Knee pain is the most common pain reported in runners and no one has contributed more to our understanding of this pathology than Irene Davis. I’m a huge fan of researchers that really sink their teeth into a topic and doggedly work to methodically shed more and more light on the subject. Dr. Davis is one of those rare individuals. Working out of the Gait Lab at the University of Delaware, Davis started exploring the biomechanics of the knee in the mid-90s, and has a formidable list of publications that numbers well over 40. Recently, she moved on to the Spaulding National Running Center at Harvard University.
One of the common observations of several studies on patellofemoral pain (PFP) has been that weakness of the hip abductors and external rotators is correlated with, and also predicts PFP. The solution to the problem then seems to be very straightforward…strengthen the muscles that are weak in controlling the valgus knee during gait and all will be splendid. Indeed, were the findings in some studies, but others were less promising. What could be the missing variables?
Last year, an elegant study co-authored by Davis indicated that perhaps the solution is as much related to software as it is to hardware. Brian Noehren, et al, demonstrated one of the most impressive effects on chronic anterior knee pain in runners ever published. And they did it using gait re-training without strength training. They took a small cohort (n=10) of runners (at least 6 mi/week, avg of 16 mi) who had at least 4/10 pain in the anterior knee with running. The average chronicity was 75 months!! They did a gait analysis as well as single leg squat, and measured kinematics including contralateral pelvic drop, peak hip adduction and internal rotation. They also measured vertical impact forces.
Intervention was verbal coaching while running in 8, 30 minute sessions on a force plate treadmill and with live gait analysis. As the runners implemented the coaching cues, they got real-time feedback via the gait analysis software which showed a representation of their peak hip adduction. After 2 weeks, pain was reduced by 86%. On follow up one month later, ALL WERE RUNNING PAINFREE! For more details, here’s a link to that study.
Here are the 3 verbal cues the coaches used to help the runners change their gait:
- Contract the gluteal muscles (or as I tell my patients, pretend you are pinching a coin between you butt cheeks. Don’t crush it, but don’t drop itj!)
- Run with the knee pointing straight ahead.
- Keep the pelvis level (or as I tell my patients, don’t run like a supermodel!)
Granted, your patients won’t have the benefit of the biofeedback equipment these guys used, but I have seen a lot of benefit in my patients over the past year when implementing these verbal cues in runners with PFP. As to the strengthening protocols and proprioceptive training that clinicians and trainers can also implement to do a thorough job of rehabbing runners, check the video tutorials at MyRehabExercise.com. Below you can see a video sample of exercises that I commonly use to correct the valgus collapse of the leg in the gait cycle.Dr. Irene Davis doesn’t get out on the speaking circuit much, but if you want to catch her live, Dr. Glen Harris and MSK+ Seminars are hosting her in Toronto on November 5-6, 2011. I highly recommend running doctors take advantage of this opportunity to learn from one of the icons of running research. Click on the link to get information about registering, Dr. Davis’ bio and the course overview are below.
Dr. Irene Davis’ Bio:Dr. Davis received her Bachelors degree in Exercise Science from the University of Massachusetts, and in Physical Therapy from the University of Florida. She earned her Masters degree in Biomechanics from the University of Virginia, and her PhD in Biomechanics from Pennsylvania State University. Over the past 20 years, she was a Professor in Physical Therapy and Director of the Running Injury Lab at the University of Delaware. In addition, she was the Director of Research for Drayer Physical Therapy Institute. During this time, Dr. Davis has been studying the relationship between lower extremity structure, mechanics and injury in runners. Dr. Davis has recently accepted a position in the Department of Physical Medicine and Rehabilitation at Harvard Medical School to develop and direct the Spaulding National Running Center. Her current areas of study include mechanical factors in tibial stress fractures and patellofemoral disorders along with the effect of physical therapy interventions such as gait retraining. She is interested in the mechanics of barefoot running and its effect on injury rates, and is a barefoot runner herself. She has received funding from the Department of Defense, Army Research Office and National Institutes of Health to support her research related to stress fractures. She serves as a consultant for patients with lower extremity problems related to overuse. Dr. Davis has given nearly 300 lectures both nationally and internationally and authored nearly 100 publications on the topic of lower extremity mechanics during running. She has been active professionally in the American Physical Therapy Association, the American Society of Biomechanics, and International Society of Biomechanics. She is also a Fellow of the American College of Sports Medicine and a Catherine Worthingham Fellow of the American Physical Therapy Association. She is currently the Past-President of the American Society of Biomechanics. She has organized and coordinated national research retreats on topics of the foot and ankle, anterior cruciate ligament injuries and patellofemoral pain syndrome. She has been featured on ABC World News Tonight, Good Morning America, Discovery, the New York Times, the Wall Street Journal, Parade and Time Magazine.Course OverviewThis is a 2-day course on the evaluation and treatment of the injured runner. Day one will focus on assessment. We will cover normal abnormal alignment and structure. In addition, normal and abnormal running mechanics will be presented. There will hands on laboratories on lower quarter assessment, as well as gait analysis in order to reinforce these principles. We will also cover common running related injuries and review research studies providing evidence for the relationship between structure, mechanics and injury. We will end the day with a discussion of the development of a clinical hypothesis upon which to base a treatment approach.On day 2, we will focus on treatment of the injured runner. This will include barefoot/minimal footwear running. We will discuss prescription of stock orthotic devices (we will not be addressing custom orthoses in this course). We will also cover strengthening and flexibility exercises, with lab time provided to practice these therapeutic approaches. We will then discuss gait retraining, followed by a lab to practice these techniques. The course will end with a series of case studies.
Spine researcher Stuart McGill, PhD, was kind enough to spend some time answering some questions I had about recent developments in the spine literature and popular culture. We discussed a recent article in Strength and Conditioning Journal by noted blogger and trainer, Bret Contreras and co-author Brad Schoenfeld entitled To Crunch or Not to Crunch: An Evidence-Based Examination of Spinal Flexion Exercises, Their Potential Risks, and Their Applicability to Program Design. This article was picked up by Gretchen Reynolds in the Health section of the New York Times. Contreras and Schoenfeld contend that some loaded flexion of the lumbar spine, in a well chosen population is not only OK, but also, perhaps even health promoting. Dr. McGill weighs in on this topic with his understanding of the literature and his experience working with elite athletes. For those interested in learning more about Dr. McGill’s approach, check out his DVDs and books at BackFitPro.com.
Osteopath, Dr. Eyal Lederman authored a rather provocatively titled paper in Journal of Bodywork and Movement Therapy entitled The Fall of the Postural-Structural-Biomechanical Model in April 2011. In that issue, several multidisciplinary luminaries responded to Dr. Lederman’s contention that a more encompassing clinical model was needed in management of musculoskeletal pain. We discussed some of the tenets of his Process Approach model, noting the similarities to Gordon Waddell’s Biopsychosocial Model.
Corrective exercises from Dr. McGill are located on MyRehabExercise.com as well as corrections from the FMS/SFMA work, Craig Liebenson, Robin McKenzie, Vlad Janda, Eric Cressey, the kettlebell community and many more. These videos are thorough tutorials, in patient/client friendly verbiage for clinicians, bodyworkers, trainers and coaches to use to help simplify patient education. Trial the site for $1 for 30 days. If you like it, it’s only $9.99 per month!
Click on the arrow below to play. Feel free to share by download or linking! Articles we mentioned are linked below. Enjoy!
References and Links:
*Catch Dr. Stuart McGill in person in LA October 15-16, 2011 when he’s hosted by Clare Frank, DPT and Cynergy Education Group. This 2 day workshop will cover Ultimate Back Fitness and Performance.
* Link to Videman’s paper, Challenging the Cumulative Injury Model: Positive Effects of Greater Body Mass on Disc Degeneration.
* Link to Hebert et al’s paper, Clinical Predictions for Success of Interventions for Managing Low Back Pain.
Some recent Facebook posts I made need a little bit more fleshing out. I was upset because I had a patient show up 9 months after I rehabbed her lumbar disc injury. She had re-injured her back while performing seated machine crunches on a machine like the one below, while UNDER THE SUPERVISION OF A TRAINER IN A ‘BIG BOX’ GYM! Several folks responded to that thread so I thought we’d explore the topic more.
Recently, some prominent trainers in the blogosphere have begun to question the “no crunch” literature of Stuart McGill and others. While I too think there is more room for us to explore limited unloaded flexion of the lumbar spine (like in Charlie Weingroff’s ‘Core Pendulum Theory’), I think the polarized environment in which this discussion often takes place really makes for a worse world for patients and clients. Young trainers can get caught up in the polarization, become adherents of an influential fitness guru, and lose site of the importance of screening clients well for personal goals and injury history. The resultant adherence to dogma on the training room floor leads to injured clients. When trainers injure patients, both patients and clinicians lose respect for trainers. Then clinicians are less likely to respect trainers and send their patients into those trainers’ gyms. This re-creates the old turf war environment where trainers think clinicians are too cautious and want to steal their clients, and clinicians are afraid to let their patients work with trainers. This represents several steps backwards. In the post-FMS world, we have Gray Cook to thank for providing an effective communication model, a sort of rehab Esperanto (look it up) that allows clinicians and trainers to liase. That handshake from rehab to training is WAY important and we need that model filled with understanding and respect.
So, let me make it clear…WE CLINICIANS NEED TRAINERS ON OUR TEAM TO HELP SEGUE PATIENTS TO SELF CARE! In the competitive environment of personal training, an excellent way for you trainers to bring clients to your door is to bone up on the literature surrounding rehab, then market to chiropractors, physical therapists and medical doctors in their community, showcasing your chops to manage their patients. In fact, just get good at avoiding injury to the most common painful tissue in back pain, the lumbar disc, and you can plan on lots of work. Any clinician worth their salt will give you audience if you send a letter explaining your understanding of the pathobiomechanics of disc injury in the lumbar spine. Those that don’t see the value in your services don’t matter. Move on until you find the heads up clinicians that want your help as much as I do. Many reading this are already savvy to much of this material. For those who aren’t, I will suggest a must-do list of education to get you prepped for your pitch. Those that already know this stuff, forward this post on to the newbies so we can up everyone’s game. There are way too many people in pain out there and we need to work together folks.
THE NEW TRAINER’S GUIDE TO NEW CLIENTS
1. Read Stu McGill’s book, Ultimate Back Fitness and Performance-The go-to manual for managing the spine on the training room floor.
2. Go get certified in FMS, here’s the calendar–Gray Cook has changed the landscape of training and rehab by providing an accessible model of assessment and corrective exercise that trainers and clinicians can both use.
3. Subscribe to StrengthCoach.com–Mike Boyle took his vast coaching experience, added that of the brightest minds in training and coaching, and created an incredible resource that is right on the cutting edge.
4. Subscribe to SportsRehabExpert.com–Joe Heiler, PT tweaked the StrengthCoach format and focused on the rehab end of things. This site is a crazy value and helps you learn the ins and outs of functional rehab so you can liase with the clinicians. Clinician that aren’t frequenting this site are falling behind the curve. Members to MyRehabExercise.com should ALL be using Joe’s site to stay current on the literature in functional correctives.
5. Get Charlie Weingroff’s Training=Rehab, Rehab=Training DVDs.-Charlie Weingroff, DPT scares me. Not only because he can squat 800 lbs, but because he’s one of the brightest folks in rehab and has the chops to crossover between elite coaching, physical therapy, and chiropractic. He also knows WAY too much about professional wrestling and fantasy football.
6. Get Craig Liebenson’s new Functional Performance Training DVDs (more on that in an upcoming post)-Craig Liebenson, DC is my ‘Sensei’…there, I’ve said it. Craig’s work in functional rehab has influenced my work going all the way back to my first year in chiro college. While his Rehabilitation of the Spine textbook is enough to keep you occupied for a year, his release of 3 new DVDs on Core Stability, Functional Training, and Flexibility will be what all of us are talking about in the next year.
7. RSS Jeff Cubos’ blog-Jeff Cubos, DC knows more than you do. He knows more than most of us do. I have never seen a more voracious appetite for learning, in a more humble individual. Jeff truly loves to share his knowledge and does so on his blog, JeffCubos.com. His participation on the recent Muscle Imbalances Revealed-Upper Body, hints at great things to come in the future.
8. And I humbly suggest you subscribe to MyRehabExercise.com just over on the right of this page. I’ve put together a roster of corrective exercise video tutorials for you to share with your clients and patients so that they can “balance their chassis” before you start loading it up with a bunch of weight and intensity. Those videos are from multiple sources (FMS, kettlebell community, McGill, Liebenson, Cressey, McKenzie and many more) but are conveniently located in one place so you don’t have to send patients and clients all over the web looking for rehab examples. The price is right too, at less than $10 per month. Heck, if that’s too much, send 10 of your colleagues to MyRehabExercise.com and you can get the service for free for a year!
Consider this approach as well. In my clinic, I encourage my patients to invite their trainers in to my office during their treatments if they are comfortable with this. I’ll then allow the trainer to stay for an afternoon and observe treatment for other patients that are okay with it. Trainers, see if the clinicians you refer to would be copacetic with this arrangement. Clinicians, offer this opportunity to local trainers.
Now, back to the topic of post-graduate education for trainers…one of the best places
you can go to start your information gathering is Stuart McGill’s work. And if you ever get a chance to see Stu in person, jump at it! It just so happens that Clare Frank, et al at Cynergy Education Group are hosting Dr. McGill in LA on Oct. 15-16. Here’s the link to that gathering, but get to it because there aren’t many seats left.
My personal journey with Dr. McGill began about 10 years ago. A nasty twisting injury to my thoracolumbar junction that occurred in my 20’s when I was a kayak guide, re-emerged after a crappy lifting episode. I found that more and more frequently, my back would seize with less and less provocation. I figured the world had little use for a chiropractor with a gimpy back so it was time for this chiropractic physician to heal himself. Sure, I had had my fill of old-school chiropractic treatment for this issue including manipulation, soft tissue therapies and lots of passive modalities. However, like so many other people’s experience with that limited toolbox, my benefit was only transient. At about that time I was introduced to Stuart McGill’s books and started to read his work suspecting intuitively that that approach of spinal stabilization was going to be my best solution. It did help me tremendously and it also transformed my practice as I shared this approach with my patient base.
I put together my first tutorial videos for McGill’s correctives about 5 years ago to help my own patients learn these exercises. Much to my surprise, clinicians, trainers, bodyworkers, yoga and Pilates instructors and the lay public started using my site and Dr. McGill’s exercises with excellent results. That experience formed the base for the current MyRehabExercise.com. Now, in addition to Stu’s exercises, we also have FMS correctives, material from Craig Liebenson, MacKenzie, the kettlebell community. We’ve even got functional rehab from Eric Cressey, Dan John and folks many of us have crossed in the blogosphere. All of these exercises are patient-friendly tutorials, and are aimed at helping patients and clients not only learn how to do the exercise, but also to learn a bit more about their conditions. Those interested in trialing the videos for use with their own patients and clients can follow the links over on the right side of the page here.
Did you know that MyRehabExercise.com works great on an iPad? Several heads-up users are already finding the service works great right out of the box on iPad and iPhone, no need for an App. This allows clinicians and bodyworkers to send the exercise prescription before they even leave the treatment room and means that trainers can send the Rx to the client while they’re performing the exercise on the training floor! So if you’d love to try that usability out, but don’t have an iPad of your very own, here’s your chance.
We’re going to give one away!
That’s right, when you sign up with MyRehabExercise.com, you may have noticed that you were asked if anyone referred you, and to input the “promo” code of the referring subscriber. You may have then noted on the My Account page, that subscribers are given their very own promo code. Well, we’re making a list and checking it twice, because the subscriber who refers the most new sign ups who stay beyond the trial period, will get a shiny new iPad for Christmas this year!
The Rehab Renaissance has all health care providers upping their game and adding functional rehab to their practice and gym. This approach is not for everyone, but the cracker-jack clinicians, bodyworkers and trainers know that this is the wave of the future. We’re dedicated to making MyRehabExercise.com the best source on the web for functional corrective exercise video instruction and need you to help get the word out. So share the site, and your promo code, with your colleagues, your Facebook friends, listees, bloggers and forum attendees!
Be the top referring subscriber and we’ll send you an iPad for Christmas!
Here are the rules:
1. This contest is open to all subscribers to MyRehabExercise.com except the host of the site.
2. Grand prize will be a 64 GB, top of the line iPad, valued at $699.
3. Winner will be the subscriber who refers the most people who maintain membership with MyRehabExercise.com beyond the 30 day trial period.
4. Tallies of referrals will be based on new signees reference of the referring subscriber’s “Promo Code”, located on the My Account page for members of MyRehabExercise.com. This method of tallying referrals is the only method that will be used and those results are final.
5. December 9, 2011 at 12:00 midnight, the subscriber who has referred the most active members who are not in the 30 day trial period will be considered the winner and will receive the Grand Prize.
6. Winner will receive the Grand Prize via mail delivery and every effort will be made to assure delivery by Christmas, December 25, 2011.
Readers here at MyRehabExercise.com are likely savvy to the work of Vladimir Janda and know the importance of developing excellent co-contraction between agonist and antagonist muscle groups to centrate joints. We’re also learning these days that the faulty joint centration can not only result in long term wear and tear in the joint, but can also result in less than optimal performance. The body reduces force production through the poorly centrated joint and this seems to occur well before arthralgia and pain inhibition processes take hold.
Since the functional rehab paradigm shift is somewhat new, I often get questions about how newbie subscribers to MyRehabExercise.com can learn more about these methods to better help their patients and to make better use of our rehab videos. Of course there are excellent subscription sites such as SportsRehabExpert.com, and StrengthCoach.com and there are also some fabulous blogs out there like CraigLiebenson.com and CharlieWeingroff.com. Folks can often get a jump start on learning the functional rehab methods when these giants synthesize their knowledge into a DVD package or book and you should definitely be all over the DVDs that Charlie and Craig have put together and have at their sites. But this post is about a different guy and what he brings to the table.
Dr. Jeff Cubos is wicked smart…scary smart! If you go to his site to check out his travels to pick up new material from the rehab literati your jaw would drop. I think I could make a decent living just being Jeff’s travel agent! Jeff has an excellent teaching style and ability to bring complicated matter down to assimilable bits. He’s now put together that knowledge and teaching ability into an excellent DVD set called Muscle Imbalances Revealed-Upper Body. In this set, Dr. Cubos has teamed with Tony Gentilcore, Rick Kaselj and Dean Somerset to produce a treatise on how to drill down to the key imbalances for each patient and client, and then how to back up and put together a detailed treatment plan to serve that person best. Dr. Cubos has taken on the somewhat esoteric topic of diaphragm integration into the core by adding tricks to teach patients and clients how to improve pain and stress with breathing techniques from the DNS world. Word on the street is that their is a discount to early orders so get over there and check it out.
Our 2nd installment to this area of the blog focuses on medial collapse of the knee. Many of the most common running-related injuries stem from this excessive aberrant motion (Milner, et al, 2010; Ferber, et al, 2010). Interestingly, in runners at least, the root of this problem is more software related than hardware related. Early studies investigating anterior and lateral knee pain in runners, found excessive hip adduction and tibial torsion during gait analysis to be positively correlated with pain in the knee. (Dierks, et al, 2008; Souza et al, 2009) It was theorized that runners with knee pain would exhibit gluteal weakness and that was born out in subsequent studies. However, follow-up studies attempting to treat by strengthening the glutes showed that despite improvement in gluteal strength after training, these runners still had knee pain when they ran.(Blønd, et al, 1998) It wasn’t until 2011, that significant success was found in these runners when they received real-time coaching + biofeedback to correct the valgus collapse. (Noehren et al, 2011) My feeling over the years has been that a glute strengthening program that targeted functional movement on 1 leg and, coupled with the verbal cues for gluteal integration while running, would improve outcomes in runners with knee pain. Some recent studies have born that out and we’ve also seen good effect with that approach.(Earl et al, 2011; Dolak et al, 2011) Below is a good example.
Bryan, 21 year old college XC runner, presented with chronic, episodic left anterolateral knee pain while running. Pain began in his freshman year of high school and usually became more noticeable each year toward the end of the XC season. He felt that the pain, while not severe enough to place him on the injured list, was sufficient enough to limit his performance by limiting his high intensity training. He had had extensive physical therapy, which he attributed with keeping him able to run, but not to run pain-free. He had limited experience with weight training, but had done bodyweight core training in the past 2 years and found some benefit in his pain incidence after. He arrives between seasons on the advice of his coach, and only experiences knee pain on his long days when mileage exceeds 12-13 miles. He had no prior direct trauma to the knee.
On ortho assessment, Ober’s and Nobles test confirmed shortened and painful ITB on the involved side. Hip adductors were shortened and Thomas-Gaenslen’s indicated shortening of the hip flexors. Palpation over the distal 1/3 of the ITB and medial and lateral peripatellar retinaculum reproduced CC pain. No patellar malalignment was noted on static exam. On movement exam, deep squat was painful in the medial patellar region and showed quad dominance and slight valgus collapse. With manual cueing to activate the glutes, he squatted without pain. Squat depth was markedly improved with a 2/4 “cheater board”. Dorsiflexion of the ankle was limited bilaterally. Lunge also produced slight pain, marked crepitus and valgus collapse. Seated slump test produced no nerve tension signs, SLR was 80 deg bilaterally. Structural diagnosis of patellofemoral syndrome was rendered and the functional exam to shed light on the cause was initiated.
Functional assessment findings were as follows:
Stecco Movement Verification: Given mobility issues raised in the ortho exam, we started here and found painful Centers of Coordination at ante-genu, media-genu, lateral-genu, lateral coxa, media-coxa and ante-coxa.
Janda Key Movement Assessment: Hip extension was delayed in glute max activation and strength was +4/5 on the involved side. Hip abduction revealed hip flexor dominance and +4/5 glute med strength on manual challenge.
Mag 7: 1 leg stand was normal on time bilaterally, but demonstrated ankle eversion on the involved side and lateral pelvic tilting. 1 leg squat was painful
with valgus collapse of the knee and again showed lateral pelvic tilt. Wall Angel revealed T4 mobility deficits.
At this point, I felt comfortable enough with the findings to render a functional cause of the PFS as shortening of the hip flexors and adductors with resultant gluteal inhibition…lower crossed syndrome. We performed PIR and Fascial Manipulation to the hip flexors (AN-PV) and re-tested the hip extension KMP and found better strength in the glute max and improved firing order. Repeat of the painful lunge pattern was still painful though. Fascial manipulation to AN-GE resulted in ability to lunge painlessly. Time constraints forced us to end this first session, so patient was briefly shown lunge stretches and goblet squats for hip mobility. However, patient’s T4 mobility deficits forced a peel back to tactical frogs for hip mobility. He was referred to MyRehabExercise.com for follow up tutorial videos on those exercises.
At the next visit, Bryan reported slightly less pain during runs the previous week. We addressed the collapse at the distal end of the kinetic chain with the Vele’s Lean + Short Foot exercise and patient was instructed to perform prior to runs along with dynamic stretching of the hip flexors and adductors. We also tested the previously observed lateral pelvic tilt in single leg positions with static side plank and patient showed endurance values of 80/95 sec on the involved side and 70/99 on the contralateral side. QL was tender to palpation on the contralateral side and patient recalled that he ofter felt fatigue in that area on very long days. no pelvic obliquity was noted on exam. For manual therapy, I made a judgement call based on previous experience, and performed Graston Technique soft tissue manipulation to the tender peripatellar retinaculae. While I don’t generally go directly to the painful area, I’ve found that with PFS of such longstanding history, the painful scarring of that tissue sometimes represents a space occupying lesion that may need to be addressed. HVLA manipulation of the T4 area into extension was also performed as well as hip long axis distraction manipulation. Bryan was able to squat and lunge without pain after.
At next visit, patient only had knee pain on the long runs and reported decreased severity when it occurred. We had no provocative movements to assess in the clinic and were left with ADLs and objective movement quality measures. Single leg squat was not painful but demonstrated valgus collapse. Patient was shown Bulgarian split squats to replace the lunges and was now able to perform Goblet squats which replaced the tactical frogs. RNT challenge was added to the Bulgarians. We also repeated Graston to the peripatellar retinaculae, which were less painful during treatment. T4 extension manipulation was once again performed.
The following visit, Bryan reported he was now able to run 13 miles without knee pain. With ADLs and clinical provocative tests now painless, we turned toward longer term training to be done at home. Patient was shown progression pattern for adding weight to the Bulgarians, and was shown single leg deadlift using cross body pattern. He was also shown single leg Pallof presses to integrate the anti-rotation training of the digital flexors. We discussed findings of previous studies in distance runners involving heavy weight half squats and he was given copy of one study to share with the trainer at school. This allowed this patient who was naive to weight training to integrate this training under supervision. Lumbar FCE was performed and patient was WNL on all quadrants in the core test.
Bryan was seen a few more times during the course of the following season, but only to address neck and shoulder stiffness around exams. He ran painlessly for the first season in his running career that year and PR’d twice. He was chosen for the XC team that competed at NCAA nationals a goal he had not been able to accomplish previously. Note that we intentionally did not attempt to take the patient into deep squats and to “correct” the ankle dorsiflexion deficits. This was a judgement call given the research the shows inverse correlation between ankle dorsiflexion ROM and performance in elite distance runners. This patient was seen only 5X to get resolution of his longstanding complaint, by using a functional approach. Removing the energy leaks in his gait by stabilizing the core, and improving transverse plane control via the foot and hip allowed him to balance his musculoskeletal system to train with higher volume and intensity. This allowed him to not only run injury free for the first season in his life, but also to run faster than before.
The exercises featured here are part of the membership-only area of MyRehabExercise.com. Members can use the extensive library of functional exercise tutorials to help improve patient care and to reduce time necessary to train patients. The service is only $9.99 monthly, and those interested may trial the service risk-free for 30 days for only $1. Click on the link below for more info.
Milner CE, Hamill J, Davis IS. Distinct hip and rearfoot kinematics in female runners with a history of tibial stress fracture. J Orthop Sports Phys Ther. 2010 Feb;40(2):59-66.
Ferber R, Noehren B, Hamill J, Davis IS. Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. J Orthop Sports Phys Ther. 2010 Feb;40(2):52-8.
Dierks TA, Manal KT, Hamill J, Davis IS. Proximal and distal influences on hip and knee kinematics in runners with patellofemoral pain during a prolonged run. J Orthop Sports Phys Ther. 2008 Aug;38(8):448-56. Epub 2008 Aug 1.
Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther 2009;39:12–19.
Blønd L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7-year retro- spective follow-up study of 250 athletes. Acta Orthop Belg 1998;64:393–400.
Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. Br J Sports Med. 2011 Jul;45(9):691-6. Epub 2010 Jun 28.
Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011 Jan;39(1):154-63. Epub 2010 Oct 7.
Dolak KL, Silkman C, Medina McKeon J, Hosey RG, Lattermann C, Uhl TL. Hip Strengthening Prior to Functional Exercises Reduces Pain Sooner Than Quadriceps Strengthening in Females With Patellofemoral Pain Syndrome: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2011 Jun 7.
Let’s kick off a regular installment here on the blog. Periodically, we’ll discuss case studies and case conceptualizations based on a functional rehab approach. Case studies were always one of my favorite ways to learn in school. Some of these will be straight up cases that we see in the clinic, some will be composites of several commonly presenting complaints somewhat like the vignettes we all knew and loved from board exams. It’s my hope that this will help those of us with a bit more familiarity with these methods provide a more direct path for learning to the newer adoptees of functional rehab. There are of course, many “Roads to Rome”, so some of the therapies applied don’t matter as much as how they are applied in the big picture. Let’s start with Mike, a recent patient in our with shoulder pain.
Mike, a 38 y.o. carpenter, presented on referral from his wife, with complaint of chronic left anterior shoulder pain of 4 months duration after lifting a heavy door by himself. He said he bent down with left arm straight under the bottom side of the door, right hand grasping the top of the door and stood up. He walked for a ways and had difficulty turning a corner. He thinks he might have felt a pulling sensation in the shoulder at that time. He continued his work day and noticed pain at rest in the shoulder the next day, and marked pain on left arm flexion, abduction and extension when putting his shirt on the in morning. After a week of pain, he saw his PCP, who prescribed OTC NSAIDs. PCP also offered steroid injection which patient says he denied because of fear of needles. Pain at rest improved over the subsequent weeks but movement related pain remained at a slightly lower level. He also found it impossible to lay down on either side and was not sleeping well as a result.
Exam revealed a sitting and standing posture with head and shoulders forward, with inwardly rotated arms. Ortho eval revealed painful arc in the left arm between 90-120 degrees. Neer’s, Yocum’s and Hawkins-Kennedy were all positive for external, anterosuperior rotator cuff impingement. Supine external rotation was limited with report of anterior tightness over the shoulder, relocation of the humerus anteriorly did not affect the pain with external rotation, making internal impingement unlikely. Active internal rotation and abduction were primary painful movement vectors. Motion palpation of the thoracic and cervical spine revealed restricted motion in extension and rotation in both areas.
- Janda Key Movement Patterns: Scapulohumeral dyskinesis with early hiking of the left shoulder on abduction. Supine neck raise revealed chin jutting and head shaking after 12/30 seconds.
- Stecco Movement verification screen implicated following Centers of Coordination: ante-scapula, ante-humerus, ante-cubitus; retro-scapula, retro-thoracic; lateral-scapula, lateral-humerus, lateral-cubitus; intra-scapula, intra-humerus; extra-humerus.
- Selective Functional Movement Assessment (SFMA): DN for MS rotation and extension. DP for squat, UE MRE/LRF bilateral, C-sp rotation and extension.
- Dynamic Neuromuscular Stabilization (DNS): Apical breathing pattern observed and patient showed insufficient activation of diaphragm/core with Diaphragm Test and Intra-Abdominal Pressure test.
Structural diagnosis of external impingement syndrome was rendered, with a functional dx of Upper Crossed Syndrome per Janda. Presumed pre-existing postural habitus contributed to the poor healing of the acute injury and resultant impingement syndrome.
Initial treatment consisted of Stecco Fascial Manipulation over AN-SC, RE-SC, IR-HU. Mid-treatment re-assessment after manual therapy revealed improved painful active abduction of the left arm to near 120 degrees before pain and perhaps 30-40% improvement in internal rotation. Thoracic extension was improved but still painful. HVLA manipulation to the T4, T6 and R1 segments allowed for painless thoracic extension.
Exercise instruction consisted of neck ups, home self mobilization using lacrosse ball with focus on mid-scap area and pecs, and Sidelying Thoracic Extension and Rotation peeled back to painless abduction to around 110-115 degrees. After the latter exercise, Mike reported a big sense of opening in his chest and upper back. He was emailed tutorial videos of the 3 exercises from MyRehabExercise.com for reference with HEP.
In subsequent follow up treatments, we worked on the areas implicated in the Stecco movement verification screen with Fascial Manipulation and continued exercise prescription, progressing from kettlebell armbars and screwdrivers, to TGU to the high hip position. Breathing/stabilization faults were addressed with Dead Bug variations incorporating diaphragmatic breathing and “sternal crunch”. He was then progressed to full TGU and early soft rolling patterns. Patient was released after having met his treatment goals after 6 treatments in 6 weeks.
COMMENT: This treatment method of assessing movement quality to determine functional deficits, applying manual therapy and re-assessing after treatment, and finding painfree multisegmental movement pattern-based exercises to build on is what marks the functional rehab approach. With every manual therapy applied in the clinic, patient was shown ways to try to accomplish similar results at home to reduce dependency on the caregiver. Exercise played a role in the treatment from Day 1. An excellent overview of this approach from one of the pioneers in functional rehab is at http://www.craigliebenson.com/?p=1595.
These multi-joint functional exercises are a bit more difficult to teach patients how to do, and having the video tutorial back up at MyRehabExercise.com helped groove those movements and allow the patient to make more headway at home. The methods of manual therapy are interchangeable, all will have some benefit. The particular exercises may differ dependent on the ability of the patient to perform them painlessly. This offers a way out of the sterotypical boxes of our respective professions. Gone are the endless chiropractic visits consisting of heat/stim and manipulation. Gone are the endless physical therapy visits of ASTYM/Graston, iontophoresis and ultrasound. Gone are the weekly spa massage treatments that help for a few days. Gone are the single joint bicep curls and leg extensions in the corporate gym environments that push unbalanced clients to injury and one of the aforementioned treatment scenarios. So let’s all of us look around our communities and find the experts in our respective fields and work together for the benefit of our patients and clients. Folks need us out there.
I would be interested to hear your respective comments and experiences, so chime in.
Also, if you’d like to see what the functional rehab video tutorial library looks like at MyRehabExercise.com, you can trial it for $1 for 30 days risk free. After that, the cost is only $9.99 per month. Click on the link below to start the trial!
After much work and some delay, we’re opening up the doors to MyRehabExercise.com today! Welcome to this new service and community which we hope will help to push the idea of empowerment of patient and client health through sustainable movement. We offer a detailed library of the latest functional rehab exercises in video tutorials, designed to help health care professionals teach corrective exercise to their patients. Coupled with appropriate manual therapy skills to aid in mobility, rehab exercise is a powerful tool to help “balance the chassis” so that folks can train at higher levels of intensity with less likelihood for injury. This ain’t your Grandma’s idea of rehab though!
This is functional corrective exercise, represented in the work of Stuart McGill, Gray Cook, Craig Liebenson, the Prague School and others. You’ll also find representation here from the cutting edge folks from the online communities spawned by Mike Boyle’s StrengthCoach.com and Joe Heiler’s SportsRehabExpert.com. You’ll see videos representing the work of folks like Eric Cressey, and the emerging kettlebell community.
The bedrock of MyRehabExercise.com is the library of patient and client friendly functional rehab exercise tutorials. These videos are detailed enough to stand alone in a pinch, but are designed to follow up on your expert assessment of your patients and clients using the popular methods of the FMS, Mag 7, and Janda’s Key Movement patterns. These videos can be viewed by your patients and clients either by email prescription, or by hard copy prescription. We also understand the reality of the landscape for non-clinician bodyworkers and trainers, and this service is open for your use too, so that you can help your clients work on correcting their imbalances to avoid injury and improve performance. However, be sensible in your use of this material. Know your limitations, and develop a referral network in your community so that you can refer your painful and injured clients to clinicians that can help co-manage those folks. Patients are well served in this atmosphere of co-management where their welfare trumps the egos and turfwars between professions. Let’s focus on getting people to higher levels of function and truly improve healthcare.
We feel we have a good product at a very reasonable rate of $9.99 per month and will even let you trial the site for 30 days for only $1. Take it for a test drive and give us feedback. Your input will help guide the future development of the site. Welcome!
In the training and rehab communities, a slight rift exists on whether rehab exercise is even necessary. Some strength training experts suggest that getting people into free weight environs and adding enough weight to their lifting challenge to stimulate the body to adapt is sufficient. While this may be enough for some individuals with few major unbalanced movement patterns (read 2’s on the FMS), others with pain and/or significant movement errors are at risk of injury in this scenario. I put together this video as an example to help get the point across, and hope it helps drive the discussion a bit.
Other recent excellent posts on this topic include Eric Cressey’s blog (Correcting Bad Posture: Are Deadlifts Enough?) and Dr. Craig Liebenson’s blog (Strength Training vs. Functional Training). Also check out one of Gray Cook’s recent posts (Gray Cook Radio-Episode 15) on how to interpret 1’s, 2’s and 3’s in your FMS screen. Gray says 3’s are perfection, and if you trained that person for a year, you wouldn’t be able to improve the pattern. 2’s are imperfect movements that can be improved on, but are acceptable and don’t represent risk of injury. 1’s are dysfunctional and warrant your immediate attention. Many of us in the rehab and strength communities that use the FMS, get myopic and start obsessing about getting people to 3 status, when we really ought to be focusing on bringing 1’s up to 2 status.
A few years ago, I started compiling videos of the functional corrective exercises I learned in weekend continuing ed seminars with Stuart McGill, Craig Liebenson, FMS and others so that I could use those videos to help support at home care for my patients. Last year, I started re-shooting those videos and adding material from folks like Eric Cressey, Brett Jones, Pavel Tsatsouline and others. All of these vids were shot not as if they were speaking to an educated health care professional, but were shot in language suitable for patients and clients. I have found that this approach of using video to support my patient’s exercise prescription is WAY better. It not only increases patient compliance, but also decreases the time needed to teach patients in the clinic.
I’m now offering that video library to other health care professionals as MyRehabExercise.com. It’s not just for clinicians like DC’s, PT’s and MD’s but will work well in the personal training/coaching environment and for bodyworkers. As time goes on, this blog will serve as a meeting place for users, as we discuss better methods of improving the mobility of those “crunchy bits” as Kelly Starrett, DPT (MobilityWod.com) refers to them, and also look at specific clinical conditions and talk about how to approach them from a functional approach. A word of warning though…this is not old school isolation exercise for the most part. The material here is from the new Rehab Renaissance and is for the other nerds out there who love this stuff but need help teaching patients and clients how to do some of this high order work. If you’re looking to distinguish yourself in your community as an expert in functional rehab exercise, this stuff will help.
MyRehabExercise.com is due to be released any day now…as soon as my beta testers give me the thumbs up the site is dialed in. We’re offering a Charter Membership to those who are stoked and sign up on the wait list above. Charter Members will be guaranteed membership to the site for only $9.99 per month for the life of the site! You nerds will also help shape the face of this project as time goes on through your feedback. Once the site is released, you can trial it for only $1 for 30 days with no obligation, after that, if you don’t like just cancel your account. If you find it helps your patient/client care as much as it has mine, then you’ll be charged $9.99 per month. Look forward to working with you all!!
Developers are currently implementing email push capability into MyRehabExercise.com. This will allow a paperless option for clinicians and allied HCPs. With just 2 clicks, without leaving the training room or treatment setting, subscribers can send patients corrective exercise tutorials that exemplify the new Rehab Renaissance. Look for Screenflow examples very soon. Release is still on target for the end of May!