so the hips stiffness to provide stability?

Core Stability vs Core Strength

Core stability is the ability for the small intersegmental muscles to stabilize the joints while moving. This is important for proper bone mechanics. Core strength is the ability of the large muscles groups to the body in a big range of motion. Stabilizers are the multifidus which are short muscles that attach a every 2-3 bone segments and the transverse abdominals (TrA) which is the deep layer of the abs. Strength muscles are erector spinae and rectus abdominals (6-pack).

Note how parts of the psoas originates
from each of the vertebra 

Note the attachment of multifidus spans
3 segments

Performing crunches and back extensions will improve your core strength but not stability your core. Lack of balance between the stabilizers and strength muscles can cause shearing of the lumbar joints causing pain. This will also contribute to the tightness. Performing stability exercises will decrease low back pain and hip tightness.

Which Exercises?

The best exercises to improve stability are marches, bent knee fall out and various planks. The key is to keep the core neutral and tight during the exercises. There are many other stability exercises such as bird-dog and dead bugs. Choose 3-4 of them 3 times a week. Progress to standing functional exercises such as a variation on a chop. You can continue other core strengthening exercises but also include spine stability exercises.

Go ahead, stretch and roll out your hip flexors. It will help to manage your symptoms. But, if you find yourself constantly rolling and stretching your hip flexor, ask yourself, how is your core stability.  In order to resolve the tightness, you have to stabilize the spine by improving the endurance of the stability muscles.
* Pictures from www.studyblue.com

Glutes - How to Transition From Exercise to Run

You've been told you have weak glutes. Whether it's hip pain, knee pain, ankle pain, it all can be "healed" by improving glute strength. You are prescribed clams, side lying leg lifts, bridges then progressed to squats and lunges. You feel stronger and released to go for a run. Your symptoms feel better but returns after getting back to your routine.

Recruiting Glutes vs. Quads

Is your strength transferring from a basic clam exercise to running? Are your glutes REALLY activating when you run? For most of us, we are very quad dominant. This means we over use our quadriceps when we should be using other muscles such as our glutes. Our sedentary lifestyle of sitting at work or relaxing on the couch has us disengaging our glutes. The quads have at a mechanical advantage to work. Also, the habitual use of quadriceps enhances the neural input from the brain is going to the quads and not the glutes. In other words, the wiring to the quads is better then wiring to the glutes. When running, demand on the muscles is so high we use whatever muscles are the easiest to recruit. The Quads.

I have seen and used different cues such as "stick out your butt"or"squeeze your butt as you stand up". However, most of my patients and clients have a difficulty "feeling the exercise". AND, the improved strength doesn't seem to translate to running.

PUSH YOUR KNEES BACK

I have been using a different cue to activate the glutes while performing standing exercises such as squats and lunges. While you are performing squats or lunges (or any standing hip exercises i.e. box step ups), pretend like there is an object behind your knee and push back as you stand up. The gluteus maximus is responsible for hip extension, getting your thigh behind you body. However when your foot is fixed on the ground and the knee is given the cue to push back, this extends the knee AND hip. This will engage your gluteus maximus.




Stand up and perform a squat. When you stand up, you feel your thighs press down into the ground and push up. Now try a squat but give the cue for your knees to push back.

FEEL the burn in your glutes.

Now, think of this cue when running. You want to let your knee land normally (with a soft bend), then push back with the knee as your body is moving over your leg. You should feel like your legs are moving in a circle, almost like pedaling a bike. At first, I recommend incorporating this during a warming up, then into sides and finally into your short normal runs. The best way to feel this is up hill sprints!
THIS CUE WORKS BEST IF YOU MIDFOOT OR FOREFOOT STRIKE!

So on top of performing clams, leg lifts and squats add this "push your knee back" cue to the standing exercises.

Please contact me if you have any questions or concerns.

Core: More then Abs and Glutes

As athletes, we spend a lot of time working on our core. We plank. We do sit-ups. We twist. However, there is one muscle which is ignored by most athletes that is use in every stride.  In order to run, swim, bike, you need to breathe. The muscle responsible for breathing is the diaphragm. As you pick up the pace, your breathing increases. Your diaphragm is working hard!

What is the Diaphragm?

The diaphragm is a thin muscle that separates the abdominal cavity from the chest cavity. When it is relaxed it rest up against the chest cavity. When we breath the diaphragm contracts and pulls the chest cavity down. This provides negative pressure in the chest cavity allowing air into the lungs. Typically, the core is just seen as the abdominals and back. The core as a box. The pelvic floor muscles on the bottom, abs and back form the side and the diaphragm is the top.

Photo credit - http://deansomerset.com/core-training-
made-incredibly-complex/

How Does It Affect my Running?

One of the biggest difficulties I see in the clinic is the inability to separate the diaphragm from the core while breathing. When most of us tighten our core, we stop breathing. OR we continue to breath without tightening our core. We have to learn how to disassociate our diaphragm from our core similar to not using your hamstring when firing your glutes. When we are not able to keep our core tight while we running we lose core stability. This will set off a whole cascade of events which can impact the mechanics of our arms and legs.

The diaphragm has multiple attachments including the hip flexors. This is important because most of us have tightness in our hip flexors. Tightness of hip flexors will not allow the diaphragm relax in  resting state. This tightness will limit our ability to take advantage of a full breath. This forces us to take shallow breaths. This can also contribute to the inability to take a full stride. When the leg is trailing behind, the hip flexor is on maximal stretch. A tight hip flexor will pull on the diaphragm limiting full exhalation.

Lastly, and most important, the diaphragm controls our breathing!

Inability to contract our abdominal muscles separate from the diaphragm and tight hips limit our ability to take full breath. Like any muscle the diaphragm can be stretched and strengthened. On top of stretching the hip flexors and strengthening our core we should also work on improving the use of our diaphragm.

Bonus Info

Side Cramps

A side cramp is when the diaphragm spasms. If you have a cramp on the right, exhale when when your left foot hits the ground. This provides a quick stretch to the diaphragm which helps alleviate symptoms. If your cramp is on your left, exhale as your right foot hits the ground

Finding balance

The diaphragm is also connected to the parasympathetic nervous symptom. This is the "rest and digest" system which allows you to relax. Everyone is busy and on the go which stimulates the sympathetic nervous symptom which is your "fight or fight" symptom. Certain chemicals are released when the sympathetic nervous symptom is activated which, over time, can be detrimental. By diaphragmatic breathing, the parasympathetic nervous system is activated balancing the sympathetic response. If I can't sleep, I focus diaphragmatic breathing and I usually fall asleep within minutes!

Exercises

Diaphragmatic Breathing

On your back with knees bent, inhale allowing the abdominal cavity to rise then the chest follows. A sign the diaphragm is under-utilized is when the chest and shoulders rise first. To make this more difficult stack a couple of books on your abdominals. Do this for 10 breaths.


This can also be performed in various positions such as sitting, standing or laying down. Eventually diaphragmatic breathing should be natural.

Diaphragmatic Breathing in 3 D

We will work the diaphragm using the lunge matrix.

Stand tall and inhale, as you lunge forward exhale as you bring both arms up. Return to standing and repeat. In the frontal plane, inhale in standing then exhale as you bringing both arms up and to the side. Lastly in the transverse plane, inhale then exhale as you pivot lunge bringing both arms toward the knee.
This exercise provides an additional cue when performing lunges. If you're already doing lunges add the breathing to your routine. You don't have to perform more diaphragmatic lunges.
Perform about 5 repetitions to each side.

*** Side note I have difficulty performing frontal plane breathing exercises. Those who know me know that I had an injury to that side. This is an exercise I will be re-evaluating in a month!