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Injury Prevention 101: Position Sense or Proprioception

I’m kicking the injury prevention series off by discussing the importance of position sense and how a lack of this can predispose you to injury. This series is useful for anyone who walks, runs or jumps as part of their exercise. You can join the Sports Injury Support group to watch the whole series via livestream or on replay and ask me question that I'll answer on the spot. The other topics that I’ll cover include core stability, glute med, glute max, hamstrings, quadriceps and calf.

In this article:

  • What is position sense?

  • How does it affect injury?

  • What can affect position sense?

  • Training position sense is not rocket science!

  • Download the exercise programme as a PDF

  • Can tape or compression garments help?


What is position sense?


In short: Position sense or proprioception is the ability of your brain to know exactly where every part of your body is and how it is moving without having to look at it. The brain then uses that information to work out where to place the body part next and with how much force it should contract each muscle.


Maybe a practical example will help you understand it better: Close your eyes. Now think about your right ankle. Slowly point your toes so that the ankle joint moves down. Then slowly pull your toes up so that your ankle joint moves up. Then turn your foot in and out.


Do you notice how you can nearly “see” your ankle move in your mind’s eye? Your skin, muscles, tendons and joints all have little receptors in them that constantly send information back to the brain. The brain then uses this information to calculate exactly how to perform the next task e.g. how far to step or how much to contract your muscles etc. without actually having to look at the body part.



It’s position sense that allows us to run up and down stairs without having to look at them or a footballer to control a ball without looking at his feet.


A good example of what happens when the brain gets it wrong, is when you step down from a step that is higher than what you expected it to be and stumble.


A lack of good position sense is also the reason that some elderly people struggle to walk on uneven surfaces. Their brains struggle to understand exactly where their feet are and how to control them and as a result they have to look down so that they can get extra feedback from their eyes.


An example of extremely good position sense is someone who can balance and walk on a tightrope. In order to do that your brain has to be acutely aware of where every joint and body part is and has to precisely calculate how much to tense every muscle in order to perfectly balance your body.


How does it affect injury in runners?


The research has shown that people who score low on position sense tests in their trunks and legs may be more likely to sustain a wide variety of lower limb injuries of the joints and muscles. Some examples include ACL tears, ankle sprains and even hamstring tears.


The explanation for this is quite simple. If the brain does not know exactly where your body parts are, it cannot produce well-coordinated movements. This means that you can easily overload specific joints, ligaments and muscles which can lead to strains and tears. It can affect any part of the body.


A common example I see in clinic is patients who report that they often sprain their ankles, even when running on flat ground. This is not normal and often related to poor proprioception.



What can affect your position sense?


For good position sense you need 2 things:

  1. Your receptors in your skin, muscles, tendons and joints must work properly.

  2. You brain must be able to interpret the signals that the receptors send to it and respond appropriately.

Factors that can negatively affect our position sense include:

  • Injury – When you sustain an injury, the message between the injured body part and your brain gets interrupted so that the brain temporarily loses its ability to know exactly where that body part is. It is quite easy to retrain again, but unfortunately this often gets neglected. A good example of this is when someone has gone over on their ankle and they then find that they keep on going over on it even when walking on flat ground. Some simple proprioception exercises can often make a big difference.

  • Disuse – Your brain needs practise to know how to control your body parts properly and if you’ve not used them for a while it gets detrained. If you’ve ever had a body part immobilised in a cast or splint, you’ll know how difficult it is afterwards to make it do what you want it to do. This is an extreme example, but a more common one is where people spend most of their time in sedentary jobs. Sitting down all day does not help to develop your brain’s control over your legs. Sure, walking around does require a basic level of position sense but you need more than that for running and walking on uneven terrain.

  • Hyper-mobility – Thanks to genetics some people have hyper-mobile joints with lax ligaments. These people usually also have reduced proprioception or position sense in those joints. Proprioceptive training can improve this and there is also some research to show that compression garments can make a difference.

  • Fatigue – The research has shown that people’s position sense decreases when they are tired. So if you’re planning to do complex movements during training, do them while you’re still fresh. Also, if you’re planning to do tough mudders or other obstacle races where the brain’s position sense will already be challenged due to the terrain, make sure that you’re fit enough!


Training position sense is not rocket science!


I tend to use 2 main types of exercises to retrain lower body position sense for walking and running:

  1. Balancing

  2. A squat movement

Principles to follow when retraining position sense:

  • always start in stable positions and practise the basic movement pattern first;

  • then move into progressively less stable positions or onto less stable surfaces;

  • master simple tasks first and then make them more complex;

  • practise it often!

The exercise examples start at minute 5:55

Balance

I provide a lot more detail in the video (from minute 5:55), but the first 3 exercises that you’ve got to conquer are:

  1. Balancing on one leg while looking straight ahead for 30sec. Your hands should be in your sides, your pelvis should remain level, the free leg should not be pressed into your standing leg and you should not wobble. Once you’ve nailed this one move on to number 2.

  2. Balance on one leg, but now slowly turn your head from side to side. You should be able to do this for 30 seconds before you move to number 3.

  3. Balance on one leg, but this time close your eyes. Again your aim is to reach 30 seconds without falling over. This is very hard as your brain no longer gets any help from the eyes and has to only rely on what the sensors in the muscles, joints, ligaments etc. in your legs tell it.

You can also make the exercises more difficult by using balance boards and standing on foam cushions etc. but make sure that you master the simple exercises on the floor before you start using other devices.


Squat movements

Your leg goes through exactly the same motion when you do a small squat as when you run or walk. This is therefore a very useful movement to use when you want to retrain your brain’s ability to properly control your legs during walking and running.


Good squat technique also requires you to have strong leg muscles so it’s a very nice all in one exercise for strength and proprioception.

  1. Practise a slow, double leg squat to about 90 degrees knee flexion. If your calves are very tight you may struggle to go low enough – placing a book under your heels will help. Your knees should move in line with the middle of your feet and you should stick your bottom out to the back so that your knees do not cross over the front of your feet. Keep your back upright and make sure that you contract your stomach muscles throughout the movement. Once you can do a double leg squat with good form, move on to number 2.

  2. Single leg squat with support. Balance on one leg, but place the other leg on a chair behind you to provide some stability. Now slowly squat down to at least 60 degrees knee flexion. You may not be able to go that low at first, but work your way up to it. You should check that your pelvis stays level and that your knee moves in line with the middle of your foot. Your trunk should stay upright. Once you can do 3 sets of 15 with good form, move on to number 3.

  3. Single leg sit to stand. During this exercise you are going to rise from sitting using only one leg while applying all the principles that we’ve discussed in the previous 2 exercises. Then you’re going to slowly sit down again using only one leg. Depending on how strong your legs are, you may have to start on a slightly higher chair or surface. Your aim should be to be able to do 25 sit-to-stand-to-sits from a chair that allows your knee to bend to a 90 degree angle. You must aim to be able to do it without any wobble in your leg.

Download the exercise programme as a PDF with pictures



Can tape or compression garments help?


At first glance the research appears to report conflicting results with some studies showing that tape and compression garments can improve proprioception or position sense and other studies showing absolutely no effect.


On closer inspection it seems to be dependent on who it is used on. Study participants who had a position sense deficit before the tape or compression was applied, showed significant improvements in position sense when tested afterwards. Study participants who had a normal score or no problems with their position sense, showed no further benefit from covering their knees or ankles in tape or wearing compression garments.


What does this mean in practise? We know that position sense is affected when you sustain an injury, so taping your injured body part can be an effective way to help improve this while you recover. BUT this is only a temporary measure and you have to do your exercises to restore it fully.


Let me know if you have any questions. You can consult me via Skype for an online diagnosis of your injury and a treatment programme tailored to your needs. I’ve also created a free Facebook group where you can ask questions about your injuries and get injury prevention advice.

Best wishes

Maryke



About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate.



References:

  1. Bailey, Daniel, and Paul Firth. "Does kinesiology taping of the ankles affect proprioceptive control in professional football (soccer) players?." Physical Therapy in Sport 25 (2017): 94-98.

  2. Cameron, Matt, Roger Adams, and Christopher Maher. "Motor control and strength as predictors of hamstring injury in elite players of Australian football." Physical Therapy in Sport 4.4 (2003): 159-166.

  3. Cameron, Matthew L., Roger D. Adams, and Chris G. Maher. "The effect of neoprene shorts on leg proprioception in Australian football players." Journal of Science and Medicine in Sport 11.3 (2008): 345-352.

  4. Dupuy, Emma G., et al. "Ehlers-Danlos Syndrome, Hypermobility Type: Impact of Somatosensory Orthoses on Postural Control (A Pilot Study)." Frontiers in human neuroscience 11 (2017): 283.

  5. Ghai, Shashank, Matthew W. Driller, and Rich SW Masters. "The influence of below-knee compression garments on knee-joint proprioception." Gait & posture 60 (2018): 258-261.

  6. Goble, Daniel J., et al. "Brain activity during ankle proprioceptive stimulation predicts balance performance in young and older adults." Journal of neuroscience 31.45 (2011): 16344-16352.

  7. Hosp, Simona, et al. "Eccentric Exercise, Kinesiology Tape, and Balance in Healthy Men." Journal of athletic training 52.7 (2017): 636-642.

  8. Hosp, Simona, et al. "Does Kinesiology tape counter exercise-related impairments of balance in the elderly?." Gait & Posture (2018).

  9. Jahjah, Akram, et al. "The effect of ankle tape on joint position sense after local muscle fatigue: a randomized controlled trial." BMC musculoskeletal disorders 19.1 (2018): 8.

  10. Long, Zhi, et al. "Optimizing ankle performance when taped: Effects of kinesiology and athletic taping on proprioception in full weight-bearing stance." Journal of science and medicine in sport 20.3 (2017): 236-240.

  11. Michael, Jacob S., et al. "What is the effect of compression garments on a balance task in female athletes?." Gait & posture 39.2 (2014): 804-809.

  12. Miura, Kazutomo, et al. "The effect of local and general fatigue on knee proprioception." Arthroscopy 20.4 (2004): 414-418. General fatigue can influence proprioception

  13. Silvers-Granelli, Holly, et al. "Efficacy of the FIFA 11+ injury prevention program in the collegiate male soccer player." The American journal of sports medicine 43.11 (2015): 2628-2637.

  14. Zazulak, Bohdanna T., et al. "The effects of core proprioception on knee injury: a prospective biomechanical-epidemiological study." The American journal of sports medicine 35.3 (2007): 368-373.

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