Corrective Exercise Is Not Just About Corrective Exercises

Learning Objectives:

1. The reader will learn that the premise behind corrective exercise is to alleviate symptoms of pain and dysfunction by addressing the underlying musculoskeletal cause(s) and/or imbalance(s).
2. The reader will be exposed to two examples demonstrating how a seemingly unrelated musculoskeletal imbalance in one area of the body can cause symptoms in another area.
3. The reader will learn how using the results of a thorough musculoskeletal assessment can help guide corrective exercise program design and increase client adherence and success.

As a presenter on the subject of corrective exercise, I am invariably asked the same question by people who attend my talks: “What exercise(s) do you recommend for someone who has been diagnosed with ________ (here you can enter any diagnosis from plantar fasciitis, Achilles tendinitis, chondromalacia patella, disc herniation, etc. – the list is endless!).

The answer to this question is simple: “There are no magic corrective exercises that can alleviate a symptom of pain permanently.” No amount of self-myofascial release exercises on one area of the body is going to prevent those tissues from getting irritated again every time the person moves, especially if their body is out of alignment or their movement patterns are faulty. Similarly, stretching every day is not going to prevent muscles from tightening up again if those muscles need to tighten to “splint” a perceived injury or potential risk for injury when the client has to move. Furthermore, isolated strengthening exercises are not going to correct a dysfunctional area of the body unless the underlying cause of this weakness/imbalance is addressed.

Corrective Exercises Alone Are Band-Aid Solutions

Granted, many corrective exercises can help a person feel better temporarily. For example, if someone has Achilles tendonitis then it is likely that some sort of self-myofascial release technique and stretch for the posterior calf muscles (e.g., soleus and gastrocnemius) will help alleviate painful symptoms in the short term to enable the person continue those activities they enjoy. However, the body does not act or react in isolation. The entire musculoskeletal system is constantly working and/or compensating to remain balanced and upright in the face of gravity and ground reaction forces. As such, chronic pain and/or dysfunction that appears in one part of the body (e.g., Achilles tendonitis) usually means that other areas are dysfunctional as well. Because of the body’s interconnectedness, the entire system must be assessed to see which area or tissues are to blame for the underlying cause of someone’s aches, pains and dysfunction (American Council on Exercise, 2010).

While it is excellent to see health and fitness professionals incorporating corrective exercise into programming, it is vital to remember this fundamental principle: Corrective exercise is so-named because of its purpose, which is to correct musculoskeletal imbalances that can cause pain. It is not referred to as corrective exercise solely because of the potential for certain exercises to eliminate pain. Although corrective exercise is ultimately about providing pain relief, it is the guided application of exercises to address musculoskeletal imbalances that makes this field such a valuable addition to the health and fitness industry.

Uncover the Cause of Pain for Lasting Results

There are literally thousands of corrective exercises. If you were to give a client a few exercises for each ache and pain they had, some of your clients would literally be doing hundreds of exercises every day. This is impractical since we all know how difficult it is to get clients to do even the least amount of exercise homework. However, if you were to find out the underlying causes of your client’s pain you could recommend a manageable number of exercises that would have the most impact on their entire system. This would not only allow you to address the cause of a person’s musculoskeletal imbalances (which would result in the disappearance of their various symptoms), but the client would be more likely to adhere to their program because the number of corrective exercises you gave them is practical and also providing relief.

Therefore, your corrective exercise selections for a client must be guided by the results of a musculoskeletal assessment. The assessment findings are the most essential aspect of designing a corrective exercise program because they can help you determine which specific corrective exercises and strategies would be most beneficial in resolving the client’s musculoskeletal issues.

Below are two common assessment findings that demonstrate how pain in one area can be the result of a musculoskeletal imbalance in another. This will help you understand why simply recommending corrective exercises to address the painful area is not the solution.

Scenario 1

• Symptom: A client complains of foot pain (e.g., plantar fasciitis).
• Assessment Findings: The client has a forward head position (i.e., their head is forward of its optimal place where the center of their ear should be over the acromion of the shoulder when standing) (Kendall et al, 2005).
• How Assessment Finding May Cause Symptom: The human head weighs 8 to 11 pounds. For every inch the head is forward of optimal position, it doubles its effective weight to the body. Therefore, if someone’s head is 2 inches forward of its optimal position, and the head weighs 10 pounds, then the effective weight of their head to their body is 40 pounds. A 40-pound weight hanging forward from the neck means that all of the body’s structures must compensate to prevent the body from falling forward and off balance. Muscles all the way down the spine will work harder to keep the head balanced atop the torso as best it can. Bones will shift elsewhere in the body to accommodate the change in the body's head position. Ultimately, this forward position of the head will result in the need for the person to push down with their feet and toes to avoid toppling over forward. Over time, this excessive stress to the structures of the feet can cause pain and irritation such as plantar fasciitis.
• Possible Solutions: People with plantar fasciitis typically receive many recommendations on how to alleviate their pain – from using orthotics, to stretching of the calves and feet to self-myofascial release techniques of the foot, calf and lower leg. However, in this case the long-term solution for the pain would be to apply corrective exercises to address the person’s forward head position thereby moving their head back in line with the rest of their body so that the center of pressure in their feet can move out of the mid- and forefoot.

Although the pain in the above scenario is felt in the feet, you know now that the real cause of the pain may have been misalignment of the head position. Obviously, there are many other possible causes of foot pain, but the above example helps you understand how important performing a thorough musculoskeletal assessment is to the success of each client’s corrective exercise program.

Scenario 2

Symptom: A client complains of right medial knee pain when running.

• Assessment Findings: The client has a protracted right scapula (i.e., their right shoulder blade has moved away from their spine and forward on the rib cage) (Kendall, 2005).
• How Assessment Finding May Cause Symptom: In order to uncover the source of the right medial knee pain, you must consider the assessment findings in light of the mechanics of running, which involves a number of structures throughout the upper and lower body. One of these structures is the gluteus maximus muscle, which originates on the back of the pelvis and the base of the spine. The gluteus maximus inserts into the iliotibial band (IT band), which attaches to the outside of the lower leg (Golding & Golding, 2003). When a person is running, the lower leg of the front foot rotates inward over the ankle when the foot hits the ground. As this happens, the back of the pelvis and base of the spine (on the same side as the forward foot) are pulled away from the front leg by the forward swinging motion of the arm on the opposite side of the body. During this series of movements the gluteus maximus muscle works eccentrically (lengthens) to help slow down the knee as it moves toward the midline of the body.

While all of the aforementioned is happening, the arm on the same side of the body as the forward leg swings behind the body. This swinging of the arm behind the body helps retract the shoulder blade on that side. The shoulder blade is connected to the ribs via the serratus anterior muscle (which comes from underneath the shoulder blade and wraps around to the front of the ribs) (Gray, 1995). Therefore, as the shoulder blade retracts it helps pull the ribcage back and rotate it over the front leg. The rib cage is connected to the pelvis by way of the obliques. When the rib cage rotates over the front leg, the pelvis gets pulled with it – which ties this series of mechanics back into the eccentric function of the gluteus maximus.

Ultimately, when a person is running the retraction of the shoulder blade helps pull the pelvis (by way of the ribcage) back on the side of the forward leg so that the gluteus maximus muscle can lengthen to help slow down the knee (via the IT band) as it moves toward the midline of the body. Someone with a protracted scapula on the right side would not be able to correctly retract their scapula to assist the gluteus maximus muscle in lengthening to slow internal rotation of the right leg when the right foot strikes the ground during running. Naturally, this could set them up to experience right medial knee pain because the impact created from running is not able to be properly transferred through the knee joint (more of the force goes to the medial side).

• Possible Solutions: People with right medial knee pain are often advised to do foam roller exercises for their IT band and isolated strengthening exercises for their glutes. While these exercises will possibly help in the short term, the long-term solution would be to retrain the right scapula retractors with corrective exercises. Such exercises would enable the client to swing their arm correctly behind them and rotate their ribcage when running to help facilitate eccentric activation of the gluteus maximus and deceleration of the right knee as it moves toward the midline.

For more discussion on addressing a common client complaint like medial knee pain, watch the video below:

Truly Effective Corrective Exercise Program Design

As a fitness professional, the overall focus of your corrective exercise services should be on uncovering your clients’ musculoskeletal imbalances and addressing them through the thoughtful application of exercises. However, when a client first comes to see you for help with a corrective exercise program they are only concerned with getting rid of their pain. If you want to get clients on board with your successful corrective exercise plans, don’t discount their pain as merely a symptom and tell them you are going to go straight to addressing the cause of their problems. Structure your program initially to include exercises that will help alleviate their symptoms as quickly as possible so they feel better. This will help decrease their anxieties and increase their trust in you and the corrective exercise process (Whitworth, 2007).

As you continue with their program, educate them about your assessment findings and, in particular, how their musculoskeletal imbalances are contributing to their symptoms of pain. As soon as you can, begin incorporating exercises that address the underlying causes of their problems so the client can eventually regain full function and elimination of their aches and pains (Rolf, 1989). Helping your clients in the short term to alleviate their symptoms and in the long-term with the underlying causes of their pain ensures that your clients will be successful. Successful clients never forget who helped them eliminate their pain and will refer their friends, family and colleagues which is great for business. Adopting an approach to corrective exercise that centers on the use of musculoskeletal assessments to guide exercise selection is the best way to ensure that both your clients and your business are successful in the long run.

References

1. Golding, L.A. & Golding, S.M. (2003). Fitness Professional’s Guide to Musculoskeletal Anatomy and Human Movement. Monterey, CA: Healthy Learning.
2. Gray, H. (1995). Gray’s Anatomy. New York: Barnes & Noble Books.
3. Kendall, F.P. et al. (2005). Muscles Testing and Function with Posture and Pain (5th ed.). Baltimore, MD.: Lippincott Williams & Wilkins.
4. American Council on Exercise. 2010. ACE Personal Trainer Manual (4th ed.). American Council on Exercise.
5. Rolf, I. P. 1989. Rolfing: Reestablishing the Natural Alignment and Structural Integration of the Human Body for Vitality and Well-Being (revised edition). Rochester, VT: Healing Arts Press.
6. Whitworth, L. et al. Co-Active Coaching: New Skills for Coaching People Toward Success in Work and Life (2nd ed.). Palo Alto, CA: Davies-Black Publishing, 2007.