Are Your Shoulders Ready for Brazilian Jiu Jitsu?

I have been keeping busy down here in Miami, Florida. I am about a quarter of the way through my first semester as a PhD student and I have been kept busy with teaching my first class (Introduction to Athletic and Sport Injuries) and by being a research assistant for my adviser as well. I have also had the opportunity to keep myself busy yet physically active by taking back up a long-lost but much loved hobby of mine: Brazilian Jiu Jitsu (BJJ).

BJJ took a backseat for me after training regularly during my bachelor's degree. It stayed on the back burner as I worked on my master's degree but my schedule has normalized enough to allow me to resume training. My sports medicine breadth of knowledge has grown and advanced while my BJJ was placed on hold, and because of that I feel that I have a expanded view on the biomechanics of the sport that I didn't necessarily have previously.

Specifically, I am going to touch briefly on a bit of injury prevention for anyone out there that may be into BJJ or for those of you that may treat people that participate in BJJ (actually this stuff applies to everybody not just BJJ guys). Nevertheless, this post is definitely geared more for the BJJ practitioner and not the clinicians out there...this may not even be new information for those who have visited this blog before.

While I am not somebody that you should go to for submission or any BJJ advice for that matter...I feel that I can give some good insight to help you stay on the mats. Specifically, when I was training I often saw a lot of people struggle with shoulder injuries. In fact, traumatic shoulder dislocations and subluxations were more prevalent than one might assume. Perhaps one wouldn't be surprised considering this is a sport where people enjoy catching each other in joint locks and submission-holds that work by forcibly placing one another's joints at their respective end ranges of motion. So when it comes to a sport where we are already pushing the limits with our body (within reason) then we need to ensure that we are not already at risk of damaging ourselves or our training partners.

I'm no Kenobi.

Having strong, mobile, and stable shoulders is just as important for your ability to submit as well as your ability to not get submitted. The status of your shoulders can also have repercussions up and down the kinetic chain. This is evident when a shoulder issue can manifest itself as a grip strength (I won't be touching on it in this post but proper grip strength can also play a huge role on proper shoulder stability) problem. Not to mention proper shoulder function, especially based upon the tests that I am about to show you, is entirely interdependent on proper function of the elbow joint, glenohumeral (shoulder) joint, the scapula (shoulder blade), the thoracic spine, and arguably the neck or cervical spine as well.

You can bet this guy needs some help, even if he doesn't have symptoms...yet.

So what is a quick an easy way to check for potential shoulder dysfunction? If you know me by now you know I am a fan of the Selective Functional Movement Assessment (SFMA) and think its a great way for everybody to look at movement despite the fact that we may all treat movement in many different ways. So that is where these tests originate!

1) Upper Extremity Pattern #1

What does this shoulder position look like?

This test requires adequate motor control and mobility of many different segments including: Shoulder internal rotation, shoulder extension, and horizontal adduction of the shoulder. Additionally it requires elbow flexion and thoracic spine extension/rotation. Any issues found here indicate a potential stability and/or mobility problem. One must not assume that it is a mobility/flexibility issue that needs stretching or cranking on.

Looks a lot like our test above...If you can't easily put your own arm here, how do you expect it to feel when does it for you?

What is a passing test? The ability for the finger tips to reach the inferior angle of the contralateral scapula without excessive scapular winging of the moving arm, without excessive effort, no deviations in starting posture, and a symmetrical result when compared to the other side. A failing test would require a local biomechanical assessment and to break down of the components of the movement to search for the weakest link. This is a normal range of motion to be able to move through. Deficiency here can lead to increased strain, tension and shearing forces through your upper extremity and its soft tissues.

#2) Upper Extremity Pattern #2

For this test you need adequate shoulder external rotation, shoulder abduction, shoulder flexion, and elbow flexion on top of thoracic extension/rotation as well. To pass this test you must be able to reach your fingers to your contralateral scapula. Where at on the scapula? The midpoint of the spine of your scapula is our targeted destination. However, you need to look for symmetry of movement from side to side, check out how much effort is required, and if there is any deviation of posture to achieve this position. Additionally, a person is not allowed to "crawl" their hands up or down their back for either test. It has to be done with one smooth motion and without "warming" up.

This is not the same as Upper Extremity Pattern #2 but it IS the same. Get it?

If you want a quick and easy way of doing this if you are unsure of your anatomical landmarks just grab yourself a tape measure and assess the distance from your longest finger tip to the first wrist "crease" or wrinkle of your wrist just below your palm. Got that measurement? Okay well you want your hands to be within 1.5 times that measurement to be considered acceptable and don't forget to switch arms and check both ways.

So what do you do if fail these tests? That is a debate for another day but you honestly need more information. However, if you want to use a trial-and-error method then all you need to do is try something out like flopping on a foam roller, lacrosse ball, or getting a massage and seeing if there is  a difference afterwards. How will you know if there is a difference? Retest! Mobility may work may not fix this so don't assume that is what it is! It could just as easily be a motor control or stability issue. Here is a sample of what breaking down one of these tests looks like.

While these tests are far from all-inclusive or the be-all-end-all they are a great starting place to screen or assess for potential risk of injury. If you can do this it doesn't mean you won't injury your shoulder or that you are 100% good to go but if you can't I do know that you deviate from normal into abnormal. Abnormal or dysfunction in my book is the same as pathological and may lead to future injury down the road. Get to work on bullet-proofing your shoulders before it is too late and you are under the scalpel.

!!Update!!

 Some people asked for a video to help clarify a few questions that they had regarding this post and I have finally gotten the time to deliver. Here it is...

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Do I Believe in Chiropractic Medicine?

Supposedly this is a painting of the first chiropractic "adjustment"

That is the question that was asked of me recently by a client. This question was offered to me in a hushed manner as if it was a taboo or risky thing to ask somebody.

In reality, I can understand the demeanor of the question due to the previous issues between the chiropractic profession and societies like the American Medical Association.

Curious to what my answer was? I told her that I do NOT believe in chiropractors...Pause...I also do not believe in physical therapists, athletic trainers, medical doctors or osteopaths. However, I do believe in critical thinking, sound clinical reasoning, clinicians that get results, evidence based practice, and the scientific method. There will always be good eggs and bad eggs in any profession. There will always be some patients that will respond to some clinicians/treatments/therapies/exercises better than others. It doesn't mean they are bad but they weren't appropriate at that moment in time.

I think she has lost her marbles.

As Charlie Weingroff would say, "I don't care if all you do is spread peanut butter on somebody, if it makes them move better or with less pain from baseline to post-testing."

Test - Intervention - Retest.

That is starting to be my new gold standard for how I feel about different clinicians. I could turn this into a profession bashing fest but its almost like discussing stereotypes...they just are not true for everybody. Not to mention it would be unprofessional of me. ;-) 

I am also biased towards systems of evaluation like SFMA/FMS/PRI/MDT because they guide treatment and funnel down issues to specific dysfunctions. This is a step in the right direction compared to trying to guess why somebody strained a hamstring, or treating all shoulder impingements the exact same way.

In conclusion, when you really start to look at stuff on a broader scale you will notice that the overlap between professions of physical medicine is constantly increasing and the points of distinction really aren't that distinct. I also see the need for more clinicians to be willing to work together. Do not let ego get in the way of referring to another provider just for the sake of keeping your cash flow constant. The real future is who can become distinct by delivering the best outcomes and results to the patient. This is customer service after all.

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Please Leave Your Poor Hamstrings Alone!

"Tight Hamstrings, The Epidemic That Never Existed."

 -Dr. Erson Religioso, DPT

Trying to touch my toes at my first SFMA seminar.

This little nugget of knowledge developed during a conversation that my good friend Dr. E of The Manual Therapist and I were having together after his recent post. It is crazy how many times you will hear people mention how tight their "hammies" are or how often you can look at people exercising in public and the only thing they stretch is their hamstring group after some light arm circles. It is bewildering to me sometimes.

I think there is a real epidemic in progress and is growing at an exponential rate. However, the epidemic is NOT hamstring tightness...The real epidemic is a plethora of people, old and young alike, that can not touch their toes. Touching your toes without bending your knees is...or should be a fundamental human movement pattern. I know many of us fear lumbar motion and especially extreme lumbar flexion but spinal (that includes lumbar) motion is completely normal and necessary. We aren't talking about lumbar flexion under load here.

On top of the population of people that can not touch their toes...there are plenty of people that can do so. However, I didn't say everyone that could do this was able to do it satisfactorily. Using the Selective Functional Movement Assessment (SFMA) standards a person should be able to touch their toes without bending the knees, should have a uniform spinal curve throughout all of the spinal segments, have a sacral angle of > 70 degrees, and should utilize a posterior weight shift or hip hinge to achieve this goal. An inability to achieve this pattern satisfactorily represents an inability for athletic movements such as the deadlift, and an inability to reflexively stabilize the spine.

So what does this have to do with hamstrings? Most people that can not touch their toes often jump the gun and assume that it is due to posterior chain tightness or tight hamstrings. In reality, this is rarely the case. In fact, I would recommend you always get a second opinion or never evaluate yourself. I actually made this mistake myself and it was evident in a previous post where I did an SFMA video of my own multi-segmental flexion (toe touch pattern). I was wrong in my assessment and I actually had a core stability/motor control dysfunction.

This wasn't evident to me because during a certain breakout assessment I falsely associated the sensation of neural tension to equal soft tissue tension. I didn't realize my mistake until I was auditing the SFMA certification course for the second time. I volunteered myself to be the case for teaching the multi-segmental flexion breakouts. This SFMA course was being taught by Behnad Honarbakhsh, MPT, BHK, CSCS, CAFCI, CGIMS, DO (c) (whom I thought was brilliant) and low and behold in front of the entire class he humbled me and showed me my true dysfunction. Nobody knew that I was humbled because I didn't discuss my prior self-assessment. However, I probably hadn't touched my toes since I was a toddler before elementary school. Michele Desser and Dr. Todd Arnold quickly took me out into the hallway and had me perfom rolling and core stability exercises for about 5 or so minutes. They then brought me back into the seminar and showcased how I went from being about 14 inches from touching my toes down to about 2 seconds. Later that night, back in the hotel room I practiced some more on my own and was able to touch my toes.

So lets find out where I went wrong really quick to showcase how you can check to see if your hamstrings are tight or not.

Step 1. Check to see if toes can be touched. If not, continue on. 

Why can't I? We don't know. Don't blame the hamstrings yet.

Step 2. Remove Parts and Compare Left to Right. 

Here I unweight one of my legs and check for change. Nothing. Continue on. Still not the hamstrings.

Step 3. Long Sitting Test - Unload body parts. 

Now the hips and below will not be bearing weight and only the spine will be partially loaded against gravity. Still can't touch the toes? Continue on. (Still not the hamstrings despite my P.E. teachers scolding me for my tight hamstrings as a kid)

Step 4. Unload More, Check Left to Right, and begin Active versus. Passive Comparison.

In this test you are looking for & 70 degrees of hip flexion with both knees remaining straight, feet dorsiflexed, and hips neutral. An inability here STILL is not due to tight hamstrings.

Step 5. Checking Passive Motion compared with Active Motion from the previous step. 

An inability here to increase motion here beyond what you achieved actively = Ding. Ding. Ding. Winner Winner, Chicken Dinner. You DO have tight hamstrings! There are a few more steps you may take after this finding to pinpoint where the mobility dysfunction is located. However, If you increase more than 10 degrees compared to active but still do not reach normal hip flexion (now 80 degrees instead of 70) then you have a mobility and stability/motor control dysfunction present! If you find that you go from ~40 degrees to normal like I do below then you sir...DO NOT HAVE TIGHT HAMSTRINGS. You have a stability/motor control dysfunction. Continue on to step 6.

Step 6. Now you must find out how poor your motor control deficit is.

To pinpoint this you regress yourself to the most basic form of stability and motor control...rolling around on the ground. If you can not roll from supine to prone with each of your different limbs then you have a primitive motor control dysfunction. Restoring the ability to roll may fix your inability to touch your toes. However, at this point we are encroaching on the area of the 4x4 matrix of the SFMA. If you aren't in pain currently then I would recommend you finding an FMS certified professional and get screened and start with working on your most dysfunctional issues there first.

Look at me now...Just a tiny bend in the knees. Working on it. No hamstring stretching needed.

In conclusion, don't evaluate yourself and if you do...Get it rechecked by another set of eyes. The plumbers pipes always leak. Don't be that plumber. Secondly, practice your systems of evaluation or assessment if you have one so you can own it. If you don't use a system how can you be sure you aren't throwing spaghetti against the fridge and hoping that something sticks? What are your metrics for improvement? It has been said a million times and I'll repeat it. You do not need to use these metrics but you should be using something to set a baseline, intervene, and then compare to baseline to check for change.

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Thoracic Extension Doesn't = Thoracic Extension

Howdy Folks! Today I wanted to take a quick moment to comment on some discrepancies that I have noticed when hearing people discuss thoracic mobility and the need for thoracic extension. Anyone that is familiar with the Functional Movement System is probably well aware of the lack of thoracic mobility that many people seem to suffer from. This is something that you often see targeted by FMS corrective exercises or may be a common finding during an Selective Functional Movement Assessment (SFMA) for some.

On the other hand, there is the kind folks associated with the Postural Restoration Institute (PRI) that are trying to promote thoracic flexion and minimize hyperextension of the thoracic spine. Then I have heard stories from colleagues at PRI courses mention how they are lacking thoracic extension only to be told they have too much. So what is the answer? Do we need thoracic extension? Who is right here?

Well I believe that both of these systems or schools of thought are trying to achieve the same thing, and are essentially saying the same thing despite it sounding different. I am arguing that people are not differentiating between the different hinge points of the spine and the exact levels of the thoracic spine that they are referencing. Look at this first squat picture below. Nobody from either school is going to like this squat form and PRI'ists will notice the excessive thoracic extension from T8 and down while FMS'ers will notice the lack of thoracic extension from T1-T4.

Now if I hit my first sticking point and decide to take another breathing cycle to help draw my ribcage down and promote lower thoracic flexion I am able to come down even further in my overhead deep squat as you can see below in the next picture. However, it is still less than ideal squat form. I still struggle with getting adequate upper thoracic spine extension

Now what happens if we lessen the burden of the upper thoracic spine and by switching this experiment over to a front squat? I am still hyper-lordotic in the lumbar spine and still extend the very last few segments of the thoracic spine.

If I perform another big exhale into the balloon I am able to decrease the lordotic curve, increase thoracic flexion from T8-T12 and my femurs actually break parallel! However, if you look closely you will still see a little bit of hyper-kyphosis in the first few segments of the upper thoracic spine.

In conclusion, I think there is a lot of confusion by some people when they learn about or speak about the thoracic spine between these two different schools of thought. In reality, I think that both schools are really trying to achieve similar things but sometimes there is definitely a lack of differentiation. I also think that these pictures can also help signify the importance of proper breathing, and the power of the diaphragm, obliques and transversus abdominus over form, function and movement. Just some food for thought! Thoughts?

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Low Back Pain in a Collegiate Basketball Player

Howdy Readers! Today I wanted to take some time to report on a case that I was presented with during this previous basketball season. Then I will discuss how I addressed the case and what I wish that I could have changed about the case. I will also be using my findings from the patient's Selective Functional Movement Assessment (SFMA), and so here is the SFMA acronym legend:

FN: Functional & Non-painful
FP: Functional & Painful
DN: Dysfunctional & Non-painful
DP: Dysfunctional & Painful

Background:

A 21 year old NCAA division III basketball player was competing in a JV basketball game when he suffered a direct blow to the low back by an opposing player's elbow. The supervising athletic trainer (I was busy prepping the varsity team to play) determined there were no gross deformities, ruled out neurological involvement (dermatomes & myotomes WNL), and ruled out any potential fractures. Nevertheless, the player was unable to return to play and finish the game due to pain.

This player had a previous history of catastrophic injury as a high school basketball player when he was undercut by an opponent. He fell on his upper back and hit his head suffering a fractured scapula and traumatic brain injury that lead to him being placed into a medically-induced coma. Additionally, he had a history of low-back pain during high school. The year previous to the current incident this athlete suffered a season-ending concussion as well.

After the game was over this athlete returned to his hometown with his parents. The parents and the athlete planned to see a family friend that is an orthopaedic surgeon in the following days. Upon consulting with the doctor it was revealed to the athlete that he had degenerative joint disease (DJD) in his lumbar spine and he was sent back to me for rehabilitation at my discretion.

Upon hearing this I definitely began to dismiss the DJD because I knew that suffering an elbow to the low back in one game of basketball didn't give this player DJD. I began to talk with the patient about pain science, how it didn't matter if he had DJD because he had it before when he was pain-free, and how we weren't going to attempt to change it. I did discuss how we would perform an SFMA and evaluate in which patterns he was moving dysfunctionally & why they were dysfunctional.

Assessment:

SFMA Top Tier Results & Breakout Findings--
Cervical Flexion = DN: Tissue Extensibility Dysfunction
Cervical Extension = FN
Cervical Rotation = Left - FN / Right - DN: (Tissue Extensibility Dysfunction)
Upper Extremity Pattern 1 = DN (Bilaterally, Left worse than Right): (Functional Shoulder Pattern Stability/Motor Control Dysfunction)
Upper Extremity Pattern 2 = FN (Bilaterally)
Multi-Segmental Flexion = DP (Posterior Chain Tissue Extensibility Dysfunction)
Multi-Segmental Extension = DN: (Thorax Extension Stability/Motor Control Dysfunction, Hip Extension Tissue Extensibility Dysfunction)
Multi-Segmental Rotation = DN (Fundamental Rotational Pattern Stability/Motor Control Dysfunction, Hip ER Tissue Extensibility Dysfunction)
Single Leg Stance = DN (Lower Posterior Chain Tissue Extensibility Dysfunction)
Overhead Deep Squat = DN (Hip and Lower Leg Posterior Chain Tissue Extensibility Dysfunction)

Plan:

Based upon my SFMA findings I decided to attack the greatest areas of dysfunction first. I determined that the hip flexion/posterior chain TED (~40 degrees passive SLR), and cervical flexion & rotation were the patient's greatest limitations. This is what I formulated my initial treatment plan around as well. I began with an easy 5 minute warm-up on a stationary bike followed by some instrument assisted soft tissue mobilization (IASTM) to the posterior neck, proximal hamstrings attachment near the ischial tuberosity and distal attachment of the biceps femoris to prepare for some Muscle Energy Technique (MET).

Day 1: Pain (7/10)

Upper Trap MET

I performed MET techniques (redundancy?) for the upper trap, scalenes, and posterior neck extensors. I performed 3 sets of autogenic isometric inhibition on the right side and an extra set on the left side. This brought cervical flexion and rotation to FN immediately following application of the MET treatment.

I then instructed the patient to perform a couple sets of supine kettlebell carries. Each set lasted until the patient neared fatigue and was unable to retract and "pack" the shoulder/scapula. This was performed bilaterally. Reassessing the upper extremity pattern 1 revealed decreased winging compared with baseline.

MET for the Scalenes

Before Treatment

Next, I performed MET for the posterior hamstrings. Specifically, I also instructed the patient on performing an autogenic isometric inhibitory technique. I performed this bilaterally and found that the patient's passive SLR increased ~20 degrees immediately by the end of treatment.

After Treatment

The patient was unable to attempt rolling exercises due to passive back pain so instead of attempting to restore rolling I had the patient perform some light stretching hip external rotation and calf stretching after having their glutes and gastroc/soleous worked out using a rolling stick by my student.

Easy Hip ER Stretch

Straight Leg Gastrocnemius Stretch - Towel prevents pronation

Bent Knee Soleus Stretch - Towel prevents pronation again

Day 2: Pain (4/10)

The patient returned the second day with increased cervical flexion and rotation patterns but they were no longer functional. I repeated the previous days IASTM and MET techniques and once again these patterns were FN after application. In attempt to prolong these gains, I applied some Rock Tape to the upper traps and scalenes. Once again I had the patient do some kettlebell carries while in a supine position. 

The passive SLR was still increased from the previous day but was still about 15 degrees short of normal. The patient was able to foam roll without increased pain and so I had him foam roll the entire posterior leg chain before IASTM to the aforementioned patterns. Again, we used the previous day's MET application to the hamstrings and this increased the passive SLR to normal.

Due to the patient's ability to have such drastic increases in mobility in such a small amount of time I suspected crucial core stability issues. In attempt to progress this patient quickly I wanted to restore rolling ASAP for the supine to prone upper extremity rolling pattern. I spent about 15 minutes working on rolling with him before calling it a day. Rolling was definitely not perfect but was much better than when we began.

Day 3: No Pain?

On the third day of treatment the athlete returned with FN cervical flexion, and rotation patterns and now Multi-Segmental Flexion was a DN. The athlete reported being sore in the shoulders and hips but no longer was experiencing any pain. We were now about 7 days out from initial injury. I continued to work on rolling patterns and was able to progress to some quadruped and tall-kneeling exercises before the day's end. I could tell that the athlete was very excited to return to basketball so I began his RTP progress with some easy free-throw shooting.

Return to Play and Further Treatment:

Unfortunately, the next day the athlete returned home for spring break and was no longer under my supervision. Despite my best efforts to provide a substantial home-exercise program for this athlete he was so enthused by his progress that he did not stick to his HEP and instead played basketball and rested his entire break.

Upon returning to school the athlete was no longer compliant with his rehab despite the presence his many dysfunctional movement patterns (MSF, MSE, UE #1, MSR, SLS, ODS) and would no longer come for rehab. Reluctantly, I continued to let him participate in practice and JV games. It wasn't because I didn't care about making him better but more because of it being an issue of me being stretched too thin between other athletes that had issues and wanted my help and patients like him that needed my help but wanted none of it because they no longer suffered. It is not an ideal situation but it is the way the world works sometimes. Ideally for me I wish I had been in a position where there was somebody(like a strength coach) that was familiar with the FMS and corrective exercises to help these athletes overcome their dysfunction.

Points of Distinction & Conclusion:

What I thought was interesting regarding this case was the patient's history of traumatic injury to the left scapula and the presence of ipsilateral hypertonic neck muscular and poor scapular stability when compared bilaterally. I do not know if this was present since his previous injury but its hard for me to ignore such a glaring "coincidence" when I see it. When I initially worked with this athlete I had a little contempt for the incomplete rehabilitation that he must have been put through following his previous injuries. 

However, I soon began to feel and conclude that much of this could have been the athlete's own doing and not that of previous clinicians. I even tried the route of touting injury prevention, performance enhancement and how he may be a ticking-time bomb for re-injury and recurrence of back pain. Some people, patients, and athletes just do not seem to want help unless they are physically writhing in pain and unable to walk. I am not sure if this is pride or pure laziness! 

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My SFMA: A Case Study - Multi-Segmental Flexion Breakouts

Today's post is the fourth part of my self-SFMA(Selective Functional Movement Assessment) case study series.  Specifically, We will look at and break out my dysfunctional Multi-segmental Flexion movement pattern from my SFMA Top Tier Post.  

I'm jealous of those that can do this.

Here are the links for the first three posts of this series:
SFMA Top Tier Pattern Assessment

SFMA CervicalSpine Pattern Breakouts

SFMA Upper Extremity Pattern Breakouts

Assessment:

The SFMA works by assessing 7 general top tier movement tests. All tests are rated and ranked by two broad categories of dysfunctional or functional, and then two sub-categorizations of painful or non-painful. This means there are four basic appraisals of FN, DN, FP or DP. From there you perform a "breakout" of each dysfunctional pattern to determine the cause of dysfunction. Dysfunctional movement patterns are broken down using an algorithm that funnels and filters the problem into either a mobility dysfunction or a stability &/or motor control dysfunction (SMCD). 

 

This video will look at the dysfunctional multi-segmental flexion pattern.  Here is the latest breakout video:

Results:

Multi-Segmental Flexion Top Tier = DN (Unable to touch toes. Why? We don't know yet. Other Criteria for passing: Uniform Spinal Curve, Posterior Weight Shift, < 70 degree Sacral Angle)

Single Leg Forward Bend Test = Bilateral DN, yet symmetrical (Still Unable to reach the toes or floor. Why? We don't know yet. Proceed to the next test.) 

This test helped to determine if the forward bend was an asymmetrical or symmetrical dysfunction…in the presence of pain with the top tier assessment we could also use this test to check for symmetry with pain provocation.

Long Sitting Test = DN (Still unable to reach toes. Why? I don’t know yet but we did pick up on a few things.)

We still do not have a clear cause of dysfunction yet, however we do know that I cannot touch my toes and I do have < 80 degree Sacral Angle. This would indicate limited hip flexion and/or limited spinal flexion, or both.

If I had been FN with this test we would have proceeded to the rolling patterns to check for a fundamental motor control dysfunction.

Active Straight Leg Raise Test: Right=DN, Left=DN (Looking for at least 70 degrees of Hip Flexion)

Passive Straight Leg Raise Test: Right=DN, Left=DN (Looking for at least 80 degrees Hip Flexion and to be within 10 degrees of the Active SLR)

It is observed that my passive SLR has more than a 10 degree difference from the active SLR. This would indicate a possibility of a core stability, hip flexion strength problem, excessive hamstring tone, guarding or a hip mobility dysfunction.

Supine Knee to Chest Holding Thighs Test = DN (Unable to bring knees and thighs to chest while supine.) This test is used to check the mobility of the hips while they are in an unloaded or non-weight-bearing position. Doing this also helps to differentiate a difference between hamstring mobility and hip mobility dysfunctions.

Breakout Findings: If we follow the breakouts one would deduce that I have a hip joint mobility dysfunction or a posterior chain tissue extensibility dysfunction or both…as well as a possible hip flexion strength or SMCD dysfunction. But that isn’t as important considering that we would need to treat the mobility dysfunction before addressing any SMCDs.

Do you have any ideas/suggestions/thoughts? Let me know in the comments below!

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My SFMA: A Case Study - Upper Extremity Breakouts

Today's post is the third part of my self-SFMA(Selective Functional Movement Assessment) case study series.  Specifically, We will look at and break out any dysfunctional upper extremity movement patterns from my SFMA Top Tier Post.  


In the first post/video, I was dysfunctional/non-painful (DN) for the Upper Extremity Pattern One (Combination of Extension/Adduction/Internal Rotation of the shoulder).  However, I was functional/non-painful (FN) for Upper Extremity Pattern Two (Combination of Flexion/Abduction/External Rotation of the shoulder). In case you missed it, here are the 7 top tier tests again. You can also check out the cervical spine patterns and breakout assessment here.

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My SFMA: A Case Study - Cervical Breakouts

Time to make an assessment of myself

Today's post is second part of my self-SFMA(Selective Functional Movement Assessment) case study series.  Specifically, We will look at the dysfunctional cervical spine movement patterns from my SFMA Top Tier Post.  In the first post/video, I was dysfunctional/non-painful (DN) for the Cervical Flexion Pattern, and the Cervical Rotation Pattern to both the Right & Left.  However, I was functional/non-painful (FN) for Cervical Extension. In case you missed it, here is the 7 top tier tests again.

The SFMA works by assessing 7 general top tier movement tests. From there you perform a "breakout" of each dysfunctional pattern to determine the cause of dysfunction. Dysfunction movement patterns are broken down using an algorithm that funnels and filters the problem into either a mobility dysfunction or a stability &/or motor control dysfunction (SMCD).

Assessment:
This video will look at the dysfunctional cervical spine patterns. Specifically, cervical flexion and cervical rotation to the left and right. I was functional for the cervical extension pattern so that pattern does not require a breakout assessment. Here is the breakout video:

Results:
Cervical Flexion Top Tier = DN (Unable to bring chin to sternum. Why? We don't know yet.)

Active Supine Cervical Flexion Test = DN (Still Unable to bring chin to sternum. Why? We don't know yet.)
If I was now FN we would know that there is a postural and motor control dysfunction or stability/motor control dysfunction...or both, affecting cervical flexion. This includes the c-spine, T-spine, and shoulder girdle postural dysfunction. Laying supine removed the postural and stability requirements of the gravity dependent/loaded standing position from the top-tier tests

Passive Supine Cervical Flexion Test = FN (Chin is now to sternum)
We can now assume the cause of the dysfunction was due to an active cervical spine flexion stability dysfunction or motor control dysfunction...or both. We know it is not a mobility issue because I had full motion when all stability and motor control requirements were removed and the movement was performed passively. If it was due to mobility reasons then my GF would not have been able to passively bring my chin to my chest. Mobility problems always present with consistent findings!

Cervical Rotation Top Tier = DN to the Left & Right (Can not rotate chin to mid-clavicle or at least 80 degrees, Why? We don't know yet)
This test no longer requires this degree of rotation and the ability to bring the chin to the clavicle, at least this is how I was instructed in October of 2013.

Active Supine Cervical Rotation Test = FN (At least 80 degrees of rotation bilaterally without a significant asymmetry)
We now know that the dysfunction was related to a postural and motor control dysfunction or a stability and motor control dysfunction...or both. This is why my top tier cervical spine rotation test was dysfunctional, not because of my perceived tissue "tightness."


Treatment:
It is said that there are many ways to skin a cat...that being said the SFMA is a tool or a system of assessment. It is not a specific approach to treatment. However, there are general guidelines based off of the findings and it also lays a road map of treatment for you(eg. mobility before stability, working your way down the top tier tests). Specifically, in my case I do not have any mobility dysfunctions within the cervical spine but if I follow the philosophy of the SFMA then I need to address the SMCD of the cervical flexion pattern before attempting to correct SMCD dysfunction of the cervical rotation.

There are many avenues for treating this dysfunction from dry needling to IASTM to MDT principles to using the 4x4 Matrix or etc. I can't advocate that one approach will be better for addressing my dysfunction than another...but I do have a system of assessment to judge the efficacy of each potential intervention. Perhaps IASTM and MDT combined will work great for 90% of my patients but I don't know that...all I need to know is how to assess-intervene-reassess. Oh and I should probably stay within my practice act, so use what tools you have and those that you are comfortable with.

Thoughts? Do you think my breakouts and assessment have been accurate so far? What would you do with me? I know what I would do....finish the SFMA breakouts, first. Come back as I continue to break out my many dysfunctional movement patterns.

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Ankle Dorsiflexion: The What, Why, and How.

Dorsiflexion. This important motion occurs at the ankle and is seen when the dorsal(top) aspect of the foot and the anterior(front) aspect of the tibia(shin) move closer together. This motion is seen with and is necessary for proper execution of many basic human movements including squatting, running, walking, jumping and more. This motion is a vital part of most functional movements and proper function up and down the entire kinetic chain. Even minor tasks such as sitting and standing from a chair or walking up and down stairs requires adequate dorsiflexion of the ankle.

There are many issues related to inadequate dorsiflexion including many lower extremity injuries and and foot deformities. Evidence exists that problems here can be related to falls in the elderly, patellar tendinopathy, ACL injuries, lower extremity kinematic changes, and patellofemoral pain syndrome to name a few. This motion could be limited by several different problems such as soft tissue mobility(muscles and fascia), bony abnormalities, joint capsule restrictions(belongs with soft tissue mobility), and impingement of these structures.

The human foot and ankle are masterpieces of complexity and natural engineering.

When a person is deficient in dorsiflexion they are not automatically limited in the aforementioned movements(besides dorsiflexion, duh) or tasks such as a squat. The human body is great at incorporating compensatory movements to allow a continuance of motion to increase our ability to survive but at the cost of our ability to thrive. 

For example, lets say I have a patient named Jim Shorts who comes to me with complaints of knee and low back pain as well as a history of chronic plantar fasciosis. Jim loves going jogging, playing basketball, and working in the garden with his wife. 

These are very common symptoms and could be caused by a variety of issues but for the sake of this post lets discuss how they could be related to dorsiflexion of the ankle. Before we even begin to evaluate Mr. Shorts lets think about how dorsiflexion might be needed during each these activities. 

Running

• The ankle plantar flexors(think calf muscles) and plantar fascia may be eccentrically (resistively stretched) loaded at initial foot strike depending on landing type (heel strike vs mid-forefoot landings).

Initial Contact

• As the gait cycle changes from initial contact to mid-stance, the ankle moves into a more dorsiflexed position. At this moment, vertical ground reaction forces are at their highest(Active Peak on the graph below) and loading of the achilles tendon is reaching its maximum peak. To allow proper dispersal of these forces and to allow some of this energy to be stored and then reused the achilles must act as a spring.  Dr. Mark Cuccuzzella has made a video that highlights these principles of running mechanics and he does a much better job of visually and audibly explaining it than I can in writing.
• Steve Magness, writer of the blog Science of Running, and Head Cross Country coach at the University of Houston wrote a great post on the most vital components of running here as well.

Midstance

• The ankle plantar flexors are now on maximum stretch(maximum dorsiflexion) and are maximally loaded now must assist the posterior chain(gluteus muscles and hamstrings) to propel the body forward and slightly upward(propulsion phase & toe-off).

These components involving the ankle and its ability to dorsiflex are vital to running and any sports that involve running. If motion is impaired we should not expect to be efficient or safe from injury. Would you expect a car to have maximum performance or to be safe from harm if you had improperly sized or damaged shocks? 

I like the analogy of the ankle plantar flexors to be a group of rubber bands. If you have soft tissue problems then these rubber bands may be tied full of knots or could be thought of as dried out and having lost their snap. If you have bony or joint capsule restrictions then you may not have the ability properly stretch out a healthy rubber band to allow maximum performance or perhaps this inability caused a degradation in the health of the rubber band itself. Double Jeopardy.

Basketball & Gardening

• Requires the ability to run(discussed previously)
• Requires the ability to jump
• You need to be able to shoot a jump-shot, lay-up, dunk or to go up for a rebound.
• Requires the ability to land after jumping
• You need to safely come down after jumping and be able to dissipate the forces from impacting the ground.
• The above can be summarized by the ability to squat. (*Only the squat applies to gardening, unless you are into some extreme gardening stuff that i've never heard of before.)
• You also need to be able to properly squat to get into sport-specific positions of basketball such as a defensive stance and you don't want to bend at the waist to work in your garden(some people still will). 

Looking at Mr. Shorts

So we begin to evaluate Mr. Shorts and we have him perform some functional movements to evaluate his movement behavior. For example, we ask Jim Shorts to do a deep squat like he would while gardening and we notice that his heels can not touch the ground and he excessively flexes his trunk forward to allow his arms to work at ground level.

Next, I have Jim show me his defensive basketball stance. We immediately notice that his knees extend past  his toes and that he has that same forwardly flexed trunk position as before. He also complains that this position immediately exacerbates the pain in his knees and low back.

At this point I decide to try something. I take either a heel lift and place it into Jim's shoes or place his heels onto a 2in. board and have him repeat his deep squat. This time Mr. Shorts is able to squat down with his heels flush to the ground (or board) and his back appears to be parallel with his shins from a side view. The only difference here is that we eliminated the demand for proper dorsiflexion. Technically, this might not be the only reason for his limitations but I wanted to show how improper dorsiflexion could change a functional movement. 

This example shows us how problems with movement at the ankle can increase forces and perhaps damage tissues further up the kinetic chain. The next step for us would be to decipher what type of dorsiflexion restriction Jim Shorts actually has but that post is for another day so lets move on to figuring out how to evaluate your own ankle dorsiflexion.

Self Evaluation

Lets discuss how you can evaluate your own ability to dorsiflexion at home. Here are a few links to some of my favorite techniques and how-tos for evaluating ankle mobility.

1. This first link is credited to Mike Reinold's blog and is an all-encompassing post that is very concise and does a great job of saying everything that I am trying to say with this post. He even has many great videos for working on improving your own mobility.
2. This link is to a blog post by Jay Dicharry, MPT, CSCS...Author of the book, Anatomy for Runners. Jay is probably one of the premier clinicians and researchers out there today when it comes to running mechanics, research and injuries. This post discusses more than just ankle dorsiflexion and is definitely recommended.
3. This next link is actually to a video made by Jay Dicharry. This video will show you a quick and easy list of self-evaluation techniques and fixes for somebody looking to transition to minimal running shoes. However, I feel that these are vital to athletes and runners regardless if they are barefoot or wearing Hoka one-ones.
4. How much dorsiflexion do you actually need? Jay Dicharry recommends at least 25 degrees of dorsiflexion at the ankle and 30 degrees of dorsiflexion of the big toe(measured at 5 degrees of ankle dorsiflexion). Mike Reinold and the minds of the Functional Movement System, such as Gray Cook sponsor the idea of the knee reaching about 5 inches past the toes while in a half kneeling stance. One study found that athletes with less than 36.5 degrees of dorsiflexion had an..."18.5 to 29.4% risk of developing patellar tendinopathy compared to a 1.8 to 2.1% risk for athletes with dorsiflexion greater than 36.5 degrees." I believe most of these values to be too similar to chose one set of thought over the other and suggest them as mere guidelines and not cut points.

How do I fix this?

I had originally planned on writing an entire section on my favorite joint mobilization, static stretching, and soft tissue mobilization techniques but the links I provided in the self-evaluation section have some great techniques included with them already. I feel like I can not top those techniques and I highly recommend them. However, I do want to summarize some thoughts about trying to increase dorsiflexion.

1. I believe that a vast majority of us living in 1st world countries that grew up with or have been wearing shoes for decades with an elevated heel have limitations in ankle dorsiflexion. There are exceptions to this but I have provided you with information to check for yourself.
2. I admit that going barefoot or  utilizing a more minimal shoe during training may not be feasible for everyone. However, I do feel that incorporating and wearing a shoe with less heel-to-toe drop or less of an elevated heel during everyday activities such as at work, around the house or out on the town can be very beneficial for restoring proper ankle dorsiflexion. What you wear on your feet 90% of the time probably has a more profound effect on your tissues than the shoes you wear 5-10% of time you spend training each week.
3. When it comes to increasing the actual mobility with manual work I believe a multi-faceted approach is best. A combination of joint mobilizations, static stretching(post exercise), foam rolling, etc is probably going to be more effective for you unless you or a manual therapist has determined that only one specific issue is limiting you. It would not be uncommon for several of these issues to be a limiting factor for a person.
4. Do not ignore above and below, tibial internal & external rotation as well as plantar fascia mobility influence movement at the ankle as well.
5. DO NOT try to treat the symptom by eliminating the need for proper dorsiflexion. Utilization of heel lifts, immobilization, restrictive tape jobs, new shoes and etc. are only treating your symptoms. These MAY be appropriate for short-term relief but they do NOT fix your problem. If you try to take the easy way out and try to eliminate this motion then you are setting yourself up for a different set of problems up and down your entire kinetic chain.

In conclusion, this is going to be an issue with a majority of people. This problem exists in both the physically active and inactive populations. Only the minority of people that I've tested have had adequate ankle dorsiflexion. I would love to see how this compares with a third world country where people have not had the "luxury" of wearing shoes with elevated heels since birth. I bet you can find plenty of pictures in a national geographic magazine where the indigenous tribespeople have perfect squat form and can hold it comfortably with ease.

Updates

Here are a few related videos that I have made that should be of value to this topic as well! Enjoy!

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