Happy New Year and welcome to 2014! This is my first post of the year and my 75th post overall. This is going to be a reflection on some of the things that I learned in the previous 365 days. I was inspired to write this post after reading many of Mike Reinold's similar posts over the last few years. I guess I learned a lot this year because this turned into an epically long post. Sorry.
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.
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.
Howdy again Readers! Today will be the first part of a series of posts that I am lamely labeling "My SFMA." Each post will feature a video related to my own personal Selective Functional Movement Assessment (SFMA). Today's video will showcase my own seven top tier SFMA tests. Each additional blogpost and video will showcase a single dysfunctional top tier test derived from this initial video. In those videos I will perform the appropriate breakouts according to the SFMA to determine the reason for failing each individual top tier test and will discuss ways of treating these issues.
The idea behind this came from the fact that I am going to start increasing my physical activity levels, getting into better shape, and eventually getting back to marathon training. Working on preventing injuries is always easier than taking time away from exercise or training to work on treating injuries.
I also thought that doing this would help me to practice more with the SFMA system and will allow me to receive guidance or feedback from others with experience using the SFMA. If you watched the video it is obvious that I have a lot of preventing...or maybe I should say correcting to do. To find out and discuss what/how I should address, don't forget to come back for part II!
It has now been exactly a month since I took the Selective Functional Movement Assessment certification course in St. Louis, MO. You can read my initial course review here. I have been trying to incorporate the SFMA into my clinical practice as much and as often as possible since then. I wanted to take the time to highlight some thoughts and self-reflections from this process so far.
This past weekend I had the pleasure of attending the Selective Functional Movement Assessment(SFMA) certification course in St. Louis, Missouri. More specifically, the course was hosted on the beautiful campus of Logan Chiropractic College/University. Logan did a great job of hosting this seminar and they were very accommodating and even had snacks/refreshments/coffee available. The only thing I could think to gripe about was my poor cellphone service in the basement classroom that we used. ;)
I was first introduced to the SFMA by a mentor of mine during my senior year of my undergraduate when he attended an SFMA course himself. He gave me some background about what it was and what they were trying to teach and ever since then I had wanted to learn it myself. Reading the book Movement by Gray Cook and becoming FMS certified didn't help my anxiousness either.
For those of you that don't know what the SFMA is..."The Selective Functional Movement Assessment (SFMA) is a series of 7 full-body movement tests designed to assess fundamental patterns of movement such as bending and squatting in those with known musculoskeletal pain. When the clinical assessment is initiated from the perspective of the movement pattern, the clinician has the opportunity to identify meaningful impairments that may be seemingly unrelated to the main musculoskeletal complaint, but contribute to the associated disability. This concept, known as Regional Interdependence, is the hallmark of the SFMA. The assessment guides the clinician to the most dysfunctional non-painful movement pattern, which is then assessed in detail. This approach is designed to complement the existing exam and serve as a model to efficiently integrate the concepts of posture, muscle balance and the fundamental patterns of movement into musculoskeletal practice. By addressing the most dysfunctional non-painful pattern, the application of targeted interventions (manual therapy and therapeutic exercise) is not adversely affected by pain." -SFMA.com
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.
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.
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.
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.
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.
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.
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.
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.
Do not ignore above and below, tibial internal & external rotation as well as plantar fascia mobility influence movement at the ankle as well.
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!
Disclaimer: Please note that some of the links on this blog are affiliate links and I will earn a commission if you purchase through those links. I have used all of these products listed and recommend them because they are helpful and are products from companies that I trust, not because of the commissions that I may earn from you using these products.
Caution
All content on this blog is meant as instructional and educational. The author and guest authors of this blog are not responsible for any harm or injury that may result. Always consult a physician or another proper medical professional for medical advice.
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