It's been white some time since I typed up a “Random Thoughts” post, so I thought I'd bring it back for today. I've usually got a few dozen things rattling around my brain at all times, so if I can dump one of them here, hopefully I'll replace it with something noteworthy. Today’s question is somewhat “Andy Rooney-esque.”

Have you ever noticed that doctors are less likely to prescribe physical therapy for foot and ankle issues than any other problem? I might be skewed by my perspective in this part of the country, but I doubt it, as Boston has a great medical reputation. “Just walk on it” is the advice I often hear folks say they've gotten. Would you do that for a hip or knee replacement?  As I discuss in my e-book, The Truth About Unstable Surface Training, following inversion ankle sprains, a lot of folks wind up with functional ankle instability due to a proprioceptive deficit of the peroneals; this muscle group just doesn’t turn on quickly enough to prevent “re-sprains” from occurring.

Additionally, some individuals present with some considerable “anterior jamming” that can’t be addressed by classic ankle mobilizations, and these individuals can benefit greatly from good manual therapy and joint manipulation by a qualified professional.  Lastly, breaking a big toe can be a big deal; it's dangerous to assume that it'll just magically heal perfectly if someone walks on it for months - and it can be problematic to brace a foot in an immobile position for an extended period of time and wind up with stiffness or compensation patterns.

Along those lines, though, maybe they just aren't prescribing physical therapy for these issues because there aren't specialized physical therapists. I know of a lot of wrist/hand physical therapists, but no true foot/ankle specialists on the PT side of things. Sure, there are PTs who do foot/ankle as part of their normal practice (and some who do it very well), but you'd think that the weight-bearing joints that connect us to the ground would receive even more specific attention than wrist/hand issues. Perhaps this lack of specialization has emerged because the foot and ankle are so complex and misunderstood; it could be a good "niche" for some of you up-and-coming physical therapists to pursue.

Again, these are just some Monday musings off the top of my head. To the general fitness folks out there, push hard to get physical therapy after a foot/ankle issue. To the rehabilitation specialists and strength and conditioning professions out there, I’d love to hear your thoughts in the comments section.

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I guess you could say that this is one more "yea" vote in favor of the whole kinetic chain concept.  Mess up an ankle and you very might be dealing with a knee, hip, or lower back issue sooner than later.

In a blog last week, I discussed how important it is to differentiate between unstable surfaces and destabilizing torques applied further up the kinetic chain, as they comprise different kinds of instability training.

I receive a great question in response to the blog:

“Eric, what do you think about unstable surface training for hockey? I’ve been using half-dome stability balls for a long time now in many settings (high school through college) with my trainers. I can’t tell if the effect wouldn’t be the same if I were doing something else but skates do wobble under weak players when pivoting and stopping quickly under loads up to 2-3 times body weight, and ankles do adjust to become more stable after training like this. What’s your experience? Thanks, Boris”

It’s an interesting case, as the blade of a hockey skate is certainly different than regular flat surface.

Even more interestingly, though, is that Boris – through his question and also his personal experience – has directly highlighted some important research that was done in this regard.

In 2005, Behm et al. (1) examined the correlation between hockey skating speed and performance on a 30-second wobble board test. Interestingly, they found a significant correlation in players under the age of 19. However, no such correlation existed with players age 19 and older. So, how does this occur?

Here’s an analogy: go to a little league park, and find the kids who have the best fastball velocity. Chances are that they are also the kids who run the fastest, jump the highest, do the most chin-ups – or any other physical test that you throw at them. Very simply, this difference can easily be attributed to different levels of motor development in young skaters.  Heck, with just a quick Google search for "youth hockey," I came across this picture.

You'll notice that the physical development is markedly different across the board.  In fact, the 6-4, 230-pound goalie drove all the other 11-year-olds to the game, taught them how to shave, and then hit on all the hockey moms after the game at the local bar.

Moving back to the aforementioned Behm et al. study, the researchers noted, “The complex skills associated with skating would necessitate a more refined balance that would improve with maturity and perhaps training. Since skating is performed on a very small surface area (blade) in contact with a low friction surface, younger individuals with greater stability may have an advantage in executing the specific skating skills” (1).

So, in reality, we’re comparing physical development and not necessarily performance on a specific test – until we level the playing field and physical maturity is roughly equal for everyone (after the age of 18). At that point, you don’t see a correlation, so I’d be very reluctant to endorse lower-body unstable surface training as a useful training implement for hockey outside of specific rehabilitation situations.

The long-term studies examining the issue have been poorly controlled in the sense that they've looked at ankle sprains over the course of an extended period of time with an unstable surface training intervention, but haven't taken into account previous history  of injury.  So, the athletes engaged in the unstable surface training group may simply have been rehabilitating previous ankle injuries with longstanding functional deficits rather than "fortifying" already healthy ankles to prevent injuries.  Interestingly, in one study of elite female soccer players, balance board training did not decrease the rate of traumatic lower extremity injuries.  The frequency of major injuries - including four of five anterior cruciate ligament tears - was actually higher in the intervention (unstable surface training) group than the control group (2).

For more information, check out my new e-book, The Truth About Unstable Surface Training.

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