Stuart M. McGill, PhD.

in

Manchester England
June 11-12th, 2011

Manchester Sport & Leisure Trust,
Manchester National Squash Centre

Sportcity, Gate 13, Rowsley Street

9:00 AM to 5:00 PM

COURSE OBJECTIVES

Global Objectives:

• To update delegates on the most recent developments in clinical biomechanics of the lumbar spine – specifically how it works and how it becomes injured. This is to develop an evidence based foundation for clinical decision making.
  
• To provide guidance in the application of this knowledge to the clinic, workplace, rehabilitation centre, and sports field to reduce the risk of injury, optimize healing of the patient, and build ultimate back performance in the athlete.
  
• To give practice and technique development with workshops throughout the day.

COURSE OUTLINE

Brief Description of Topics:

3 hours
Building the foundation: Dispel the myths about how the spine works and becomes injured. Anatomical, biomechanical and motor control perspectives are provided to setup the clinical approaches.

2 hours
Interpreting patient presentation: Understand aberrant motion and motor patterns and possibilities for corrective exercise. Provocative tests and their mechanical basis provide guidance for optimal exercise design. Lecture and workshop

1 Hour
Preventing Back Disorders: No clinician can be successful without removing the cause of back troubles in patients. This section teaches delegates how to identify the causes and how to remove them. Lecture and workshop.

4 hours
Rehabilitation Exercise: Biomechanics and Clinical Practices – Many exercises prescribed to low back patients have not been subjected to scientific examination.  This component of the course attempts to quantify and rank exercises for their spine loading, muscle usage and stabilizing potential. Algorithms for choosing the best exercise approach for each individual are provided. Lecture and workshop

4 hours
Training for performance: Training the back for performance (either athletic or occupational) requires different approaches and objectives than training to fulfil rehabilitation objectives. Some of the techniques developed in our work with world class athletes will be introduced and discussed within the context of valid mechanisms and evidence. These include the progressions from establishing motor control patterns, through to stability, endurance, strength, power and agility. Formalization of some of the performance “tricks” including how to get through “sticking points”, and developing “superstiffness” will be done in lecture and practical sessions.

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REGISTER EARLY — LIMITED SEATING — EARLY BIRD PRICING BEFORE MAY 25TH

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Note: Dr McGill has authored two textbooks: “Low Back Disorders: Evidence based prevention and rehabilitation”, Second Edition, published by Human Kinetics publishers, (www.humankinetics.com), 2007, and “Ultimate back fitness and performance” published by Backfitpro Inc (www.backfitpro.com). These books synthesize the material presented in this course and are recommended as resource material for interested delegates.

BRIEF BIOGRAPHY – Stuart M. McGill

Professor Stuart McGill is a Professor of Spine Biomechanics and a well known international lecturer and author with over 200 scientific publications that address the issues of lumbar function, low back injury mechanisms, patient assessment, investigation of the mechanisms involved in rehabilitation programs, injury avoidance strategies, and performance training of the back.  He is a consultant to many medical management groups, elite sports teams and athletes, governments, corporations and legal firms.   He has won numerous including the prestigious Volvo Bioengineering Award for Low Back Pain Research from Sweden. He is one of the few scientists who is regularly referred challenging patients for consult from around the world.

To register, click here or download the brochure.

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Study Title: The Lumbar and Sacrum Movement Pattern During the Back Squat Exercise

Authors: MR McKean, PK Dunn & BJ Burkett

Journal: Journal of Strength & Conditioning Research

Date: October 2010

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Summary:

• Here is a recent article that takes a deeper look at the obvious. McKean and colleagues utilized thirty upper year personal training students and personal trainers to examine 1) the timing and range of movement of the lumbar and sacral regions and 2) the influence of stance width, gender, and ascent / descent phases during the back squat exercise. Incorporating no load and 1.5 x body weight loaded trials, measurements from 3-D tracking devices placed on the above regions were evaluated for maximum lumbar and sacrum angles, the time at maximum lumbar and angles, maximum lumbar flexion angles, and the time at maximum lumbar flexion angles. Unsurprisingly, it was revealed that both men and women achieved a deeper squat position with wider stance (twice ASIS width) versus narrow stance (equal to ASIS width) positions. For those interested in the technical rationale, the reasoning behind this was lower maximum lumbar, sacrum and lumbar flexion angles leading to the ability to maintain more upright lumbar spine positions. Men and women, however, differed in movements and timing of maximums where men achieved maximum sacral angles sooner for both the ascent and descent phases of the squat in comparison with women who achieved earlier maximum lumbar angles in both phases. As a result, this modification in sacrum position and timing in men appears to allow them to accommodate for the known gender differences in pelvic girdle morphology. From a safety perspective, the above differences between the narrow and wider stance positions allow the lumbar spine to maintain a more upright position decreasing the load on the posterior structures of the spine.  That said, kyphosis of the lumbar spine does occur during the deep squat although measurements were not collected beyond ASIS width.

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McKean MR et al. (2010). The lumbar and sacrum movement pattern during the back squat exercise. Journal of Strength and Conditioning Research, 24(10); 2731-2741

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

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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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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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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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FOOT AND ANKLE

Pes Planus

During the movement screen, we examine your foot to determine if the movement in your foot is optimal.  Specifically, the most common type of dysfunction in the foot that can lead to energy leaks is a pes planus.  Pes planus, or flat feet, is a very common finding among the general population.  When dynamically tested, individuals with pes planus will exhibit turning out of their feet and a collapse of the main arch of their feet (longitudinal arch).  This finding can also contribute to the other findings within the movement screen.

Limited Dorsiflexion

This finding represents a limitation ankle joint’s range of motion.  Specifically, it means that the top of the foot does not get as close to the shin as it should while being loaded such as while performing a squat.   What this means is that those who have limited dorsiflexion in their ankle are likely make up for this lack of range by compensating somewhere else to get to the same depth of a squat.  Often times, people will use their backs predisposing them to injury due to overuse/misuse, or they may simply not be able to achieve the same range of movement while performing the specific movement in question.

External Foot Flare

This finding represents turning out of the foot while under dynamic load.  This may be a result of poor foot posture stemming from over pronation or pes planus.

KNEE

Dynamic Valgus

This finding represents the knees inability to maintain its dynamic integrity (position during movement) while under load.  What we see is a collapsing medially (inward) of the involved knee representing poor control, weakness of the hip musculature, and/or poor foundational support from poorly controlled foot motion.

Sagittal Control

This concept represents the importance of muscular control of one’s knee while under dynamic load.  What we see at times is a “shimmy” in the knee while the patient attempts to control knee movements such as a single leg squat.  This can represent poor muscular control and coordination  of the knee, hip and foot musculature.

LUMBOPELVIS AND HIP

Where your spine and hip attaches to your pelvis

Hip Hinge

This finding represents the correct way to perform a squat and generally to “bend at the hips”.  A good “bend” is initiated at the hip and not the low back where, as the name implies, you literally hinge your movement at your hips.  Those who cannot perform this movement and tend to favour bending through their back are predisposed to developing low back pain and poor performance, because instead of using their legs they use their spines to lift. Correcting this movement yields tremendous improvements for patients or athletes in terms of low back pain and performance.

Hip Mobility

This finding represents your hip range of motion in flexion, extension, internal and external rotation, and all combined movements of the aforementioned ranges. As a car needs lubricant to function properly you need hip mobility to keep your hips, low back and knees functioning properly. Tightness in the hips lead to stress and strain into joints that can create many musculoskeletal conditions that overtime can easily lead to arthritis in the previously mentioned sites. Sitting and our normal activities of daily living reduce our hip mobility. Therefore to be able to achieve your full athletic potential combined with staying injury proof requires you to constantly maintain proper hip mobility.

Hip Strength Quality

This finding examines the strength and ease of movement the athlete or patient displays during the various movements assessed. It is seen during low load testing as the depth the individual is able to achieve for example during the squat, lunge, and single leg squats. During high load conditions it is the individuals’ ability to absorb forces through the muscular system and to develop power (rate of force development)

Spine Buckling

This finding represents the spines inability to handle load.  What this means is that the spine is unable to support itself due to poor core musculature support.  Much like a mast on a ship, the spine requires guide wires to tightly hold the mast upright otherwise it will crack and the ship will lose its sails.  Similarly, without appropriate conditioning of the core muscles around the spine and pelvis, the body’s mast (your spine) will buckle causing you to lose the wind in your sails and the spring in your step.  Simple movement such as bending forward becomes painful.  This finding tends to become apparent while perform any bending movement.

Sandwich Movement

This finding represents when a person has does not display a hip hinge, has poor mobility through their hips, and favours using their back while perform a specific movement.  Essentially, what is seen is the torso and legs form the “bread” of the sandwich while the space in between becomes the filling.  A well conditioned pattern finds that the torso is in a neutral position with the chest up; while a “sandwich pattern” finds the chest bent into the legs and facing down – they look like a sandwich. In this position the low back is doing the lifting not the legs. Adopting this pattern negates the most powerful muscles in your body in favour of the back which predisposed the individual to developing chronic low back pain. Correcting this movement pattern and developing a proper hip hinge would be tremendously beneficial. In fact, most people with low back pain display this dysfunction that once corrected no longer have back pain.

Pelvic Control

Much like the above three findings, pelvic control reflects the patient’s ability to dynamically (through movement) maintain a stable pelvis (foundation) while performing various movements.  Dysfunctions are seen as aberrant movements of the pelvis; shifting, tilting, hiking and rotating. These dysfunctions occur largely because of an inability to maintain neutral spine control and are linked to the findings throughout the other anatomical sites, such as your ankle and foot. The impact of poor pelvic control relates to its’ central position in the body. Your pelvis is the transfer point for forces generated in your hips (the main power centre in the body) combined with force contributions from other areas of the body. Pelvic control is like the drive train of a car which functions to transfer power developed from the engine to the wheels. Many problems throughout the body will occur with poor pelvic control such as low back pain, hip problems, knee problems, and even shoulder problems.

Something to Think About:

Regardless of whether you are an athlete or not, pelvic control is essential. If you are an athlete the demands for pelvic control are much higher and are reflective of the demands of your sport. For example it well known that hip and leg contribution to pitching velocity and tennis serve velocity is over 50 percent. This is only possible through pelvic control, or “THE CORE”. Many athletes that fail to develop the core suffer injuries by trying to make up the power elsewhere, such as the elbow and shoulder for both pitchers and tennis players.

SCAPULO-THORACIC HUMERAL

Where your arms attach to your spine

Thoracic Collapse

This is a secondary finding often times associated with sandwich movement.  This finding indicates that the patient is not hinging from the hips resulting in a back dominant initiation of movement resulting in thoracic or mid back collapse.  Essentially, the mid-back often times follows the lead of the low back; if the low back is poorly supported, then the same will be seen in the mid-back.

Thoracic Rigidity/Hyperkyphosis

This finding is the opposite of the thoracic collapse.  It represents the inability of the patient to maintain a “chest up” position while under load and undergoing specific movements, irrespective of the stability of the low back.  In chronic situations, this finding can contribute to thoracic outlet syndrome, neck pain, and headaches.

Scapular Winging

This finding represents poor posture of your should blades (aka scapulae).  This finding indicates that you are chest dominant in your posture with likely tight, forward rolled shoulders and weak mid-back muscles.  This can predispose patients to developing chronic rotator cuff tendons, mid-back, shoulder, and neck pain.

Internal GH Rotation

Internal glenohumeral rotation represents a finding that is often associated with hyperkyphosis and scapular winging.  This can also predispose the patient to chronic rotator cuff injuries leading to pain and poor function while attempting to participate in their chosen activity or job.

CRANIO-CERVICAL JUNCTION

Where your neck meets your head

Anterior Head Carriage

This represents the general finding found in almost all people to some degree or another.  It’s what I call the modern cave man position in which our head juts forward in front of our bodies when we primarily sit in a poor position in front of the computer, read or slouch. This finding can represent poor muscular control of the deep muscles of your neck and may lead to chronic neck and jaw pain as well as headaches due to hyperactive posterior neck musculature.

Lateral Shift

Lateral shift of your head on your shoulders may represent a muscle imbalance present at your shoulder, neck, or upper back.  It may also represent a favoured motor pattern that if not corrected can lead to over stressing specific structures and tissue, resulting in breakdown and injury.

Rotation

Rotation is very similar to the finding of lateral shift and is often found in conjunction with it. Rotation may also represent a favoured motor pattern that can indicate the presence of weak and tight neck muscles.

Courtesy of Dr. Thomas Lam

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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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