Study Title: Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study.

Authors: A. Robb & J. Pajaczkowski

Journal: Journal of Bodywork & Movement Therapies

Date: January 2011

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Summary:

• Here is a nice little pilot study by two of my colleagues from Toronto on the effect of Active Release Techniques on immediate pain thresholds in elite ice hockey players. Using 9 players from AAA to the major junior level, they studied the influence of this popular manual therapy technique on its ability to modulate reported pain pressure thresholds (PPT) in acute adductor muscle strains. Up until now, the majority of the current literature on this technique had looked at the beneficial application of ART through case studies, however, few if any have looked deeper into the therapeutic effect of such protocols. PPT, “the minimal amount of pressure applied to the tissue to change the pressure sensation to discomfort or pain”,  was assessed both pre- and post-treatment via a hand-held mechanical pressure algometer. A significant improvement in PPT was demonstrated in this study. Since the painful experience involves both a bottom-up and top-down process, this study sheds some light into the potential positive effects manual therapy may have in acute pain patients. While the authors disclose that it is still difficult to conclude with certainty the exact pathophysiological and histological mechanisms responsible for these outcomes, they do provide some potential mechanisms for such reduction of pain. Certainly this study lacked a large sample size and randomization (hence a pilot study), however, the work of Drs. Robb and Pajaczkowski do pave the way for further research to validate a therapy that carries with it an extreme wealth of anecdotal evidence.

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Robb, A. & Pajaczkowski, J. (2011). Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study. Journal of Bodywork and Movement Therapies, 15, 57-62

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36 year old retired hockey player.

Long history of low back pain.

Radiation down the lateral aspect of the leg to the foot.

Discogenic right?

Maybe.

However, pain was not worse with coughing or sneezing and a sudden weakness of the right foot became apparent.

Know this guy? He might be of some help.

A motor weakness was found distally in the right lower limb and the deep tendon reflexes were within normal limits (2+). Notably, an “up-going toe” was revealed on the same limb. This is a significant sign as “down-going” is considered a “normal” response.

Along with other specific tests, such findings may indicate an upper motor neuron lesion so it is important that we keep our clinical examination skills equally as sharp as our history taking.

You just never know when something may be hiding in the bushes!

If this post seemed brief, it was supposed to. It was simply a reminder that your examination shouldn’t be…

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Please be aware that the following information is based on my interpretation of each lecture and therefore, may be subject to “lost in translation”.

Please click here for Part 1

Please click here for Part 2

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‘Clinical Update: Emerging trends in exercise management of spinal pain’

~ Paul Hodges & Stuart McGill

This lecture was the meat and potatoes of the symposium. Dr. Hodges was the main presenter and often asked Dr. McGill to provide some practical insight into some of his interventions for low back pain. While they both stressed that they were likely very similar in their approach to spinal care, it was evident from this talk that the divergence is still glaring. In fact, even the miracle blade could not cut the tension in the air although both were very professional in their “debate”.

Here are my notes:

Basic principles:

• Dynamic control far exceeds static control
• The system as a whole is what’s important, not a single muscle
• The biopsychosocial framework must be considered during intervention
• The assessment is highly important
• The principles are drawn from multiple approaches in training

5 basic but key components to DYNAMIC CONTROL:

• Posture
• Movement
• Underactivity (tends to involve local structures)
• Overactivity (tends to be global structures)
• Evaluation of both provocative and relieving factors

Treatment Goals:

• Postural correction
• Movement correction
• Muscle Activation Optimization

Posture:

Dr. McGill gave an example of the importance of posture and its relationship with our breathing. Feel free to perform a self-assessment in the various positions

• Regular sitting – normal breath
• Slouched – breath goes directly to mid-chest level
• Military position (shoulder retraction, thoracic extension) – breath goes down to base of lungs
• Rotate and list to one side – one lung becomes compromised and breath is taken up by contralateral lung

Movement:

Dr. McGill also provided us with a movement correction example

• Upright stance and muscle activity
• A forward posture (slouched or neck protraction) vs neutral spine
• Bottom line: change posture during movement may change activity of lumbar musculature (i.e. extensors)
• For those of you who have his newest DVD, he also demonstrates this example there.

*All three (posture, movement, muscle activation optimization) are important but we as clinicians have to figure out which of these is our priority in treatment.

“STATIC STABILITY DOES NOT EQUAL FUNCTION”

Interplay between dynamic and stiffness:

• This is a continuum
• Depends on the load (high load requires high stiffness)
• Depends on the movement (greater movement requires greater dynamic control)
• Depends on the predictability (low predictability requires high stiffness)
• We need to find the right balance!

“Change in motor control is about looking at the whole system not the parts.”

Common features of motor control strategies:

Dr. McGill on posture correction:

• First try to achieve elastic equilibrium
  • First start with a position of least load / stress concentration
• Then try to modulate that with pain
  • Can be standing
  • Can be seated
  • This seated example touched upon correct posture. Rather than actively extending the thoracic spine (which increases extensor muscle activity), tilting the pelvis anteriorly is preferred

Preservation of feedback control may be via taping:

• I found this to be quite interesting in light of the various taping techniques currently on utilized in the rehabilitation and sport medicine settings
• Taping may also be used for modifying muscle activation strategies

“NEUTRAL SPINE IS NOT STATIC!”

• It needs to be variable…and within the functional range

“The gluteus maximus is a (free) knee extensor!”

• When standing, active contraction of this muscle passively extends the knee
• “Spread the floor and use the hips”
• This is advantageous as it unloads the quadriceps muscle

Activating the HIGH glutes & glute med:

• Needs core stiffness
• Externally rotate hips
• This may be done actively and reactively (minibands around the knees and around the feet)

Activating LOW glutes:

• Only achieved in a deep squat position

Posture and Movement is about load:

• How does pain change with the addition and removal of load?
• McGill  – “tolerance is a function of posture and movement”

McGill on Bracing:

• Become a dimmer switch not a light bulb
• Its all about tuning!

Hodges: There’s a difference between just making a muscle active (Transversus Abdominis) vs an optimal way of using the muscle:

• It’s not enough just to activate the muscle…you have to learn how to use it!

Hodges:

“There is no doubt that Stu and I have differing positions on the role of the deep muscles in the clinical approach but I think it is good that we have different ideas because all individuals patients are different.”

“The Transversus Abdominis is not the most important thing in low back pain but our data show that it is the most consistent deficit in low back pain presentation. Therefore it is important to address this muscle as part of the comprehensive package of treating low back pain.”

“Improving the activation of the deep muscles may decrease the over activity of the global/superficial muscles.”

Dr. McGill on the Transversus Abdominis:

• He understands that the TrA is important. His problem is that there are so many other important aspects to low back pain patients.
• …and far too often the patients that he sees are “paralyzed” by the concept of a dysfunctional TrA. They are always asking, “is my TrA working?”, “why isn’t my TrA working?”
• This is why he subscribes to the method of external focus for motor learning by Gabrielle Wulf.

Dr. Hodges:

• Counters that there is data to show that simply an internal focus to “wake the muscle up” is ok. As long as there are subsequently more functional goals to focus on

*In my opinion, It’s an apples vs oranges debate!

“Train movement control, posture and muscle activity during rehabilitation”

• If they flex the spine while bending forward then train them not to flex the spine while bending forward.
• Its that simple!

Dr. McGill:

“Fix the biggest things first to get them out of pain…THEN fine tune!

• This was his rebuttal to the TrA and MF controversy. He states that he has never encountered a patient where the TrA deficit was the most significant dysfunction

Dr. Hodges’ strategy of multifidus activation:

• Can you turn it on?
• What else happens when you turn it on?
• Do you have control over the strategies?
• Most important and effective strategy is to use imagery.

“There’s something about attention to detail that’s driving changes in neuroplasticity”

Dr. McGill:

• States that his athletes cannot individually activate muscles medial to lateral but they can superiorly and inferiorly
• BUT THE MENTAL FOCUS WAS IDEAL!!!

Dr. Hodges:

“Delays are significant in a motor system.”

• This deficit is NOT the dysfunction but only a window of opportunity to look into the system.

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As mentioned earlier, this turned out to be an interesting and enlightening high tension academic debate but both experts argue that it would be most valuable to have a patient on hand to both assess to really truly get an idea of how each think. They agreed that this would truly provide valuable insight into the magnitude of their agreement/disagreement.  Out of all of this, they state that there is mostly convergence between the two and that it may be the last (5%)…i.e. their specific methods…that may be different.

“Divergence is healthy. Because if not, what would drive research?”

*The purpose of everything is the individualized goals of each patient. That’s it!

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Please be aware that the following information is based on my interpretation of each lecture and therefore, may be subject to “lost in translation”.

Note: Please click here for Part 1

It must be stated that each of the two esteemed researchers prefaced their talks with addressing the fact that misconceptions often occur when one is asked to speak about a specific facet of their research. Both of them stated that the oft-requested material is simply a part of the big picture and as a result, labeling and misinterpretation typically occurs.

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‘Motor control changes in spinal pain: effects, mechanisms and efficacy of interventions’ ~ Paul Hodges

Adaptation & Rehabilitation: How does motor control change in the presence of pain?

Some common myths explained (in red):

The Transversus Abdominis and Multifidus are NOT the most important muscles for spine control

• However, he states that they do make a contribution and that this is often modified in the presence of low back pain.
• His rationale for addressing the importance of specific musculature is compromised control (of the system) in the presence of weakness or inhibition.
• Note: he was adamant in stating that rehabilitation does not stop here…that training these muscles should not be the sole target of lumbar rehabilitation

With respect to the debate surrounding the delay of motor activity with arm movement:

• He states that this delay is not necessarily a dysfunction in and of itself -> but simply is a “window” to look into the system.

Motor control training is NOT just about training the Transversus Abdominis

• The aim should be placed on addressing postures, movement patterns and muscle activation patterns
• A consideration of the deep musculature is simply one aspect of motor control

People should NOT be encouraged to isolate the Transversus Abdominis and Multifidus in function

• The aim should be to change their activation patterns while introducing them into function…in addition to the correction of posture, movement, and muscle activation (if necessary).

The need to isolate deep muscle activity in rehabilitation

• Some of the reasons presented pertained to organizational changes within the brain, the relationship between motor activity improvement and clinical improvement, and the applicability for the identification of individuals who may respond to motor control rehabilitation
• This was one area where he stood his ground

Some explanations as to why motor activity decreases during pain:

• Reflex inhibition
  • Change in excitability of the motor neuron (descending motor pathway) secondary to injury
• Change in organization of the motor cortex
  • In the presence of low back pain, he reported that the cortical area of TrA representation is shifted posterolaterally
  • Interestingly, individuals with the biggest temporal delays in motor activity have the largest shift in displacement (note: this does not necessarily imply causation).

Motor control isn’t always about giving people more…it may also be about taking things away

• Some people have OVERactivity!!!!
• That often individuals with low back pain have increased muscle stiffness and subsequently, poor control.

So does an increase in muscle activity during pain allow us to adapt? Yes!

Is this adaptation about protection of the injured part? Yes – the high threshold strategy

• But is this a good thing or a bad thing? Does that alter motor control?

Hmm…

Adaptation ALSO occurs in the presence of a “threat” of pain

• The “threat” of nociception caused alterations in motor activity
• Therefore nociception is actually not necessary

Adaptation may be good in the short term…but it may be detrimental in the long term

• In the short term, adaptation facilitates alteration in stresses and loads placed on the body. i.e increased trunk stiffness for spine stability
• BUT…too much secondary stiffness may perpetuate back pain due to increased compression forces
• Thus, variability is necessary to adapt to change in conditions/environment…

We have to match the system to the demands of the task!

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"...and in this corner"

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“Opinions on the links between back pain and motor control: The disconnect between clinical practice and research” ~ Stuart McGill

A WHOLE BUNCH OF OPINIONS (in red)

As mentioned earlier, Stu prefaced his lecture by stating that clinical groups develop preconceived notions of different researchers due to the requests they receive to speak about a specific component about their research.

• He is always asked to talk about stabilization strategies and therefore never gets a chance to talk about anything more than what they ask for
• He hazards a guess that there is actually about 95% convergence between himself, Hodges, and the various researchers within the field!

Notice the space in between…its actually larger than each of these two think!

• Lately he asks questions not on what causes pain but what takes pain away

“Its at the concentrations of stress where the tissues break down.”

“It is extremely important to ask if your patients have good days and bad days.”

• If so, you know you’re going to be successful – so find out what creates the good days!

“People get painful backs because of the way they move”

• We must assess Postures, Motions, and Loads to find out (within each variable) what
  • Causes pain
  • Takes pain away
  • Prevention and treatment therefore, can be summed up as “don’t do what hurts you!”

Postural dominance:

• Flexion (cyclists), extension (gymnasts), lateral flexion/rotation (cricket bowlers), etc
• Neutral spine is imperative to minimize shear loads
  • At spine neutral, the longissimus muscle is at 45 deg and therefore,  able to buttresses this shear
  • With spinal flexion, the longissimus is at 10 deg and therefore, unable to buttress this shear

Movement screening:

“Just because they can (perform an ideal movement upon screening), it doesn’t mean they will!”

• Movement screening may show you what they can do (i.e. deep squat) but it doesn’t necessarily show you what they will do….with the various tasks they have to perform throughout the day.
• Therefore, provocative testing must also be performed!

On using the term  chronic non-specific low back pain:

“Wouldn’t it be funny if we lumped all leg pain into “leg pain” and did a research study to determine the efficacy of various treatment approaches for “leg pain” (chiropractic care vs physical therapy vs massage therapy)”

• Note: In general, I, myself think researchers may be missing the boat on this argument altogether. That is, researching the efficacy of various treatment modalities on CNSLBP…especially since more evidence is pointing toward a weaker relationship between pain and tissue disruption/dysfunction the greater the chronicity of pain

“Muscles of the torso are fundamentally different than those of the limbs”

• Limb/extremity muscles – generate motion
• Torso muscles – stop motion
  • No such thing as agonist and antagonist in the spine. They all work together.

“The rectus abdominis, with its transverse tendons, is designed to create short range stiffness – otherwise God would have given us a hamstring!”

Quadratus Lumborum vs Gluteus Medius for lumbopelvic stability in the frontal plane:

• During the unilateral suitcase carry – McGill argues that the QL eccentrically contracts to hold the pelvis up during the swing phase as opposed to the current widespread belief that the gluteus medius is the primary stabilizer of femoral adduction during the stance phase

On the problem with performing a physical exam/assessment on a patient in jeans:

• Whether you ask them to perform a quadruped rock or straight leg raise, jeans tend to lock the hips and force the spine to move in greater ranges of motion than normal

Internal vs External Focus for Skill Transfer:

• Gabrielle Wulf: suggests that external focus in motor learning more effectively facilitates performance
• E.g. Pelvic Floor control
  • Rather than asking a patient to contract and relax their pelvic floor, he suggests one should focus on farting and preventing a fart

Insert random quote here:

“Pavel will kick you in the feet randomly and put you on your back before you even know it.”

On the Transversus Abdominis:

“Most clinicians would be more successful ignoring this muscle”

• His rationale was that stiffness and stability in the spine comes from a corset action – synergistic action between all core musculature
• That the TrA can simply be “tuned” up by raising ones voice

“I would be so bold to argue that Gluteal problems are much more dominant as a whole than the TVA”

• Karel Lewitt – push navel down and out to facilitate intraabdominal pressure. Stop drawing navel in!

On creating deep oblique training:

• Lay on one’s back with hips and knees flexed
• Breath with normal tidal volume – go to full tidal expiration – then KEEP FORCING AIR OUT

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There you have it. A recap of the lectures presented by arguably the two most prominent leading researchers in the field of spine control. I apologize for withholding personal opinion from this summary, but I felt that doing so would provide everyone with an unbiased narrative of their lectures. Tune in tomorrow for Part 3 of the 2010 Spine Control Symposium Recap as Professors McGill and Hodges “join forces” to provide a clinical update on the emerging trends in exercise management of spinal pain.

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“Spinal Stability: The six blind men and the elephant” ~ Peter Reeves

A Reductionist vs Systems approach to management

• Interaction of the various systems is extremely important
• It is normally difficult to target the actual cause of LBP, especially in the presence of multiple findings
  • Systems approach allows you to look into the interactions between the various findings
• He uses the popular parable, “Six blind men and the elephant” to demonstrate that focusing on just one sign or symptom of low back pain is analogous to taking a reductionist approach.

• When trying to determine if something is stable, all one has to do is apply a small perturbation and observe the response
  • Systems that are in a low energy configuration are going to be stable
  • For further explanation, please see my previous post titled “Variability for Stability“
• Feedback control is probably the most important aspect of dynamic stability and this corresponds to both positive and negative feedback.
  • For stability, we always have negative feedback control
  • But there’s more than one pathway for feedback control (voluntary and reflex)
    • Note: Unfortunately, the presence of pain and dysfunction will result in delays within the reflex pathways
• Reeves demonstrated a stick balancing example to explain feedback control for stability. He introduced this concept in a recent letter to the editor in the European Spine Journal. Essentially there are two main necessities for feedback mechanisms for stability:
  • The need for tracking – we need to know the position of the mass that we are concerned with.
  • The need to know the velocity of the mass’ movement
  • Lacking this results in an impairment in feedback control, and subsequently greater effort and / or displacement.
  • Note: impairments in feedback control are generally less significant during slow movement
• The future of his research and the heart of systems science lies in the modeling and its manipulation in the search for answers. His goal is to see how the system, aka the plant and the controller (see my “Variability for Stability” post), responds to different types of perturbations (not just one type of perturbation)

• The definition of “stability” is content dependent
  • Therefore he uses the concept of “risk of injury” instead.
  • He’s less concerned with the definition of stability and more concerned with how stability is achieved

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“Motor Control Changes and Back Pain: Chicken, Egg, neither or both?” ~ Lorimer Moseley

Central themes (in red)

“pain and spinal control abnormalities result from implicitly evaluated needs of the organism.”

• His focus was not on the relationship between spine control and back pain but on why people with back pain actually have pain.
• (Stu McGill taking notes as always)
• Aside from humans, even the most basic biological organisms (i.e. unicellular organisms) will repel away from threat…its all about protection!

Pain vs Nociception

• Pain – unpleasant conscious sensory and emotional experiences
• The purpose of pain is protection

• The purpose of nociception is to facilitate those protective devices that humans possess

Quote:

It is “seductive” to conclude that recorded activity in c fibers and a-delta fibers will result in pain.

• Role of the thalamus is to relay and prioritize information – “what is important for the brain to know RIGHT NOW?”
• The brain is modulating nociception all the time (we have about 600 neurons descending from periaqueductal gray to modulate one ascending nociceptive neuron).
• The relationship between nociception and pain is a variable one.

• Vision is purely a sensory experience and the brain modifies it.

Pain and the Brain

• Pain is an output of the brain into consciousness
• “What is the most appropriate conscious output here?”

“trunk muscle activity results from the implicitly perceived demands on the trunk.”

• Inducing experimental pain changes motor imagery performance

“we really don’t know whether motor control changes BECAUSE of pain”

– it’s a chicken and egg argument.

Considerations pertaining to the concept of nociception and protective motor control changes:

• Is it NECESSARY?
• Is it SUFFICIENT?
• *his answer was it is sufficient but it may not be necessary

Considerations pertaining to the concept of pain and protective motor control changes:

• Is it NECESSARY?
• Is it SUFFICIENT?
• *he quoted a previous paper by Hodges that stated “recurrent back pain patients in whom motor control changes are observed are often pain-free at the time of testing.

Motor control as an output of the brain to the muscles:

• The brain often asks “what are the demands on my trunk?” based on the current state, position, mobility, and vulnerability of the spine.
• Therefore, the brain can impart non-volitional motor control changes!!!

Pain as an output of the brain to the muscles:

• The brain often asks “how dangerous is this (nociceptive information) really?“
• Therefore, the brain will determine the need and presence of pain

So consequently, the brain asking itself “How Dangerous is this REALLY?” is in his view, what determines back pain.

…tune in tomorrow for Part 2 of the 2010 Spine Control Symposium Recap. You won’t want to miss the great McGill and Hodges “debate”!

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The above question is just one reason why I am looking forward to the 7th Interdisciplinary World Congress on Low Back and Pelvic Pain. Among other “questions”, answers (or at least directions) to the above will be addressed throughout this congress. Here’s a look at the preliminary program.

What are your thoughts on the above question?

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• The data from this study came from two sources (firefighters and kinesiology students).

• The main objective of this study was to assess the relationship between the V-sit test and the plank test for torso flexion endurance.

• The pearson correlation was r=0.34 (low correlation) as well as the r-squared value. It almost seems obvious that these two wouldn’t correlate well as they are two totally different positions.

I think the main reason McGill did this study was because people were using the PLANK test in place of the V-SIT to test flexion endurance (which has plenty of data correlating poor endurance times with low back disorders).

• The moral of the story is to use the V-sit when doing your tests for flexion endurance.

• He also cautioned against “training the test” due to the high compressive loads.

I do not have an image of the V-Sit test but can send you a copy of the full article if you would like. Just reply below with your email and I’ll shoot it over.

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DO YOU SWIM?

If you answered “yes” to the above, please proceed to the next question. If not, thanks for visiting!

Question # 2:

DO YOU PREPARE YOURSELF TO SWIM?

If you answered “no” to the above, please view the following videos to help you prepare for your next run using the GRID by Trigger Point Performance Therapy.

Quadriceps – 60 seconds each leg (Total = 2 min)

Tensor Fascia Lata – 30 seconds each hip (Total = 1 min)

Mid – Latissimus Dorsi – 30 seconds each side (Total = 1 min)

Thoracic Spine Rotation – 30 seconds each side (Total = 1 min)

Quadruped Reach & Roll – 60 seconds

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DO YOU RUN?

If you answered “yes” to the above, please proceed to the next question. If not, thanks for visiting!

Question # 2:

DO YOU PREPARE YOURSELF TO RUN?

If you answered “no” to the above, please view the following videos to help you prepare for your next run using the GRID by Trigger Point Performance Therapy.

Calves – 45 seconds each leg (Total = 1.5 min)

Quadriceps – 60 seconds each leg (Total = 2 min)

Tensor Fascia Lata – 30 seconds each hip (Total = 1 min)

Thoracic Spine Rotation – 45 seconds each side (Total = 1.5 min)

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Using a yoga mat to explain the lumbar origin of the psoas muscle

Glute Bridging / Hip Thrusts for hip extension strength

A more effective way of stretching the quadriceps complex

Core activation with self raking

Teaching the Quadriped Rockback

Looking for intersegmental buckling – I couldn’t find it (Great job!)

Team Rockback – very few lumbar hinges in this group!

I really have no clue what I was explaining

Clamshell party

All in all, a successful event. Special thanks to Christina and Kristy for having me! Again, for more specific information on the content of this workshop, click here. To check out the rest of the photos, click here

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What we need:

• Dorsiflexion mobility

Why we need it:

• Minimize stress on knee

How we can get it:

KNEE:
What we need:

• We need to realize that the knee is often an innocent bystander

Why we need it:

• We need to realize this because the research says so

How we can get it

• We can achieve optimal knee mechanics by looking both above (the hip) and below (the ankle) this joint.

HIP:

What we need:

• Saggittal plane mobility
• Extension strength

Why we need it:

• Minimize stress on lumbar spine

How we can get it:

• Glute Bridge
• Glute Bridge – Marching
• Glute Bridge – 1 Leg

What we need:

• Frontal & Transverse plane dynamic stability

Why we need it:

• Minimize dynamic valgus at knee and dynamic internal rotation at knee

How we can get it

• Side Lying Abduction
• Clam Shells (Hip – External Rotation)
• Mini Band – External Rotation
• Airplane (I’ll get a video of this up soon)

LOW BACK / CORE:

What we need:

• Antirotation, Antiextension, Antilateral flexion STABILITY

Why we need it:

• To be able to transfer forces THROUGH not TO the “joint” (aka Core”)

How we can get it:

• Antirotation: “Pig on a Spit” Roll
• Antiextension: Front Plank series including the Body Saw
• Antilateral flexion: Farmer walk / Suitcase carry

What we need:

• Lumbar intersegmental stability

Why we need it:

• To be able to transfer forces THROUGH not TO the “joint” (aka Core”)

How we can get it:

• Effective “core activation” methods

THORACIC SPINE:

What we need:

• Rotation & Extension mobility

Why we need it:

• Lumbar relief & Shoulder mobility

How we can get it:

SHOULDER:

What we need:

• Scapular stability

Why we need it:

• Shoulder mobility

How we can get it:

For those of you who are unfamiliar with this approach of looking at the body, please have a look at Coach Boyle’s The Joint by Joint approach and FITS Toronto’s 5-site Integrity

Anatomical photos courtesy of Primal Pictures

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• An inability to stabilize the pelvis while performing dynamic lower body movements (i.e. performing lunges in the weight room or skating in hockey) may result in shear forces sustained by the spine, creating a compensatory pattern of inefficient/lack of gluteal activation, muscle spasm, and undue stress on the hip joints and muscles.

Therefore, to minimize the risks to specific muscles that cross this joint, we must maximize the integrity of the slings that cross it. Four myofascial slings are involved here, and they include:

• Posterior oblique sling – located across the back from gluteus maximus, through the thoracodorsal fascia, and up to the latissimus dorsi.
• Anterior oblique sling – in the front of the body from the external oblique, through the anterior abdominal fascia, to the contralateral internal oblique and the adductor musculature
• Longitudinal sling – from the peroneii/fibularis group in the lateral lower leg, up the biceps femoris, the sacroiliac ligaments, through the deep thoracodorsal fascia, and up the erector musculature
• Lateral sling – containing the PRIMARY frontal plane stabilizers for the hip joint – the gluteus medius, tensor fascia lata, and the lateral stabilizers of thoracopelvic region (i.e. quadratus lumborum)

Therefore, to assess and correct one’s risk for hip and groin injuries, it would be prudent to test the integrity of these slings and their myofascial components through such testing procedures as the BUNKIE TEST.

One of the most important tenets in minimizing these injuries is the ability to CONTROL and STABILIZE this region while power is being generated. We want loads to be generated THROUGH THE JOINT and not to it!

Other considerations include ADDuctor to ABDuctor strength ratio, hip static and dynamic mobility, and joint centration.

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