The use of the SANDDUNE in treating pathologies of the foot, ankle, knee, hip, and lower back.
-by Dr. Keith Kleven, M.S.,R.P.T., AT.C.


One does not have to look very hard to see the revealing statistics of hundreds of individuals both students as well as the lay population of our society being involved in dance and aerobic injuries. Of the injuries that continue to be reported in the area of dance and aerobic classes, the majority of these injuries are reported in the lower extremities. The next most vulnerable location and pathology appear to be the back.

One of the most commonly encountered pathologies in dealing with aerobic exercise appears to be the “shin splint syndrome” more specifically; this is an anterior compartment problem that has to do with the forces acting on the muscular and stabilizing structures of the dorsum of the foot and leg which is out of proportion to the posterior musculoskeletal structures. In conjunction with the anterior compartment problem, there appears to be a great number of feet and heal problems which centers around abnormal stress for normal arches or pathological arches as well underdevelopment of the intrinsic and extrinsic structures of the foot and ankle. Ligament injuries and tendon injuries have always been a major classification of pathology in the lower extremity. Knee problems are being reported with pathology diagnosed as cartilage tears, dislocations and a heavy percentage of chondromalacia or inflammation of the articulating surfaces of the femur in relationship with the knee cap or patella. Hip problems are reported in less frequency and are primarily ligamentous in nature although muscle strains of the hip are also involved. Back injuries are reported in the category of the soft tissue injury with classifications of “muscle strain” in the lumbar region and low back sprain involving lumbar ligaments.


As one investigates the alarming statistics coming from this category of exercises termed “aerobics”, one must be concerned that new programs and equipment center low impact versus high impact activity. The statistics in aerobics supports having mechanism to exercise on that will produce a softening effect to the structures of the lower extremity such as can be illustrated with theSANDDUNE. Concepts that can be taught in conjunction with this piece of apparatus are as follows:


Ability to teach proper breathing and muscular relaxation during lower extremity exercise.
Ability to teach and maintain good muscle tone, strength and postural components in functional training.
All proprioceptive training to occur in teaching the concepts of “centering” or maintaining center of gravity in the proper positioning and changes of forces while proceeding in a low impact program.

It is possible with this type of apparatus to incorporate aerobic training to the individual’s tolerance altering the heart rate with periods of anti-aerobic stress that thus may be more suitable for a certain individual.

In dealing with dance medicine, this new piece of apparatus has a major advantage in teaching “Pointe work”. This type of training can be facilitated by using the apparatus to develop:

Balance
Strength
Coordination
Assisting in the mental maturity needed to be successful in the progression of dance education and training.

Ankle position can be maintained that will facilitate that ability to extend knees and hips while concentrating on the reduction of lordosis or the ability to perform isometric, isotonic and dynamic training and facilitate strengthening of both the medial and longitudinal arches of the foot.

This new apparatus also is of the value in managing stress fractures in the lower extremity which before was treated primarily through sensation of activity and also incorporating casting. This system can allow for training of the lower extremities particularly the distal structures of the legs and feet by reducing stress of the 5th metatarsal and reducing forces result in compression fractures of sesamoid bones of the volar aspects of the foot particularly the first metatarsal phalangeal joint.

This system also allows for reduction of stresses that may relate to progressions of herniated discs and allows for the patient with low back pain or low back pathology to proceed with a systematic protocol through low impact measures yet obtain tissue and joint mobility and musculoskeletal strength at the same time. This type of apparatus allows for coordination efforts in both loading and nonloading activity.

Shock-Absorbing Surface
There is a greater need at present than there ever has been regarding providing athletes, dancers, and the lay person the proper surface for exercising of all types. It is recognized that a good exercise surface or dance surface should be shock absorbing and should give under impact and absorb some of the impact but not deform permanently. The SANDDUNE allows for proper shock absorption and return of “bounce” to the participating lower extremities. The design of this new piece of apparatus allows for compliancy of the foot and ankle contact allowing for dampening and absorption.

Here again this type of training instrument may allow for a marked reduction in tendonitis, knee pathology, leg pathology, and stress pathology of the lower extremity and back.

In summary, I believe that probably the most important element in prevention of aerobic injuries is proper education and teaching along with the specific exercise. I feel the second most important factor is not recognizing the deconditioned athlete and/or participant in the program and thus applying normal forces and stresses to an inadequate body. Third, I think there is a major deficit in providing proper environmental conditions which include the surface in which the athlete and/or participant exercises on. Here the SANDDUNEbecomes a major contributing factor in reducing pathology and providing the clinician and the lay person a tool to work with in not only improving skill and function through improved tissue and joint mobility and strength but also in preventing unnecessary fatigue components, exaggeration of normal stresses, and applying a poor noncompliant surface for exercise.

The pathologies that can be treated successfully with theSANDDUNE are as follows:


An acute and sub acute strain, foot, ankle, and leg.
Acute, sub acute, and chronic tendonitis which often results from muscle strains. Once developed tendonitis is often chronic and recurrent and becomes acute when an already inflamed tendon is subject to further stress


One of the most involved and common forms of tendonitis in the foot is the flexor hallucis longus tendon. Strains and tendonitis are by far the most common related soft tissue injury of the foot and ankle as a result of running, dance, and intense aerobic stress. Other classifications are as follows.


Bursitis an inflammation of the bursa sac is generally caused by friction forces or the inability of tissue to adapt to the forces or the inability of tissue to adapt to the forces surrounding specific muscles and/or tendons. Aerobic dancers frequently develop bursitis behind the heel in the calcaneal region where the Achilles tendon attaches to the calcaneus.

Contusions or a bruise of tissue and/or bone is swelling as a result of bleeding within the tissue that has received direct trauma. This is another pathology that can be treated successfully utilizing the SANDDUNE which allows for modified stress in assisting in the reduction of fluid and blood that has accumulated in the area we call a hematoma. A sprain is a tear of a ligament and is graded as a 1, 2, or 3. A sprain occurs in any joint or series of joints in the body and includes everything from microscopic tears grade 1 to complete ruptures grade 3.

Again an optimal source of rehabilitation with sprains is utilizing the SANDDUNE which allows one to minimize excessive force applied to the joints in the unstable tissues and yet allows for facilitation of involved structures by allowing rolling motions of the foot and ankle, controlled forward and back flexion motions, as well as biasing positions of the ligaments as determined by the clinician which will assist in proper repair forces to the affected joint tissues.

Prevention of muscle weakness is a major component to reduce the joint’s vulnerability to reoccurrence of  sprain and theSANDDUNE allows for not only isolated ankle and leg strengthening, but also allows the knee to assume particular positions which will determine the demands on the muscular support system  of the ankle and foot.  Dislocation is a joint injury that involves not only tearing of ligaments but in most cases allows for a partial disruption of the relationship between the bones that make up the joint.


Often there is a fracture. In the case of dislocations of the knee, the patella or the kneecap is pulled away from its tracking groove and also structures that allow for proper tracking of the kneecap are traumatized. The relationship between the bones usually restores itself by spontaneous reducing and with proper guidance and medical direction, isometric and light isotonic prepositioning exercises can be initiated and the SANDDUNE is again a piece of equipment that one would choose in this rehabilitative process.

Concepts that center around the utilization of the SANDDUNE:


Proportions– SANDDUNE allows for adaptability of size. This is in reference to length of lower extremity, amount of soft tissue, curvatures of joints and postural deviation.
Ligamentous laxity- SANDDUNE allows for justibility and the prevention of further ligamentous laxity and/ or for facilitation of healing which will allow for ligamentous tightening and restoration of muscular strength. These systems allow for stretching tight muscular and tendinous structures and also allows for prepositioning to avoid abnormal stress which has a tendency to produce hypermobility of specific ligamentous and muscular structures. Recognition of proper joint positioning and joint function is of utmost importance.
Soft tissue- SANDDUNE allows for the management of joint positioning in the lower extremities with consideration of pathologies such as Achilles tendon tear, sublaxation and dislocations, torn cartilage, torn ligaments and contusions of soft tissue.

In Summary

It is important that we maintain equipment and techniques in rehabilitation that allow the human body to adapt to stress applied in small increments and allow this adaptation to occur with adequate time. SANDDUNE allows for adaptation which is specific to controlled stress. It is important that we recognize that we begin using equipment which is am adjunct to traditional strengthening and conditioning methods and programs. We need to increase a broader foundation to work from and train so that we condition participants to works close to their limits of physical capability in a safe and protected manner.

SANDDUNE can be used for effective warm-up for it is designed to increase blood flow to the working muscular structure and tissue. It can present a method of controlled walking and running in place as well as specific low impact movement sequences. Warm-up and cool-down is extremely important in relationship to performance, prevention and maintaining a healthy injury-free system. One must allow for a gradual return to resting equilibrium or warm-down process allowing for increased flexibility, passive stretching and/ or a cooling process to occur.

Again, SANDDUNE can be utilized to facilitate and/ or prevent strength imbalances, restore normal joint movement from an asymmetrical flexibility level as well as manage effected traumatic tissue in the reduction of effusion and the side effect neurologically termed pain.

I feel it is important particularly in the mention of the SANDDUNE to stress the ability of this system to assist in cardiovascular training and conditioning. Dance in many forms has a most positive effect on the cardiovascular system particularly aerobic dance.

The SANDDUNE is an effective way of facilitating cardiovascular conditioning through controlled measures with variable intensity, position, and force.

The SANDDUNE can be used to reduce the risk factors in controlling:


​Training errors including changes in intensity, rate and style of movement controlling increasing and decreasing stress on the lower extremity structures.
Incorporating proper posturing and positioning including the trunk as well as lower extremities.
With the ability to control the weight bearing surface as well as foot wear, the additional related factors implied to the training program can be controlled through proper education and instruction. With recognition of growth centers in our young people and the force that affects these centers, this piece of equipment assists the clinician in control of the forces applied through these growth centers as well as the position that the joints and bony structures are allowed to function within.
The SANDDUNE plays a major role in prevention of upper back strain, low back pain and can specifically be utilized in the treatment of spondylolysis which is particularly prevalent in many dancers and aerobic exercise participants. Young and novice athletes and exercise participants can enhance their mechanics as well as proceed with proper tissue and joint mobility and strength training with the use of the SANDDUNE equipment. Warm-up and warm-down may be controlled within a very slow progression or very rapid progression based on the pathology, tissue and joint stability and specific training program.


This piece of equipment may be utilized in the areas of:


​Standing position and normal balance training.
Functional training of the lumbopelvic unit.
Management of the primary traumatic lesion.
Assist in the biomechanics and pathophysiology of the pelvis independent of the lower extremity.
Work in static and dynamic fashions to assist in management of joint, tendon, muscle pathologies of the lower extremity including peripheral vascular disease.


The protocols that I feel will be initiated in with this equipment are related to:

Flexibility Exercises
Endurance Exercise Training
Strengthening Exercise

Flexibility exercises will consist of sitting, turning, and twisting procedures of the lower extremity applying various forces at the foot, ankle, and knee. These exercises will also be incorporated for certain tissues and joints are immobilized and only a selected joint may be facilitated at a given time.

The endurance exercises will be incorporated in techniques such as running, cycling motions, climbing motions, walking motion with variable forces and demands dictated by the pathology and examiner. The cardiovascular and respiratory systems will be facilitated through training programs  utilizing this piece of equipment as well.



The strengthening exercises will consist of working with added resistance in upper and lower extremities as well as set protocols based on joint position and resistive forces specific to muscle and joints.

Again, a warm-up and a cool-down program will be incorporated with this equipment based on the individual’s pathology and the clinician’s direction.

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