Let me explain by first providing you with several definitions of “diagnosis” as provided by the Merriam-Webster dictionary.

Diagnosis:

• the art or act of identifying a disease from its signs and symptoms
• investigation or analysis of the cause or nature of a condition, situation, or problem

As you can see from above, the words identifying, investigation, and analysis form the foundation of these definitions. Secondary to these, but no less important, are the words disease, cause, and problem.

What happens in many clinical practices unfortunately, is the overpowering presence of the technician above the diagnostician. Undoubtably, these two hats may be worn by the same individual. That is kosher. But what we must remember however, is that our first and foremost priority is to identify the true reason for their presentation.

Because it is more important that we address the cause of their symptoms, rather than treat the symptoms themselves. Be it a joint dysfunction, an incoordinated movement pattern, or central sensitization, finding the key link is not finding something that we think is important, it is finding something that the patient shows is important. You see, what we think is important is quite often clouded by the treatment methods we employ in practice.

We are always learning the newest, most cutting edge methods. But the methods must serve the goals and unfortunately, we often become defined by our methods. The skills, techniques, and methods are not the Grastons, the ARTs, the kinesiology tapes, and the mulligan mobilizations.  The true skills are how to identify and how to asess the body.

It is not about our methods, it is about our analysis.

As Gray Cook states in his new book, Movement,

“…the purity of the evaluation process should not be clouded by the treatment options.”

We must be thorough in our evaluation process, leaving no stone unturned. Borrowing from Dr. Craig Liebenson, a thorough history will identify our patients’ goals and a thorough examination will identify our patients’ capacities. It is our objective to ensure that their capacities exceed their goals. Because in rehabilitation,

“we must look for the requisite frequency exercise that accesses the software in order to reboot the computer”

Happy hunting!

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Here’s a brief summary of the study:

Study Purpose:

• To determine the presence of a relationship between hamstring length and PFJ stress at 3 specific knee joint angles of flexion.

Study Population:

• 16 recreationally active males divided into two groups based on knee joint angle-measured hamstring length.

Methodology:

• A biomechanical model incorporating knee joint angle, knee extensor moment, and PFJ contact area was used to quantify PFJ stress.
• MRI and 3D motion analyses were also utilized in this study.
• A one-way ANOVA to determine the variations in PFJ stress between the 2 groups (with and without reduced hamstring length) was used.

Main Findings:

• Patellofemoral Joint stresses differed significantly between the two groups at specific angles of knee flexion.
• No significant differences in hip angles between the two groups.

Clinical Application:

• This study demonstrated that subjects with reduced hamstring lengths have increased PFJ stress during various positions of the squatting movement.  As a result, such a decrease in length MAY contribute to the pathogenesis of various conditions relating to the knee.
• These results enable us to consider another factor when managing those with knee pathology.

For a complete and “evidence-informed” understanding of the study, check out my review. I have obviously left out specifics from this study in this post as Research Review Service is a paid membership site. However, if you would like more information, please do not hesitate to ask.

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*note: the above link for RRS is an affiliate link

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In sports, distal biceps tendon ruptures (DBTR) have been reported in to occur waterpolo, weightlifting, football and gymnastics, and professional hockey player. The management of acute, complete distal biceps tendon ruptures is a surgical emergency, with improved prognosis and decreased risk of complications when surgery occurs within ten days of injury.  Primary health care providers are often the first professionals to assess the acutely injured individuals and therefore, confidence in making a definitive clinical diagnosis of complete DBTR may prevent the inherent cost and time delay in obtaining “confirmatory” imaging.

Clinical presentation and patient history are important factors in diagnosing complete DBTR. Rupture of the distal biceps tendon predominantly affects males within the 40 to 60-age range and typically occurs as a result of an eccentric contraction at the dominant elbow.  Therefore, these injuries may occur in sports with a large extension force applied to the elbow from a concentrically flexed and supinated position (another reason why you shouldn’t do barbell curls), generally resulting in injury at the tendinous insertion to the radial tuberosity. Sometimes chronic in nature, injured patients often describe an acute traumatic event with hearing a “pop” or feeling sharp pain. Typically they are aware of the nature of their injury.  Pain is often sharp and well localized, although dull and achy sensations have also been reported. Ecchymosis, swelling, and proximal retraction of the muscle belly are common signs in acute tendon ruptures though not always present.

Orthopaedic tests for this DBTR have recently been described and individually have been accurate in detecting complete tendon ruptures. Elmaraghy et al described the Biceps Crease Interval and reported a sensitivity of 96% and diagnostic accuracy of 93% in 29 patients with a diagnostic threshold of an interval greater than 6.0cm or crease ratio greater than 1.2.  A high interrater reliability of measuring the BCI was also reported (0.79). The Hook Test by O’Driscoll et al was reported to have 100% sensitivity and specificity (33 of 33 patients with complete DBTR) although interrater reliability data for this technique was not included. A positive Flexion Initiation Test has also been described in the literature although its requirement of attempting to flex a 10-pound weight in an acute symptomatic individual seems impractical and may not be clinically useful.

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Diagnostic imaging for distal biceps tendon ruptures are still commonly performed though may not entirely be necessary. With respect to diagnostic ultrasound, its utility seems questionable as diagnosis can be difficult in partial tears or complete ruptures without tendon retraction. In addition, sonography has been equivocal in cases of long-standing injuries with a delayed diagnosis. It may seem to play a role, however, in rare, atypical presentations; rupture without traumatic mechanism, clinically suspected partial tears, clinically suspected complete, non-retracted tears, and incomplete clinical pictures. Lastly, although relatively quick to obtain and of minimal cost, its accuracy is generally highly operator dependent.  The detrimental risk of the time delay associated with obtaining an U/S may outweigh any potential benefit in addition to as appropriately applied clinical assessment protocol in most cases.

Magnetic resonance imaging is considered the gold standard imaging procedure in the detection of distal biceps tendon ruptures. It can also be useful in rare, atypical presentations such as clinically confusing cases where the biceps tendon can still be palpated in the antecubital fossa, as well as in complete non-retracted tears. In fact, the use of MRI in clinically confusing cases MAY lead to a change in the treatment protocol. Unfortunately however, MRI comes at an increased cost, decreased accessibility and lengthy wait times and this may negatively affect the prognosis of acute distal biceps tendon ruptures.

Surgical delays greater than 10 days post injury increase the risk of complications and the extent of anterior dissection required. Therefore, in light of the questionability of ultrasound, and the expense and wait time of MRI, a a rapid and thorough clinical assessment protocol was developed, and and can be found below. This protocol MAY circumvent the need for diagnostic imaging, however, it must be noted that if either of sonography and MRI have the potential to change the treatment protocol as described in Magee above, then its use may be warranted.

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“At what age should you start developing movement patterns for the purposes of injury prevention?”

In my opinion, this was a significant question in light of the fact that there as been ongoing discussion on several forums as to what minimum age would be most appropriate for the application of the Functional Movement Screen.

Since many of the athletes I work with fall within the 12 to 21 year old age range, it seems only appropriate that I address this question. Here are some tidbits of information that may assist in clarification:

Childhood ranges from 6 to 9 years of age and is marked by significant physical changes that in general, exhibit a linear growth. Development is typically somewhat predictable.

Adolescence, in contrast, ranges from 10 to 16 years of age and is marked by dramatic and rapid physical changes.

When considering the appropriate minimum age, it is also important to understand the differences between growth and maturation.

• Growth: actual changes in size occurring over a period of time
• Maturation: progress towards biological maturity (timing and rate of maturation generally varies between and within individuals).

Adolescent growth spurts generally occur between 13 and 15 years of age in males and between 11 and 13 years of age in females, while the age of maximal rate of growth (aka peak height velocity) generally occurs approximately 1 to 2 years following the commencement of sexual maturation. These variables may indeed influence motor learning and control.

In general, young children lack the motor skills required to adequately run, jump, and throw. With growth and maturation of the neurological and musculoskeletal systems, so do the development of these skills. The adult forms of these skills are generally acquired between 6 and 10 years of age and while the nervous system reaches 90% of its adult size by the age of 6 and full maturation by puberty, ultimate skill development depends highly on practice and training.

Gender differences do occur with motor performance with boys generally outperforming girls in run, jump, and throw performance. Further, males generally demonstrate continual improvement until early adulthood while improvement in females often slow by age 14…likely a result of proven decreases in levels of physical activity. It should be noted however, that in general, females tend to perform better than males on fine motor tasks.

Through an examination of the Long Term Athletic Development stages from the Canadian Sport for Life resource, it is apparent that the Learn to Train stage (Boys 9 – 12, Girls 8 – 11) is the stage at which adolescents should be developing and refining all movement skills, since the brain is capable of highly refined skill performance.

Interestingly, those who may be classified as “late developers” actually have an advantage since this learn to train stage is actually lengthened in this population.

During my graduate education experience, I had the privilege of working closely with Joe Baker, Phd of York University who’s primary focus and interests lie in optimal human development. When asking his opinion of this topic, his response was:

“…‘lack of consensus’ is a good way to describe most of the recommendations regarding training and rehab issues with youth and adolescent athletes. It’s clear that there are significant and persistent problems with this population but no real consistency in the recommended approach to deal with them. The immature motor system is part of the explanation but it also relates to the motor system’s interaction with the still developing cognitive and physiological systems. Adolescent athletes are at a stage of development that is almost constantly in flux making a ‘one size fits all’ approach very difficult…Unfortunately, I’m not sure of any rehab recommendations for this population.”

So in consideration of the above information, my recommendations would be as follows:

• Movement pattern development for the purpose of injury prevention may be implemented at the ages corresponding to early adolescence

• Functional Movement Screening for the purpose of identification of injury risk may be implemented at a similar age, HOWEVER, it is my opinion that the development and refinement of general movement skills take priority over the screen itself.

• Focus should be on the fundamental of motor development until mid to late adolescents – at least that’s what our research would suggest for most late maturation sports. (a recommendation from Dr. Baker)

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The following information was derived primarily from the text, “Scientific Foundations and Principles of Practice in Musculoskeletal Rehabilitation” by Magee et al as well as the Canadian Sport for Life website.

For more information on youth development please visit the International Youth Fitness Association and Canadian Sport for Life.

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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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August 28, 2010

8:00am – 8:30am Check-in and registration

8:30am – 8:45am Welcome and Introduction – Professor Paul Hodges

8:45am – 9:35am Professor Stu McGill

• Opinions on the links between back pain and motor control: The disconnect between clinical practice and research

9:35am– 10:25am Dr. Lorimer Moseley

• Talk title TBC

10:25am – 10:40am Morning Coffee Break

10:40am – 11:30am Professor Paul Hodges

• Motor control changes in spinal pain: effects mechanisms and efficacy of interventions.

11:30am – 12:20pm Associate Professor Peter N. Reeves

• Spine Stability: the six blind men and the elephant

12:20pm – 1:00pm Lunch

1:00pm – 2:00pm Clinical Update – Professor Paul Hodges

• Emerging trends in exercise management of spinal pain

2:00pm – 2:30pm Symposium Update

• Panel discussion on areas of convergence and divergence

2:30pm – 3:00pm Question and answer session.

3:00pm Symposium Close

Register here

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The Deep Line as Patrick states, consists of the following:

Posterior tibialis > interosseuos membrane > Knee capsule > adductor hiatus > intermuscular septum > femoral triangle > psoas > anterior longitudinal ligament > diaphragm > pericardium > mediastinum > parietal pleura > fascia prevertebralis > scalenes

Patrick goes on to explain how breathing plays a very important role in the function of this line and provides some excellent strategies for correction and progression.

This got me thinking…

Often times I will use the Bunkie Testing method to assess the various lines throughout the body. I wrote a piece about the Bunkie Test late last year and it can be viewed here. Kevin Neeled also wrote a piece and shot some video on how and why this testing method may play an important role in kinetic linking for hockey players. You can read that here.

As mentioned last fall, the Bunkie Test consists of tests for the following

• Anterior power line
• Medial stabilizing line
• Lateral stabilizing line
• Posterior stabilizing line
• Posterior power line

Do we truly know that we’re testing each of the above? Who knows, but based on Patrick’s article, I think we need to revisit the test and see how we can start testing the DEEP FRONT LINE. That is, the Deep Stabilizing Line. Maybe we can’t. But perhaps we can. I am not trying to reinvent the testing method here. I am simply seeing a flaw in the testing procedure and am now looking for a way to improve it. Joe Heiler of Sports Rehab Expert recently invited me to do an interview and discuss the Bunkie Method of Testing. I hope to do this interview in July so maybe I’ll have some answers by then.

Perhaps there are other ways to test this. I can’t remember off the top of my head right now so if you can think of one, make sure you let me know.

When a patient does present with “dysfunction” of this Deep Front Line, aside from attacking their breathing patterns, I progress to improving their rolling patterns as well. Generally, I will work the supine to prone rolling pattern to improve this line and specifically target the right arm / left leg or left arm / right leg combinations as needed. Carson Boddicker has written several pieces on these topics, one of which is a must read.  For an introduction, make sure you read Core Competencies. Mark Young makes a good argument about testing the roll, but personally, I think quality is more important than quantity in this case…but that’s just my opinion!

Progression from here would be to the Dead Bug tract (not dissimilar to Patrick’s videos) and onward to chops and lifts (thanks Mike) and beyond to really attack their stabilizing function. Check out Nick Tumminello’s video of the Vertical Pallof Press for anterior stabilization (to combat lumbar extension).

Lots of info to digest here and certainly plenty of hot links to click on. So thanks to Patrick, Mike, Kevin, Mark, Carson, Nick, and Perry for unknowingly being participants in this post!

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A new released article from Dr McGill :

click here

See Below for details on his upcoming course:

Building the Ultimate back: from Rehabilitation to Performance

November 20 and 21, 2010 in Toronto

• 4 hours – Building the foundation
• 2 hours – Interpreting patient presentation
• 1 Hour – Preventing Back Disorders
• 4.5 hours – Rehabilitation Exercise
• 4.5 hours – Training for performance

This 16 hour lecture / workshop weekend with Dr. McGill will be located at  the Westin Harbour Castle, 1 Harbour Square, Toronto. I am also thinking of hosting a social this weekend so if you are attending please let me know.

For more information on Dr. McGill visit www.backfitpro.com

Visit  www.msk-plus.ca/Courses.htm for more information and online registration, or email info@msk-plus.ca for more details.

See you there!

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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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Also make sure to check out the following posts as scapular dyskinesia may play a role in both:

• Neurovascular Problems in the Athlete’s Shoulder
• Rotator Cuff Tears: Predictive Factors for Management

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The Functional Movement Screen (FMS) is a ranking and grading system that documents movement patterns that are key to normal function. By screening these patterns, the FMS readily identifies functional limitations and asymmetries. These are issues that can reduce the effects of functional training and physical conditioning and distort body awareness.

The FMS generates the Functional Movement Screen Score, which is used to target problems and track progress. This scoring system is directly linked to the most beneficial corrective exercises to restore mechanically sound movement patterns.

Exercise professionals monitor the FMS score to track progress and to identify those exercises that will be most effective to restore proper movement and build strength in each individual. (…cont’d)

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. (…cont’d)

To describe the above in layman’s terms, the FMS is a screen to identify who may be at risk based on their presenting movement patterns. Why they are at risk is not the objective here, it is simply a filter. On the other hand, the SFMA is an assessment tool aimed at determining one’s cause of pain.

If you are interested in learning more about these systems and especially how to apply them in a clinical / rehabilitation setting, I urge you to join Sports Rehabilitation Expert.

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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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