Using Tissue Function to Guide Exercise Selection

Clinicians are often faced with the uncertainty of HOW to load an injured tissue as part of their therapeutic exercise prescriptions.

Whilst exercise selection may appear simple to some, for those clinicians who are either new to exercise prescription &/or have limited exposure, it can be a very daunting experience when you have an injured client in front of you and you're scratching your head trying to think of where to start.

Today we'll be exploring one approach that will begin to simplify the process and improve your confidence when it comes to identifying what exercise(s) will formulate your rehabilitation programs.

The key word here is function.

Therapeutic exercise prescription is underpinned by our therapeutic goals.

For a brief refresher on therapeutic goals ↓ (read more here...)

Tissue Function → Therapeutic Goals

We know that all healing tissues need movement (read more), but what movement(s) do they need?

Whilst there are a number of inputs that can guide our therapeutic exercise prescription, one of the simplest methods for clinicians, especially those who are less experienced in exercise prescription is simply going back to basics - that is, understanding tissue function.

When we have an understanding of how tissues function in the absence & presence of pathology, we have already identified some of our crucial therapeutic goals.

For example;

Plantar Fascia

Whilst there are a number of functions of the plantar fascia (read more), one of the primary functions that our rehabilitation programs should focus on, is the storage & release of elastic strain energy during locomotion.

Summarising the function of the plantar fascia simply (McDonald, 2016).

During the first half of stance phase a passive stretch is experienced by the MLA ligaments...
↓
= energy stored

When the arch recoils in the second half of stance…
↓
= energy returned

The process by which energy is stored & returned sees strain energy applied to the tissue (ie: tensile load), followed by elastic recoil of the plantar fascia.

In the presence of pathology (ie: plantar fasciitis or plantar fasciopathy) we will often see a decrease in strain tolerance & elastic strain energy recycling of the plantar fascia under load.

Combining the presenting load intolerances with our knowledge of usual function should guide us towards selecting exercises that will improve strain load tolerance, in addition to restoring the energy storage-release capacity of the structure.

What exercises/movements will place strain/tensile loads on the plantar fascia?

What exercises/movements will create environments where
energy storage-release of the plantar fascia is required?

Achilles Tendon

The function of the gastroc-soleus muscle tendon unit, serves to both decelerate & accelerate the lower limb during loading tasks (walking, running, jumping etc...), in addition to recycling elastic strain energy.

The type of pathology present and the subsequent load intolerances will further influence our exercise selections. Whilst the below examples are not definitive, it shows how we can apply our knowledge of function to assist with exercise selection/focus.

As there are a number of pathologies that may affect the gastroc-soleus muscle tendon unit, the injury itself, the mechanism(s) of injury & functional deficits will further guide our exercise selections.

For example; in the presence of mid-portion Achilles tendinopathy, we may see a decrease in strain load tolerance, in addition to impairments of the energy storage-release capacity of the tendon itself.

What exercises/movements will place strain/tensile
loads on the Achilles tendon? 

What exercise/movements may improve the energy
storage-release capacity of the Achilles tendon?

Another example may be a strain injury at the medial gastroc-Achilles myotendinous junction, in which heightened levels of tissue stiffness coupled with decreases in eccentric strength may have been the underlying causative mechanisms of the injury developing. Resulting in decreases in eccentric load tolerance & concentric force generation.

What exercises/movements may increase tissue compliance at the
gastroc-Achilles myotendinous junction?

 What exercise/movements may improve eccentric/deceleration
strength of the gastroc-soleus muscle-tendon complex?

Understanding the potential mechanisms of injury, in addition to the presenting functional deficits relative to the desired functional goal, will guide the exercise selection & progressions.

Ligament

Our viscoelastic ligaments contribute to joint homeostasis, joint stability and provide proprioceptive & kinaesthetic data that influences muscle function & activation.

Stabilise joints throughout tensile loading
↓
Tensile loading exercises

 
Proprioceptive function
↓
Proprioceptive exercises

In Summary

By approaching our therapeutic exercise prescriptions through a lens of functional restoration (as opposed to focusing on symptom management - read more), we begin the process developing meaningful programs that will help our clients achieve their goals.

Once we have reviewed the normal function of the affected structure(s), we then need to ask ourselves;

What exercises load the tissue in a way that replicates normal function?
↓
Exercise Selection

Where further nuance & refinement of our exercises selections and prescriptions come from, are the other pieces of the puzzle that we must consider; client goals, tissue capacity & desired tissue capacity.

These elements and their interrelationships will be explored more in the future.

Hopefully this gives clinicians some clarity on where you can start with your exercise selections and we will build upon this in future articles. When all else fails, think about what the client wants to achieve and what the function of the tissue is and let this guide the way.

Stay tuned for future articles where I'll be exploring these elements in more depth.

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If you're wanting to take your clinical practice to the next level and want to improve your knowledge, skills & confidence when it comes to prescribing rehabilitation exercises for lower extremity musculoskeletal pathologies - P3's #1 Online Course - Exercise Therapies in Podiatric Practice is designed to do just that.

Building your knowledge from the ground up, ExTxPP will guide you through learning the essential components required to formulate effective, individualised exercise programs for your clients. 

To find out more, follow the link below ↓