Concussions in Sports: Part 1 – Risk and Recovery Process

Concussion in SportConcussions in sports are becoming more and more of a problem as our athletes continue to get bigger, stronger, and faster.  As our understanding of the impact of concussions continues to increase, the need for knowledge of how to manage and rehabilitate athlete’s with concussion becomes paramount.

Today’s guest post discusses Concussions in Sports from Shaun Logan, DPT.  This is part 1 of a 2 part series on Concussions in Sports that will give a brief overview of concussions and the recovery process.  This information is needed before we can even discuss how we can best manage these injuries.  (Photo from Wikipedia)

Part 2 will specifically discuss the role of physical therapy in concussion management.  If you are interested in learning more about concussions in sports, read my past article on the evaluation and treatment of concussions that includes a nice link to a Journal of Athletic Training consensus statement.


Concussions in Sports

Between 1.4 and 3.6 million sports and recreation-related concussions occur each year, with the majority happening at the high school level.[1] Studies estimate 10-19 percent of all athletes involved in contact sport sustain a concussion each season.[2] As concussions have become more prevalent in the every day media, with more research being conducted and information discovered every day, the role of rehab and physical therapy for concussions has been emerging.  This is something that has been discussed and practiced by few for several years, but is still relatively new to most clinicians.


Concussions in Sport

In the 3rd International conference on Concussion in Sport in Zurich (2009), McCory et al. defines concussion as, “A complex pathological process affecting the brain, induced by traumatic biomechanical forces.”  In general terms, a concussion is an injury to the brain that occurs when a force is transmitted to the head that causes the brain to “shake” inside of the skull resulting in injury.  This can be a direct hit to the head, face, or neck – or can be caused by a force applied elsewhere on the body that is then transmitted into the head. [3] Helmets were not made to prevent concussions, as they are unable to prevent the brain from shaking in the skull. Helmets were made to prevent skull fractures and blood vessel injury. [4]


Recovery from Concussion

Headaches, fogginess, confusion, and disorientation are among the most common symptoms of concussion in the first week. [4]  Generally, most concussive symptoms will subside within 7-10 days without any treatment other than rest. [1][3][4]  Therefore, most athletes completely recover within that 7-10 day time period. However, concussed athletes still need to be progressed properly and continually assessed for any symptoms that may arise with increased movement, activity, or exertion.

The accepted best practice for concussion management, recovery and eventual return to play is for the athlete to be on complete rest both physically and cognitively until symptoms are no longer worsening.  Cognitive, or mental, rest includes, but is not limited to, not participating in the following activities: watching TV, texting, reading, going to school, and being in loud crowded places. This rest period can take anywhere from a few hours to days or weeks, depending on the severity and symptoms of the concussion.

Following a concussion, there is a period of change in brain function that may last anywhere from 24 hours to 10 days. During this time, the brain may be vulnerable to more severe or permanent injury. If the athlete sustains a second concussion during this time period, the risk of permanent brain injury increases. [2] This is what is known as Second Impact Syndrome.  In documented cases, when a second brain injury occurs within 3 weeks of the initial concussion (most commonly within 7-10 days) there is some form of permanent brain damage in 100% of cases, with 50% resulting in mortality. [4] (There is a small sample size of documented cases, but this is still an astounding result)


Post-Concussion Syndrome

Not all concussed athletes will completely recover in the 7-10 days.  Studies show only about 10% of athletes show symptoms beyond 1 week and 1-5% with symptoms for longer than a month.  The prevalence of extended symptoms for high school athletes was about double that of college athletes.  These are the athletes who require rehabilitation. [4]

Athletes who continue with signs and symptoms for more than 3 weeks are considered as having Post-Concussion Syndrome (PCS). Though there is not a concrete agreed upon definition of PCS, the World Health Organization defines PCS as: “Three or more of the following symptoms: headache, dizziness, fatigue, irritability, insomnia, concentration difficulty, or memory difficulty experienced for weeks, months, or occasionally years after a concussion”. Other symptoms would include photophobia, tinnitus (ringing in ears), visual, and balance problems. [4]

The athlete must be appropriately monitored and progressed through activities by a health care profession, such as a physical therapist or athletic trainer, to prevent mismanagement of the concussion. Mismanaging a concussion is associated with several risks. [4]

Short-term risks of mismanaging concussion include:

  • Persistence or worsening of post concussion signs and symptoms
  • Repeat concussion with post-concussion syndrome
  • Second impact syndrome

Long term Risks of mismanaging concussion include:

  • Prolonged post-concussion syndrome
  • Depression, cognitive impairment, Chronic Traumatic Encephalopathy


Rehabilitation and the Concussed Athlete

Current thought is once the concussed athlete is asymptomatic at rest the physical therapist and athletic trainer’s role emerges in the form of a graded program of exertion, which will be discussed later in part 2. This is true, but it is only part of what we are able to do to aid in recovery and progress towards safe return to sport.

Read on to part 2 regarding the rehabilitation following concussions in athletes.



  1. University of Pittsburg Medical Center. (2011)
  2. University of Pittsburg Medical Center. (2011)
  3. McCory P, Meeuwisse W, Johnston K, et al. (2009) Consensus Statement on Concussion in Sport: the 3rd International Conference on Concusion in Sport held in Zurich, November 2008. Br J Sports Med; 43: i76-i84
  4. Guskiewicz, K. Concussion and Postconcussive Syndrome: When to Rest, Exercise, or Return to Sport. 2010. APTA Annual Meeting, Boston, MA
  5. Wallace, B. (2011) Concussion Health: Program
  6. Mucha, A. Physical Therapist’s Guide to Concussion. American Physical Therapy Association. 3/24/2011
  7. Wallace, B. Concussion Management Guidelines: Balance 360. By Concussion Health. (2011)

 About the Author

Shaun LoganShaun Logan, DPT practices out of The Training Room: Sports and Orthopeadic Physical Therapy located within Velocity Sports Performance in Cherry Hill and Washington Township in South Jersey where he has recently started a concussion program. Shaun graduated from Penn State University with Bachelor of Science degree in Kinesiology: Movement Science and from Drexel University’s DPT program in 2010. When his schedule allows, he returns to Drexel University to assist in teaching orthopedics. Shaun is working towards becoming board certified in sports.


Assessing the Sacroiliac Joint: The Best Tests for SI Joint Pain

SI JointThe sacroilliac joint, or SI joint, is one of those challenging areas of the body that we all have to deal with from time to time.  When I learned how to assess the SI joint, I know that I felt like I didn’t have a firm grasp on the best way to test for SI joint pain.  Many of the commonly performed assessments for SI joint pain seemed to not be very reliable and sometimes not even valid.

So treatment almost sometimes became taking a shot in the dark as I never truely felt confident in my exam findings.  This led me to perform treatments and progressions of patients based on trial and error rather than because of exam findings.  (Photo from Wikipedia)

Assessing the Sacroiliac Joint

Treating this way, to me, is a huge pet peeve, so I started to research the area to gain more comfort in my SI joint examination.  I found some interesting research regarding palpation, SI joint motion, and provocative testing.  Here are some of the things that I found along that way that really helped me get better at diagnosing SI joint pain, hope it helps you too.

Palpating the SI Joint

One of the simplest methods of assess the SI joint is palpation.  However, the reliability and validity of palpating the SI joint has come into question in recent years.  Several studies have been published showing poor inter-tester reliability for static SI joint palpation, including a nice study from Holgren and Waling.

McGrath has published an interesting article, entitled “Palpation of the sacroiliac joint: an anatomical and sensory challenge” in which the concept of SI joint palpation is scrutinized.  It is an interesting paper, that certainly makes you think.  In the paper, the author describes the several layers of tissue that sit between the skin and the posterior SI joint, which is 5-7cm deep to the skin, and the inherent challenge of both reliability and validity of palpating something so deep.

Assessing SI Joint Motion and Symmetry

Assessing the amount of SI joint motion and the symmetry of the SI joint itself is a very commonly performed technique during SI joint examination.  This method of examining the SI joint is popular and accepted, despite the lack of research supporting the technique.

Based on the above information regarding palpating the SI joint, one would question the ability to palpate AND now accurately assess motion in addition.  If palpation has poor reliability, this automatically makes assessing motion difficult.

Freburger and Riddle performed a literature review looking at our ability to perform SI joint motion testing.  They found poor inter-tester reliability, low sensitivity, and low specificity in several commonly performed tests.  This is a particularly interesting article to read if you have interest in this area.

Another study from Robinson et al had similar conclusions, stating that SI joint motion palpation tests have poor inter-tester reliability.

Riddle and Freburger in another study noted that the ability to detect positional faults of the SI joint also has poor reliability.

Thus it appears that the reliability and validity of assessing SI joint symmetry and motion may be too poor to be used clinically.  The amount of motion of the SI joint motion is extremely small, perhaps less than 2mm and 2 degrees of translation and rotation.  This makes detecting patholgoical movement extremely challenging.

However, I still think symmetry and motion assessment may be a valuable component of the SI joint examination in the case of significant malalignment and pathology, and still should be assessed.  Just realize that you are looking to “rule in” more significant pathology.  I would not “rule out” SI joint dysfunction based solely on symmetry and motion assessment.

Location of SI Joint Symptoms

Van der Wurf et al (2006) published an interesting study looking at the location of symptoms reported in patients with SI joint pain and dysfunction.  In the study, the authors performed local SI joint injections to block the patients’ pain.  The authors found that:

  • All subjects that responded to the SI joint block had symptoms located at the Fortin area (3cm horizontally by 10 cm vertically inferior to the PSIS)
  • All subjects that did NOT respond to the SI joint block had symptoms at the Tuber area (just inferolateral to the ischial tuberosity)

Again, I wouldn’t rule in or rule out SI joint dysfunction based on this alone, but it appears that if you DO have pain at the Fortin area AND do NOT have pain at the Tuber Area, you may be experiencing SI joint pain.

SI Joint Provocative Tests

Two recent studies by Laslett et al and Van der Wurff et al have demonstrated that there probably isn’t one perfect SI joint provocative test that we can perform to definitively diagnose SI joint pain or dysfunction.  Basically, there is no “gold standard” such as using the Lachman test for ACL tears in the knee.

However, by performing several tests together, you can increase your sensitivity and specificity of detecting SI joint dysfunction.

Combining the two studies, there are 5 provocative tests to perform when attempting to diagnose SI joint pain:

  1. Gaenslen
  2. FABER / Patrick’s test
  3. Thigh thrust / femoral shear test
  4. ASIS distraction (supine)
  5. Sacral compression (sidelying)

Laslett et al report that the accuracy of detecting SI joint dysfunction is increased with at least 3 of the 5 tests are positive.  Furthermore, if all 5 tests are negative, you can likely look at structures other that the SI joint.  Van der Wurff et al report that if at least 3/5 of these tests were positive, there was 85% sensitivity and 79% specificity for detecting the SI joint as the source of pain.  Interestingly, another study by Kokmeyer et al agreed with the previous findings, but also noted that the thigh trust test alone was almost as good at detecting SI joint dysfunction as the entire serious performed together.

It seems like performing a series of provactive SI joint tests is better than one true test in isolation, though I would specifically emphasize the thigh thrust test.  In my experience, you have to use a decent amount of force during the thigh thrust technique to avoid missing a positive provactive sign.

In an attempt to find good demonstration videos on youtube of these techniques, I came across Harrison Vaughn’s excellent videos (I mentioned Harrison in the past and recommend you also check out his website).  Great job and thanks for sharing Harrison!  These are the tests recommended by the above authors to use together:

Gaenslen Test

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FABER / Patrick Test

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Thigh Thrust / Femoral Shear Test

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ASIS Distraction

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Sacral Compression

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The Best Tests for SI Joint Pain

I will admit that I am not a SI joint expert, so I am interested in hearing the opinion of my readers that deal with a lot of SI joint dysfunction.  It appears that palpation, symmetry, and motion testing of the SI joint may have concerns in regard to reliability and validity.

Some things to keep in mind when assess the sacroiliac joint:

  • It is difficult to palpate the deep SI joint, making reliability and validity challenging
  • The reliability of assessing symmetry, SI joint motion, and SI joint position also has poor reliability
  • Pain along the Fortin Area without pain in the Tuber Area may indicate SI joint pain
  • A series of provocative SI joint tests yields better results that performing tests in isolation, with at least 3/5 positive tests demonstrating the highest accuracy of detecting SI joint dysfunction

Based on some of the research above, we should all consider the location of symptoms and a series of provocative testing when attempting assessing the sacroilliac joint and diagnosis SI joint pain and dysfunction.


Core Stability From the Inside Out

The core stabilization concept keeps being a hot topic for discussions. After more than a decade of core-training frenzy there is still very little evidence that core-training actually produces any positive effects. There is no universally accepted definition of what the make-up and function of the core is.

It all started with the Transversus Abdominis and the abdominal hollowing theory, where people were instructed to pull the belly-button in towards the spine when exercising. It has since been shown that abdominal bracing (tensing the abdominal wall as if preparing for being punched in the stomach) is superior to abdominal hollowing in regards to providing stability for the lumbar spine. Abdominal bracing is good, but it is still approaching the core from the outside in. The abdominal wall is the focus of the training. Real core activation has to come from the inside out.

Definition of Core

Core Stability Model

When looking up “core” in a dictionary we get descriptions like: centre, nucleus, middle, heart and interior.

If someone refers to the core of our planet they mean the absolute centre.  When people train their core they concentrate on the outer layers of the wall equal to the crust and the mantle.

People have to stop treating the core as a hollow tube and learn how to pressurize the “centre” of the tube instead of just tensing the walls.

Core Function

How do we pressurize the “centre”?

Intra-abdominal PressureThe diaphragm contracts and pushes down into the abdominal cavity, which combined with the resistance created by the pelvic floor, and an eccentric contraction of the entire abdominal wall, increases the pressure in front of the spine. The pressure from the front is counteracted by contraction of the lumbar extensor muscles and the spine is fully stabilized.  Without proper diaphragm contraction the increased  IAP will not reach all the way down to the lower lumbar spine, where the loading is most prominent.


The diaphragm is the key component to core stability. The diaphragm has to contract first and then the abdominal wall and not the other way around. A too early or too strong contraction of the abdominal wall prevents the diaphragm from descending properly and is therefore counterproductive in stabilizing the spine.

At this point I would like to present the results of two interesting MRI studies of the diaphragm by Professor Kolar and colleagues that demonstrated that the diaphragm has dual functions of respiration and stabilization.

The first study (1) demonstrated that the diaphragm has a postural function that can be voluntarily controlled and is independent upon breathing.

The second study (2) showed that the diaphragm can performed its dual functions of stabilization and respiration simultaneously. The diaphragm can perform the breathing task at a lowered position ensuring that the stabilizing pressure is maintained throughout the breathing cycles. There is a close relationship between the diaphragm and Transversus Abdominis which contributes to the respiratory and postural control.

These two studies pointed out that the activity of the diaphragm during stabilization varies greatly amongst individuals, which supports Kolar’s clinical evidence that individuals with limited capability to contract the diaphragm for stabilization have a higher risk of developing back-pain.  The simultaneous activation of the diaphragm’s dual functions is the key to proper core stabilization

It is interesting to note that in the study by Hodges and colleagues which started the core craze, it showed that not only the transversus abdominis but also the diaphragm was activated to stabilize the trunk prior to any limb movement. The transversus got all the attention and turned into the core super-star while the diaphragm got ignored.

Respiratory function of the diaphragm

During inspiration the diaphragm contracts and pushes down into the abdominal cavity which decreases the pressure in the thoracic cavity and the lungs fill up with air.


The diaphragm participates in all breathing patterns whether they are ideal or dysfunctional. You cannot avoid using the diaphragm when breathing even if you try, unless there is a medical condition preventing the diaphragm from contracting. The commonly used instruction “breathe with the diaphragm“, has no value.  Chest breathing and straight belly-breathing, where only the posterior part of the diaphragm pushes downwards, are two commonly observed dysfunctional breathing patterns, which reduce both the respiratory capacity and core stabilization. In ideal diaphragm contraction the entire diaphragm pushes down into the abdominal cavity and can be observed by an expansion of the lower ribcage and the abdominal wall in all directions.

Assessing diaphragm function

Breathing AssessmentThe diaphragm’s respiratory function can be assessed sitting or lying on the back. Holding the fingers at the lower ribcage, an examiner can feel for a lateral expansion of the ribcage and activation of the postero-lateral parts of the abdominal wall.  An upward or inward movement of the ribcage is a sign of dysfunctional breathing.

Next, the subject’s ability to pressurize all the way down to the lower part of the abdominal cavity when breathing is assessed, both in laying and sitting (holding the ribcage down assists the activation) .

Proper Breathing

After that, the postural function of the diaphragm is assessed. Instruct the individual to pressurize all the way down to the bottom of the abdomen while holding their breath. The instructor should be able to feel the pressure against a hand placed at the lower abdomen.

And finally, get the person to breathe all the way down to the lower abdomen and then maintain that pressure while going through normal breathing cycles. The diaphragm is now performing its breathing function at a lower position. This is real core stabilization.

Each of these steps should be properly activated and the testing positions are excellent to use as entry-level exercises. A resistance band can be strapped around the ribcage or the lower abdomen to pressurize against. It is worth spending a fair amount of time ensuring proper activation of the core before progressing to other exercises.

Here is a video, explaining core activation from the inside out:

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Once proper activation of the core is achieved, only the individual’s imagination limits the exercise progression. Planks, bird-dogs, dead-bugs would be reasonable next steps. Uni-lateral work is an inventive way of keep challenging the core.

Frequently we see discussions regarding whether to perform core-exercises before or after other exercises. After reading this I hope everybody can see that once the diaphragm is properly activated the core will be trained in all exercises and activities. Proper core-activation is fundamental and should be part of everything we do.

The ability of the core to stabilize the spine and torso is the limiting factor in all exercises. Pay close attention to the signs of proper core activation.


Abdominal Wall

My favourite method of determining if the core is activated is to observe the lower lateral abdominal wall.  If there are concavities the core is not properly activated. Concavities indicate a Rectus Abdominis dominant pattern.

The contour of the abdominal wall should take on a balanced, slightly rounded appearance which should be maintained throughout performing the exercise with normal respiration.

Some individuals cannot activate the diaphragm properly by themselves and I would recommend they seek assistance from a DNS or Postural Restoration Institute trained Practitioner. Practicing with faulty patterns will only reinforce the dysfunction.

Core-stabilization has to come from the inside out and is controlled via the diaphragm. I recommend anyone who is interested in improving their performance and preventing low back pain to spend the required time to properly activate the core. It is really worth it. I have had experienced Strength athletes achieve new PB’s straight after we have activated their core.



1-   Kolar P, Neuwirth J, Sanda J, Suchanek V, Svata Z, Pivec M. Analysis of diaphragm movement during tidal breathing and during its activation while breath holding using MRI synchronized with spirometry. Physiol Res 58:383-392, 2009

2-   Kolar P, Sulc J, Kyncl M, Sanda J, Neuwirth J, Bokarius AV, Kriz J, Kobesova A. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Applied Physiol Aug 2010


About the author:

Hans LindgrenHans Lindgren is a Doctor of Chiropractic and DNS Practitioner in Brisbane, Australia.  He has a special interest in Functional Stabilization, Rehabilitation and Sports-Performance. Hans runs courses about these topics and also writes a blog on

Free Lower Body Assessment Video by Eric Cressey

Eric Cressey Lower Body AssessmentFor those that have read this website for some time, you know that I am a big fan of online education.  That is why I do this.  I always talk about how much I personally enjoy and learn from websites like,, and  I have had 100’s of people join my in my online mentorship program on the shoulder at  These are all great resources that I use almost daily.

I was recently talking to my friends Eric Cressey and Mike Robertson.  They have  teamed together with Dave Schmitz and BJ Gaddour to start offering an online virtual mentorship program.  This is a no-brainer resource for personal trainers and strength coaches, but I can’t stress enough to the physical therapy, athletic training, and other rehab communities how much I have learned from these guys over the years.  Integrating the thoughts of great strength coaches has made me a better clinician, no doubt in my mind.

These guys are going to share with the world how they deliver staff training, teach movements, design programs and get results for their clients.  I can’t tell you how jealous I am of these guys for being able to share their knowledge in this format.  I wish I could do something like this, but it’s a little different in my current setting, perhaps one day!

They’ll be releasing this program, Elite Training Mentorship, next week but in the mean time Eric just shared an example of some of the great information they’ll be providing.

Watch Eric deliver a complete staff training on Lower Body Assessments.  This is exactly what Eric uses to train his staff and work with his clients.

If you are interested in the Elite Training Mentorship, members will get private access to a secure website where our Eric, Mike, Dave, and BJ will upload private, member only curriculum like:

  • Videos from staff training they hold in their own facilities
  • Examples of programs they’ve written for their actual clients
  • Video examples of how they teach exercises and progressions
  • Handouts they provide to their own staff or interns
  • Templates they use in their own business

I would definitively check this out, as you will get amazing inside access to the minds of some great coaches.  But at least check out the free video from Cressey.  I just finished watching it and thought he did a really good job.

[button link=””]Watch the Free Video[/button]

Movement Quality and Compensation

Movement QualityAs humans, we have all mastered one thing in regard to motor control and function – compensation – not exactly the greatest when we talk about movement quality.  We will develop a motor strategy and pattern to accomplish our goals, regardless of wether or not it is efficient.  Many probably consider this a positive trait, but not for those of us that emphasize human performance enhancement.

Can’t extend your hip with your glutes?  Oh well, I guess you have to use your hamstrings more.

Is your rotator cuff torn?  Shoulder stiff?  Well, guess what?  You are still going to figure out a way to reach up and grab something overhead.  Perhaps you will wing your scapula more or contort your spine to accomplish this range of motion, it doesn’t matter exactly what, but you WILL find a way to accomplish this task.

This is even more obvious when we start to talk about those that use their bodies to it’s highest potential, such as athletes.  It seems like athletes can adapt to things like fatigue, tightness, and weakness and still develop a motor strategy to perform successfully.  Perhaps this is what makes them the elite athlete, the ability to compensate better than everyone else!

[box]We have all probably been guilty of getting caught up in worrying about the quantity of movement instead of the quality of movement when looking for dysfunction.  [/box]

Every motion has a group of prime movers and a group of secondary movers.  This is important so that if you have dysfunction of one muscle, you can compensate and still function.  But don’t forget that sometimes our job is to activate that prime mover and get back to efficient movement patterns, focusing on restoring the quality of the movement.

FMS gray cook DVDIf you are interested in this kind of thought process, be sure to check out Gray Cook’s new DVD FMS: Applying the Model to Real Life Examples from Perform Better.  I just ordered a copy and haven’t had a chance to check it out, but it sounds excellent as usual from Gray.  I’ll try to post a review of the DVD after I get a chance to watch it.

Sometimes our goal is not to just see IF a person can move from point A to point B, but rather to see HOW a person performs this task. Keep this in the back of your mind with every person you work with and you’ll gain a new appreciation of performance enhancement.


The Importance of Hip Flexion Strength

Today’s post is a guest article written by Chris Johnson on the the importance of hip flexion strength when dealing with lower extremity pathology.


The Importance of Seated Hip Flexion Strength

Just over eight years ago, I accepted my first job as a physical therapist at the Nicholas Institute of Sports Medicine and Athletic Trauma (NISMAT) of Lenox Hill Hospital. This experience afforded me the opportunity to train under the late Dr. James A Nicholas, one of the “Founding Fathers” of sports medicine, and the winner of the 2004 President’s Cup award from the Sports Section of the American Physical Therapy Association (APTA). One of the greatest lessons I learned from Dr. Nicholas pertained to “linkage” and the importance of assessing seated hip flexion strength in patients presenting with lower extremity pathology, especially patellofemoral pain syndrome (PFPS).

In 1976, Dr. Nicholas and colleagues published an article in The American Journal of Sports Medicine entitled, “A study of thigh muscle weakness in different pathological states of the lower extremity.” This study documented that subjects with patellofemoral problems exhibited significant hip flexor weakness on the involved side when compared to a group of controls. Furthermore, Dr. Nicholas and his co-authors concluded that the hip flexor resistance test affords a quick and accurate way of detecting unilateral weakness of the trunk, thigh flexors, and quadriceps group making it a valuable clinical assessment tool.

More recently (2006), Tim Tyler and colleagues did a study investigating the role of hip muscle function in the treatment of PFPS. This study corroborated Dr. Nicholas’s original findings and demonstrated the importance of addressing hip flexor strength in the context of PFPS. The authors proposed that improving hip flexor strength helps to establish a stable pelvis during gait thus preventing it from going into excessive anterior tilt, which would result in excessive femoral internal rotation. The iliopsoas is also a secondary femoral external rotator and strengthening this muscle helps to align the trochlear groove and patella. It should also be mentioned that this study documented the importance of establishing adequate flexibility of the hip flexors and iliotibial band (ITB), which would induce posterior pelvic tilt and relative femoral external rotation. One of the major takeaways from this article is that in addition to resolving any hip flexor tightness, it is also important to ensure adequate strength of this muscle group.


Assessing Hip Flexion Strength

While clinicians and fitness professionals routinely assess for and correct hip flexor tightness, it has been my experience that screening for hip flexor weakness in a seated position is not routinely performed. Considering the research, medical and allied health professionals should include this as part of their screening or examination process, especially in the context of lower extremity pathology such as PFPS. To perform this test, the patient should be seated at the edge of a table or plinth with their back straight and legs dangling over the edge of the table while holding on to the front of the table. The patient is then instructed to flex one hip by bringing the knee up towards the chest and to hold it in place while the examiner pushes down on the thigh with the palm of his or her hand. Comparison is then made to the contralateral side. It is the author’s opinions that break testing is the best approach to strength test the hip flexors given the limited range available in a seated position. Standard manual muscle testing grades can be applied or clinicians can use a handheld dynamometer/manual muscle tester to establish a more specific strength index.

When assessing seated hip flexion strength, there are several key to ensure the test is properly performed. First off, patients should have 120 degrees of clean hip flexion so that they can get the involved extremity in to the proper test position without any compensatory motion. Secondly, patients should hold on the front of the plinth to prevent leaning back, which is a common substitution or trick movement when testing hip flexor strength. This will allow the examiner to isolate the hip flexor muscle group as well, thereby ensuring accurate results. Lastly, pay close attention to the low back during testing as patients presenting with hip flexor weakness often fall into excessive anterior pelvic tilt secondary to poor spinal stability, which can result in shearing of the lumbar segments. This may also indicate the need to incorporate spinal stabilization exercises in to the overall treatment program.  Here is a quick video demonstration:

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Next time you find yourself evaluating or treating a patient suffering from a lower extremity injury, make sure to test their seated hip flexion strength, especially in the context of PFPS.  And remember that it is not only important for the hip flexors to be extensible but also for them to be STRONG, and without assign hip flexion strength you’ll never know!



  1. Nicholas JA, Strizak AM, Veras G. A study of thigh muscle weakness in different pathological states of the lower extremity. Am J Sports Med. 1976 Nov-Dec:4: 241-8.
  2. Tyler TF, Nicholas SJ, Mullaney MJ, McHugh MP. The role of hip muscle function in the treatment of patellofemoral pain syndrome. Am J Sports Med. 2006 Apr; 34(4): 630-6.


About the Author

Chris Johnson, MPT, MCMT, ITCA is a physical therapist and competititive triathlete.  He has a private physical therapy practice in Manhattan.  Youcan learn more from Chris at his website and Twitter.

Chris has a great website that has a lot of information, especially in regard to running and triathlons.  Thanks for such a great article on the importance of hip flexion strength!




The Difference Between the Location of Symptoms and the Source of Dysfunction

kinetic chain ripple effectLast week we talked about the kinetic chain ripple effect theory and how the kinetic chain has an impact throughout the body, but more of an impact closer to the source of dysfunction.  For this week, I wanted to discuss 3 common injuries that we all see that may actual just be a symptom, and not the actual injury or source of dysfunction.

As a general rule of thumb, we should probably consider that many of our traditional “injuries” that seem to be relentless and not responsive to treatments may actually be coming from elsewhere in the body.  Think back to how patellofemoral pain has been referred to as “the black hole” of orthopedics and how surgery and rehabilitation to correct patella alignment is often unsuccessful.  Perhaps patellofemoral pain is actually just a symptom and not the source of dysfunction.

Below are what I have found to be 3 common “injuries” that may actually just be symptoms from dysfunction somewhere else within the kinetic chain.  There are many more than 3, but these are likely to be some of the most common that you may encounter.  Feel free to leave a comment of more examples that you have encountered.  Furthermore, all three fit into the kinetic chain ripple effect theory as the source of dysfunction is pretty close to the location of symptoms


Groin Pain – Source: Hip Joint

I have to admit that in my career I have been stumped by groin strains that seem to be difficult to treat or frequently reinjured.  I am sure we have all seen this in our practices, groin pain that doesn’t really look like a groin strain, but what is it?  As our understanding of the hip has improved, we find that many people with intra-articular hip joint pathology present with groin pain, which is a common pain referral pattern from the hip joint.

Next time you have a patient with groin pain, clear the hip, you’ll be surprised how many times we find that the symptoms are coming from the hip and that will drastically change our treatment program.


Lateral Epicondylitis – Source: Cervical Spine

lateral epicondylitisAnother commonly misdiagnosis that I have seen involves lateral epicondylitis.  The C6 nerve root is one of the most commonly involved nerve roots involved in cervical radiculopathy as it exits between the 5th and 6th vertebrae.  Any radiculopathy from this nerve root can cause weakness in wrist extension.  I have seen even a subtle loss of strength of wrist extension cause a raging lateral epicondylitis.  Sometimes this weakness is so subtle that the person doesn’t even realize they have weakness until it is too late.  We continue to function and use our hands with this weakness and overload the area.  So, we can treat the heck out of the lateral epicondylitis, but if we don’t solve the nerve root issue at the cervical spine we will never regain the wrist extension strength that is needed to decrease the symptoms of lateral epicondylitis.

Patellofemoral Pain – Source: The Hip

patellofemoral painWe’ve spent a lot of time discussing the contribution of the hip has on symptoms of patellofemoral pain.  [If you haven’t yet, this would be a great time to sign up for my newsletter and receive a bunch of goodies, including my eBook on Solving the Patellofemoral Mystery.]  Over the last several years, we have made a giant leap in our understanding of why some forms of patellofemoral pain occurs.  More often than not, weakness and dysfunction of the hip muscles, specifically the abductors and external rotators, is a leading cause of biomechanical faults at the knee and subsequent patellofemoral pain.  Similar to lateral epicondylitis above, you can treat the symptoms all day but you aren’t going to solve the problem if you don’t address the source, weakness and dysfunction of the hip.


Take Home Message

I’m sure that many of my readers have observed all of the above findings.  Please do comment and add more examples.  So what is the take home message?  For the younger clinicians in the audience, I guess it would have to be that we should probably take a step back a rethink all of the injuries that we see that we consider “difficult to treat” or “unrelenting” such as lateral epicondylitis and patellofemoral pain.  Maybe we need to think of the bigger kinetic chain principle.  Perhaps we are only treating the symptoms and not the true source of the dysfunction.  So next time you seem to have a patient that is not responding to your treatments, take a step back, re-evaluate and assess elsewhere in the kinetic chain and make sure that you haven’t missed the true source of the person’s symptoms.

Does Hip Range Of Motion Correlate to Low Back Pain? Maybe Not in Everyone

hip range of motion back painThe correlation between hip range of motion and low back pain is commonly discussed, though most people tend to agree that limitations or asymmetries in hip motion is a contributing factor to low back pain.  You can read a summary of some research on the correlation between low back pain and hip range of motion in a previous post of mine.  But while there are several studies that show this to be true, there are also some studies that show no correlation at all.  To me, this isn’t very surprising as you really need to assure adequate control of study methodology when designing a research project like this. Grouping several different body types, activity levels, and handiness (righties and lefties) as well as poorly defining “low back pain” can surely throw a wrench in your project and possible allow some false assumptions.


Does a Small Loss of Hip Motion Matter to Everyone?

Biomechanically, a loss of hip motion contributing to low back pain makes perfect sense.  Any lack of mobility of the hips needs to be compensated for elsewhere, and unfortunately this will likely occur in the lumbar spine.  The knee is pretty stable, I can see the foot and ankle also contributing, but realistically moving at the lumbar spine is probably going to achieve the person’s goal of rotating the pelvic region the easiest.  This is unfortunate as we would all rather rotate from our hips and thoracic spines rather than lumbar spines.

hip range of motion contribute to low back painWhen looking closely at the research studies that show correlations between lose of hip motion and low back pain, subjects with low back pain had ~5 degrees less motion of their hips.  That is a decent amount of loss of motion, but I’m not sure 5 degrees is limiting for all people.   What if the person you are working with doesn’t need to use their body in the end range of rotation very often?  I bet that the majority of sedentary people don’t really need full hip range of motion to perform their everyday activities.  Walking, for example, only requires approximately 15 degrees in hip and pelvic rotation, no where near full motion.  Yes, a large deviation in hip range of motion will likely be a problem in everyone, but would a small amount of loss of hip rotation impact everyone’s chances of suffering from low back pain?  Maybe not.


Hip Range of Motion and Low Back Pain in Rotational Athletes

hip range of motion correlate to low back painRecent studies have assess the correlation between hip range of motion and low back pain in rotational sport athletes, sports like tennis, racquetball, and golf.  To me, this is a much better study design using a specific population of people that need to function at their end range of spine, pelvic, and hip rotation.  One particular study that I thought did a great job with research design, methodology, and subject selection was by Van Dillen in a 2008 issue of Physical Therapy in Sport.

The authors examined 48 subjects that participated in rotational sports.  When comparing those with a history of low back pain to those without, subjects with low back pain exhibited significantly less motion of their hips and significantly more asymmetry between their two hips.  The rotation of their left hips were more limited than their right hips, though only 1 subject in the group was left handed, so I’m not sure if this finding is significant to me or not.

So far, studies looking at rotational athletes have all shown a positive correlation between hip range of motion and low back pain while other studies with less specific patient populations have showed less consistent findings.  So does this mean that tight hips correlate to low back pain?  In rotational athlete it looks like the answer is yes, but in sedentary people, maybe not.

Photo by StuSeeger

Assess All Factors

Regardless, I agree with the thought process of “why not” work on everyone’s tight hips anyway, but just food for thought when working with your next person with low back pain.  Resist the urge to go with what is trendy now and bark up the wrong tree.  Don’t just assume that because they have 5 degrees less hip IR on one side that this is the main contributing factor in their back pain.  Thoroughly assess each person before assuming that their loss of hip range of motion contributes to low back pain.

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