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!

 

References:

  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 ChrisJohnsonPT.com 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.

Femoroacetabular Impingement – Etiology, Diagnosis, and Treatment of FAI

femoroacetabular impingementFemoroacetabular impingement is a pretty hot topic right now.  This week, we have a great guest post from frequent contributor Trevor Winnegge.

Recently, femoroacetabular impingement, or FAI, has been increasingly recognized as a cause of hip pain. While femoroacetabular impingement can be a source of hip pain at any age, this post will focus primarily on the adolescent and young adult.  Femoroacetabular impingement is considered a cause of labral and chondral injuries as well as secondary osteoarthritis of the hip. Emerging evidence suggests that early surgical intervention improves function and perhaps prevents or delays the onset of degenerative changes in the hip joint.[1] I hope to provide a thorough overview of FAI, the signs and symptoms of it, and how to treat FAI in an effort to allow us to play an important role in the management of these patients.  (Photo from Bryan Kelly)

What is Femoroacetabular Impingement?

Femoroacetabular impingement occurs when the femoral head and acetabulum rub abnormally, resulting in damage to the articular cartilage and/or the labrum, as well as limited range of motion (ROM). FAI is commonly classified into 3 forms

  1. Cam impingement deformity
  2. Pincer impingement deformity
  3. Mixed impingement deformity resulting in a combination of the two.

These are clearly seen in the following illustration taken from Lavigne et al.[2]:

femoroacetabular impingement

In a Cam impingement, there is an abnormal contour of the femoral head-neck junction, resulting in impingement against the acetabulum, particularly with flexion, internal rotation, or a combination of flexion and internal rotation of the hip.[3]

Pincer impingement is caused by an acetabular abnormality, usually anterior, resulting in overcoverage of the femoral head. This could be an isolated bony protrusion or it could be a degree of acetabular retroversion. Here the ROM is limited as the femoral head impacts the extended acetabulum which can also lead to labral tears and chondral lesions.[5]

A Mixed type of femoroacetabular impingement is a combination of both Cam and Pincer impingement deformities. It is important to note that both Cam and Pincer impingement have been associated with progressive joint degeneration.

Etiology of Femoroacetabular Impingement

Femoroacetabular impingement is linked to childhood hip disorders such as Legg-Calve-Perthes Disease, Slipped Capitol Femoral Epiphysis, hip dysplasia, septic hip, and prior fractures of the pelvis or femur. [7] Despite those correlations, the majority of FAI cases are of unclear etiology[8]. It is theorized that physeal stresses placed on the femoral head and/or acetabulum during development may play a key role in the onset of FAI. Activities such as gymnastics, dancing, and rigorous sports during the development process are potential sources of FAI.

Diagnosis of Femoroacetabular Impingement

hip c signDiagnosing femoracetabular impingement starts with a good subjective history. Patients will often complain of hip or groin pain- laterally, anterior or posterior. This pain is often acute during a sporting activity or will be insidious onset after prolonged exertion. Patients with FAI are often quite capable of completing their daily tasks, but have difficulty with high demand sports/activities. Typically there is no rest or night pain. When asked to pinpoint their pain, they will often demonstrate a “C” sign, described by Byrd[9], and seen below in this picture from hiparthroscopy-Ireland.com[10].

Patients will report a lack of ROM of the hip, which in an adolescent patient is often described as a functional deficit such as “I can’t do a split anymore” or “I can’t move my leg in this position”. When asked about their activity level, these patients will often be involved in a high level sport or activity such as dance, gymnastics, lacrosse, hockey, tennis, baseball, and football. Objectively, there will be a loss of ROM, particularly hip flexion, IR and adduction. Joint capsule hypomobility may or may not be present. A positive hip impingement sign will often be present, which is flexion, adduction and IR of the hip in a combined movement[11].

Diagnostic Imaging in Femoroacetabular Impingement

Plain film X-rays are most commonly used to view the bony changes of the femoral head and acetabulum. MRI or MR-arthrograms are useful in diagnosing secondary injuries such as chondral lesions and labral tears.

Differential Diagnosis for Femoroacetabular Impingement

Often times, patients with femoroacetabular impingement get misdiagnosed early on and are treated for a variety of diagnoses such as back pain, hip pain, groin pain, bursitis, piriformis syndrome, tendonitis of iliopsoas, groin strain, apophysitis, and “growing pains”[12].

Treatment of Femoroacetabular Impingement

While surgical management of the femoroacetabular impingement remains the an option for treatment, non-operative care can sometimes be successful. Unfortunately, we can not alter the bony changes, but we can normalize soft tissue length, joint capsule mobility, strength and educate on joint preservation techniques. Think of it as treating a patient with a large bone spur in the shoulder that has subacromial impingement. Treatment can be successful despite the bony changes, if the objective deficits are addressed. The success of conservative care for FAI is largely dependent on the patients willingness to modify their sport/activity and become less active in impact sports.

For most adolescents and young adults, this is not an option. While most patients will try conservative care first, often they are unable to fully participate in their sport/activity and seek further management of their FAI. Surgical management can be done open or via the arthroscope, which is becoming the more commonly used method due to its lower level of invasiveness. Surgical treatment is aimed at addressing the secondary injuries such as the chondral lesions and labral tears. The surgeon will address the primary cause of the femoracetabular impingement, typically performing a decompression/osteoplasty.[13] Post-operative rehabilitation is dependent on the procedure performed (labral debridement vs repair; open vs arthroscopy, etc). Typically, recovery from most FAI surgical procedures is 3-4 months, with the expectation that the patient is then able to return to full, unrestricted activity and sport.

In conclusion, I think it is important that we are aware of femoroacetabular impingement and the presentation of FAI. Given it is often misdiagnosed early on, we can play an integral role in the management of these patients. Early diagnosis and treatment is critical for long term health of the hip joint and to allow the patient a lifetime of active living.


  • [1] Roy D. Arthroscopy of the hip in children and adolescents. JChild orthop. 2009 April; 3(2):89-100.
  • [2] www.hipfai.com
  • [3] Leunig M, et al. The Concept of Femoroacetabular Impingement: Current Status and Future Perspectives.
  • Clin Orthop Relat Res. 2009 March; 46793): 616-622.
  • [4] http://www.choa.org/child-health-glossary/f/fe/femoroacetabular-impingement
  • [5] Leunig M, et al. The Concept of Femoroacetabular Impingement: Current Status and Future Perspectives.
  • Clin Orthop Relat Res. 2009 March; 46793): 616-622.
  • [6] http://www.choa.org/child-health-glossary/f/fe/femoroacetabular-impingement
  • [7] Leunig M, et al. The Concept of Femoroacetabular Impingement: Current Status and Future Perspectives.
  • Clin Orthop Relat Res. 2009 March; 46793): 616-622.
  • [8] Philippon M, et al. Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression. Knee Surg Sports Traumatol Arthrosc. 2007 July; 1597):908-914.
  • [9] Byrd JW (2005) Operative hip arthroscopy, 2nd edn. Springer, Berlin.
  • [10] www.hiparthroscopy-Ireland.com
  • [11] Dooley P. Femoroacetabular impingement syndrome. Can Fam Physician. 2008 January; 5491):42-47.
  • [12] www.hipfai.com
  • [13] Ilizaliturri V. Complications of Arthroscopic Femoroacetabular Impingement Treatment: A Review. Clin Orthop Relat Res. 2009 March; 467 (3): 760-768.

Trevor has been practicing PT for over 10 years. He graduated from Northeastern University with a bachelors in PT and a master of science degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He is currently the Clinical Coordinator of Rehabilitation at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA.

Mike’s Thoughts

Trevor, great post as always.  Femoroacetabular impingement is a diagnosis that we are seeing more of each year, likely from a combination better awareness and diagnostics.  Unfortunately, we have all probably all missed some patients that were having early symptoms of FAI and treating them for the wrong reasons, like groin pain!  Personally, I have seen “groin strains,” “hip flexor strains,” and even “oblique strains” that were probably actually coming from the hip joint.  Bottom line to me, if the symptoms and exam are not adding up or the person is not responding to treatments be sure to clear the hip of FAI symptoms to make sure you are not missing femoroacetabular impingement.

In regard to treatment, there really are some similarities to the shoulder that can help take the “fear of the unknown” out of treating the hip.  For example, a pincer lesion is really pretty similar to hooked acromion.  How do we treat that in the shoulder?  Open up the subacromial space with retraction and posterior tilt of the shoulder.  How would we treat the hip?  Open up the joint with posterior pelvic tilting, and gaining mobility of the groins and hip flexors.  Just one quick example but enough to get our brains rolling!

If you want to see a great webinar on these types of hip injuries, including some surgical demonstration videos, there is a great webinar on the Recognition and Treatment of Hip Injuries at RehabWebinars.com.  If you are a subscriber, search for that webinar.  If not, click here to learn how to get access to this webinar and many more at RehabWebinars.com.

RehabWebinars.com

 

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Graston Technique: A Case Study and Other Thoughts on Instrument Assisted Soft Tissue Mobilization Techniques

[box type=”note” icon=”none”]UPDATE: There is a new article that discusses my current recommendations for the best IASTM tool.  This newer article contains my updated recommendation for several Graston alternatives and information on my online educational programming teaching you how to use IASTM.[/box]

Today’s guest post is quick overview of the Graston technique and it’s application within a case study by Eric Schoenberg, MSPT, CSCS.  I thought Eric did a great job with the post and have will share some of my thoughts on instrument assisted soft tissue techniques, such as Graston technique, at the end of this article.

Graston Technique

graston techniqueRegardless of treatment philosophy, it is difficult to dispute the importance of soft tissue work to help treat pathology, correct muscle imbalance, decrease recovery time, and restore proper muscle recruitment and firing patterns.

While there are many available soft tissue options, in my practice, I have found Graston techniques to be particularly useful in both treatment and evaluation.  Many people don’t realize that the Graston technique can also be a valuable diagnostic tool to quickly “scan” or evaluate a patient’s soft tissue quality and determine its contribution to a patient’s current symptoms or injury risk factor.

The Graston technoique concept is grounded in the works of English orthopedist James Cyriax and the concept of cross fiber treatment. The treatment edge of the Graston instruments allows for improved precision in the treatment of fascial restriction and fibrotic/scar tissue.

I wanted to share my experience and techniques with the Graston technique and will use a case study to illustrate the benefits and specificity of the Graston Technique.

The patient is an 18 year old male who is a 3-sport athlete (football, basketball, baseball) presenting with 9 month history of anterior knee pain consistent with patellar tendinosis. The patient presents with the following objective findings at evaluation:

  • Point tenderness at inferior pole of patella
  • Pain at end-range supine and prone knee flexion
  • Pain with resisted concentric and eccentric knee extension (Kendall MMT position)
  • Decreased hip mobility B
  • Decreased ankle DF ROM B
  • Decreased lumbopelvic/hip and single leg stability
  • Decreased gluteal/core strength B

The patient is participating in pre-season football conditioning with emphasis on sagittal plane squat/split squat/lunge activities, sprinting (including hills), and plyometrics (sagittal plane). He is using foam roller daily on own to improve tissue quality. His symptoms are gradually worsening with increased training intensity.

After evaluating the patient, I decided to include Graston technique treatment focused on the quadriceps, ITB, adductors, hamstring, gastroc/soleus, and tibialis anterior muscle groups.  Here are a couple of examples:

Graston Technique – Seated Quadciceps

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Graston Technique – Seated Patellar Tendon

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One specific application of Graston technique is the ability to effectively treat the injured area in positions of provocation. This patient experiences symptom reproduction in the split squat/forward lunge position:

Graston Technique – 1/2 Kneel Position

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Graston Technique – Dynamic With Squat:

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Treatment Outcomes

The patient was seen for 3 treatments with full resolution of symptoms. Treatments consisted of the following:

  1. 1. Tissue quality: Graston technique, daily lower body foam roller program
  2. 2. Mobility: hip and ankle mobility exercises, active warm-up corrective exercises
  3. 3. Multiplanar strength: frontal and transverse plane strength (emphasized single leg activity, band walks, lateral lunges, lumbopelvic stability- chops/lifts)
  4. 4. Activity Modification: patient educated in proper jump/land technique, limited sagittal plane repetitions, proper muscle firing patterns

Clinical Observations From Using the Graston Technique:

1. The specificity of the treatment edge and the ability to provide uniform pressure is what sets the technique apart from other manual approaches.

2. The instruments truly enhance the clinician’s ability to detect and treat fascial restrictions and adhesions (particularly effective in positions of provocation).

3. Incorporating stretching and strengthening (tendon-loading) exercises with the instrument assisted soft tissue mobilization is the key to promoting re-alignment of the fibers and helping to fully remodel the injured tissue.

4. Coupling Graston in the clinical setting with self myofascial release (SMR) products, such as foam rollers and other similar equipment at home or in an athletic setting (pre/post activity) is an ideal way to achieve maximum success.

Lastly, at least for me, the most exciting part of using Graston Technique in the clinical setting is feeling better suited to treat the more difficult diagnoses (plantar fasciitis, chronic tendonosis, etc) with the expectation of good clinical outcomes.

 

My goal in writing this article is to present a simple case to allow the reader to appreciate the functionality and ease of use of the Graston Technique. In addition, it is important to note that Graston (along with any soft tissue treatment) should be used in conjunction with skIASTMilled movement evaluation and prescription of corrective exercise to allow for the most effective clinical outcomes.

Eric Schoenberg, MSPT, CSCS is co-owner of Momentum Physical Therapy with offices in Milford, MA and Wellesley, MA.  The owners of Momentum PT are experts in the human movement system. Their mission is to bridge the gap between traditional medicine and fitness with emphasis on patient education and injury prevention.  Visit eric’s blog at www.momentumptblog.blogspot.com.

 

Mike’s Thoughts

[box type=”note” icon=”none”]UPDATE: There is a new article that discusses my current recommendations for the best IASTM tool.  This newer article contains my updated recommendation for several Graston alternatives and information on my online educational programming teaching you how to use IASTM.[/box]

Eric, great article and examples of use of the Graston technique.  I’m sure the patient got better from your very well thought out treatment plan and all of the techniques and exercises you performed in combination with Graston technique.

It is important to note that while this article is specifically about the Graston technique, it also applies to instrumented assisted soft tissue mobilization (IASTM) techniques in general.  Late last year I polled my readers and 20% of you said you used IASTM, including Graston technique, SASTM, and ASTYM.  We could also group in the traditional Gua Sha to this mix as well.

I have used these techniques and do incorporate IASTM in my practice, I have also taken the basic Graston class (though have not taken SASTM and ASYTM classes and have not used their tools).  Here are my thoughts:

  • IASTM is a valuable component of my treatments, but just a component.  Just like everything else, it has its value and it has areas where I would choose another technique.
  • There are a lot of misconceptions here and the internet makes this worse – a huge black and blue down the leg is not what you are trying to achieve using IASTM.  I consider this a sign that you’ve done too much.  This is a misconception.
  • The actual Graston Technique tools and courses are really good.  If you have the budget to go all out for these, great, they will be great to work with. Visit their website for more info, I would be surprised if you were not satisfied with the course and their tools.  They have put a lot of thought and effort into their technique and tools.
  • I do not use the Graston instruments.  I think many more people should learn IASTM techniques.  If you really like the technique and want to learn more or get the better Graston tools, great.  But cost should not be a reason that you don’t learn how to use IASTM.
  • In regard to tools, I go traditional Gua Sha from China.  I have tried other tools, like the Starr Tool, they are good, but more expensive.
  • In regard to Gua Sha tools, you can Google them, there are many shapes and materials for anywhere from $2 to $10.  Horn is a good starting point, but in the grand scheme I would grade them as stone > jade > horn.  Just my opinion.  I have a bunch of horns as they come in a variety of versatile shapes, and a few jades and stones.  So far Bian or Energy stones have felt best for me, but these are closer to $20-$40.  Still cheap in contrast to some of the other instruments.  If you are not sure, start with the horn.

 

What do you think?  What has been your clinical experience with Graston technique, instruments, and other instrument assisted soft tissue mobilization techniques?

Ankle Dorsiflexion Mobility Impairs the Lateral Step Down Test

Deficits with ankle dorsiflexion mobility can have a dramatic impact on functional movements such as deep squatting, lunging, and the lateral step down.  If you are familiar with the functional movement screen, you know that this is taken into consideration when a person does not grade out with a perfect score on many of the tests.

The Lateral Step Down Test

lateral step down testOne component that I have always felt is missing from the functional movement screen (FMS) is assessing the lateral step down.  I understand that the FMS needs to be applicable to a large variety of people and that the hurdle step test is included, but I have always felt I gain additional information from using the lateral step down test, especially in high level people.

I feel that the lateral step down test is an important test to include in your movement screening as it is often a movement that is dysfunctional in people with patellofemoral pain, patellar tendonitis, ACL injuries, and other lower extremity injuries.  During the lateral step down movement, the body is challenged in a very dynamic position to produce a combination of lower extremity strength, foot and ankle stability, core stability, and probably most importantly the ability to eccentrically control or decelerate the weight of the body.

A common finding during the test is the person that can’t resist medial displacement of the knee, resulting in hip adduction, hip internal rotation, and pronation at the subtalar joint.  This places the individual in a very disadvantageous position and makes them more susceptible to lower extremity injuries.  When analyzing people with this dysfunctional movement pattern, weakness of hip abduction and external rotation is commonly found.

Ankle Dorsiflexion Tightness Alters the Lateral Step Down

Ankle Dorsiflexion TightnessA recent study in JOSPT has found that ankle dorsiflexion restrictions can also cause poor quality of movement during the lateral step down test.  Examiners studied 29 healthy women and coached them through the lateral step down test.  The subjects were graded on the quality of their lateral step down with a 6 point scale.  Results showed that subjects that performed poorly in the lateral step down test had a significant amount of ankle dorsiflexion mobility restrictions when measured in both weightbearing and nonweightbearing.  Dorsiflexion was ~10 degrees more in subjects that scored well on the lateral step down test.

Interestingly, the authors did not find a correlation between hip abduction and hip external rotation strength with poor movement quality during the test.  I was surprised by this finding but realize that there were some limitations of the study, such as the use of healthy subjects that were coached well on technique.  I continue to believe this as experience and other past research has shown this, perhaps the limitations of the study can help explain.

In my experience, the three areas that I have focused on when someone does not score well on the lateral step down test are:

  1. Hip weakness, specifically hip abduction and hip external rotation
  2. Subtalar pronation
  3. Core stability

But the results of this study are going to make me assess ankle dorsiflexion a little more closely.  It makes sense that if ankle mobility is limited, the body would have to compensate to perform the task.  In this example, to achieve greater depth of motion while stepping down, the hip strategy observed was potentially due to the lack of ankle dorsiflexion.

In your experience have you seen this?  How many people incorporate the lateral step down test in their functional movement screen, and why or why not?  The results of this study should show us that ankle mobility, specifically ankle dorsiflexion tightness, can have a profound effect on the lateral step down test.

Risk Factors for Groin Strains in Sports

DSC01635Groin strains and other injuries are very commonly observed in sports, and have been reported to cause up to 16% of injuries in sports like soccer.  For those that work with athletes and who have seen these injuries, you know that groin strains can be tricky and often times become a recurrent problem.  Thus, it is important to identify risk factors associated with groin injuries to assist in identifying those at risk for injury as well as serving as a potential criteria to return to play.

A recent study from the American Journal of Sports Medicine followed 508 soccer players over the course of one season in an attempt to identify potential factors correlating to groin injury.  The authors examined several functional tests (such as jumpy tests and a 40-m sprint) a several clinical examinations including strength, flexibility, and palpation of the hips and lower extremity muscles.

10% of players followed sustained a groin strain.  The authors demonstrated that the two most significant risk factors were:

  1. History of previous groin injury – those with a history of previous groin injuries were twice as likely to sustain another groin injury
  2. Weak adductor muscle – those with weak adductor muscle groups show a 4x greater chance of sustaining a groin injury.

 

Clinical Implications

Several studies in the past have shown similar results in regard to previous injuries and this is one of the main things I preach when developing and implementing injury prevention programs:

The #1 risk factor for muscle strain injuries is a previous muscle strain injury

Therefore, attempting to prevent injuries is key.  The second component of this study is a good step in that direction.  Adductor weakness had a very large contribution to groin injuries.  I think we could also extrapolate this information to other muscle groups as well, such as the quad or hamstring.  The way I think of it is that a healthy athlete with muscle weakness or imbalance is still going to perform at 100% intensity.  But if a specific muscle group was at, perhaps 80% strength, something has to give and a strain occurs.

This information really underscores three take home messages for me:

  1. Past injuries are going to lead to future injuries, often times there was a reason this person was injured the first time, right?
  2. We need to do our best to identify those at risk for injuries to prevent this future cycle of injury and reinjury – this includes screening for muscle weakness and imbalances
  3. We need to make sure that the athlete returns to activities when they have restored this weakness or imbalance.  I bet one of the reasons that these injuries continue to reoccur is because we far too often rely on pain as our criteria to return to play.  Just because the athlete is asymptomatic does not mean they are ready to compete.

What have you found to be helpful in reducing these reinjuries?  What do you do to screen for lower extremity imbalances?  Have you found them to be effective in preventing injuries?

Shoulder Impingement – 3 Keys to Assessment and Treatment

shoulder impingement

Today’s post is in response to a question that I received regarding shoulder impingement rehabilitation and my DVD Optimal Shoulder Performance.

Hey Mike,
I’m watching my
Optimal Shoulder Performance DVDs. You and Eric Cressey did a fantastic job. I’m just curious – how would you manage subcoracoid impingement differently than a subacromial or internal impingement case?  What treatment options for shoulder impingement are suitable?
Thanks,
Mario

Great question Mario and thanks for the kind words on the DVDs.  I’m glad you liked the portion where I show how to differentiate between the different types of  shoulder impingement on your examination.  Let’s discuss this in detail but first take a step back and discuss these types of impingements for those who have not seen the DVD (those crazy people!).

Shoulder Impingement – 3 Keys to Classifying

Shoulder impingement really is a pretty broad term that most of us likely take for granted.  It has become much of a junk term, such as “patellofemoral pain.”  The use of nondescriptive terminology, like “shoulder impingement,” is fine when describing the injury to the general public, but as professionals, it is in our best interest to be as descriptive as possible to assure to assess and treat the person appropriately.  There is no magical “shoulder impingement protocol” that you can pull out of your notebook and apply to a specific person.

There are three things that I consider to classify and differentiate shoulder impingement:

1. Location – This is general in reference to the side of the rotator cuff that the impingement is located, either the bursal side or articular side.  See the photo of a shoulder MRI below.  The bursal side is the outside of the rotator cuff, shown with the red arrow.  This is probably your “standard” subacromial impingement that everyone refers to when simply stating “shoulder impingement.”  The green arrow shows the inside, or articular surface, of the rotator cuff.  Impingement on this side is termed “internal impingement.”  The two are different in terms of cause, evaluation, and treatment, so this first distinction is important.  More about these later.

shoulder impingement

2. Impinging Structures – To me, this is more for the bursal sided, or subacromial, impingement and refers to what structure the rotator cuff is impinging against.  As you can see in the pictures below (both side views), your subacromial space is pretty small without a lot if room for error.  In fact, there really isn’t a “space”, there are many structures running in this area including your rotator cuff and subacromial bursa.  You actually “impinge” every time you move your arm.  Impingement itself is normal and happens in all of us, it is when it becomes excessive that pathology occurs.  I try to differentiate between acromial and coracoacromial arch impingement, which can happen in combination or isolation.  There are fairly similar in regard to assessment and treatment, but I would make a couple of mild modifications for coracoacromial impingement, which we will discuss below.

shoulder impingementimage

3. Cause of Impingement – This is what I refer to as “primary” and “secondary”shoulder  impingement.  Primary impingement means that the impingement is the main problem with the person.  A good example of this is someone that has impingement due to their anatomy, with a hooked tip of the acromion like this in the picture below.  Many acromions are flat or curved, but some have a hook or even a spur attached to the tip (drawn in red):

shoulder impingement

Secondary impingement means that someone is causing impingement, perhaps their activities, posture, tightness, or muscle imbalances are causing the humeral head to shift in it’s center of rotation and cause impingement.  The most simply example of this is weakness of the rotator cuff.  In this scenario, the deltoid will overpower the cuff and cause the humeral head to superiorly migrate, thus impinging the cuff between the humeral head and the acromion:

deltoid pull

Differentiating Between the Types of Shoulder Impingement

In our DVD Optimal Shoulder Performance, we talk about different ways to assess shoulder impingement that may impact your rehab or training.  There are specific tests to assess each type of impingement we discussed above.  The two most popular tests for shoulder impingement are the Neer test and the Hawkins test.  In the Neer test (below left), the examiner stabilizes the scapula while passively elevating the shoulder, in effect jamming the humeral head into the acromion.  In the Hawkins test (below right) the examiner elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, grinding the cuff under the subacromial arch.

DSC01916 DSC01917

You can alter these tests slightly to see if they elicit different symptoms that would be more indicative to the coracoacromial arch type of subacromial impingement.  This would involve the cuff impingement more anteriorly so the tests below attempt to simulate this area of vulnerability.  The Hawkins test (below left) can be modified and performed in a more horizontally adducted position.  Another shoulder impingement test (below right) can be performed by asking the patient to grasp their opposite shoulder and to actively elevate the shoulder.

DSC01919 image

There is a good chance that many patients with subacromial impingement may be symptomatic with all of the above tests, but you may be able to detect the location of subacromial impingement (acromial versus coracoacromial arch) by watching for subtle changes in symptoms with the above four tests.

Internal impingement is a different beast.  This type of impingement, which is most commonly seen in overhead athletes, is typically the result of some hyperlaxity in the anterior direction.  As the athlete comes into full external rotation, such as the position of baseball pitch, tennis serve, etc., the humeral head slides anterior slightly causing the undersurface of the cuff to impingement on the inside against the posterior glenoid rim and labrum.  This is what you hear of when baseball players have “partial thickness rotator cuff tears” the majority of time.

internal impingement

The test for this is simple and is exactly the same as an anterior apprehension test.  The examiner externally rotates the arm at 90 degrees abduction and watches for pain.  Unlike the shoulder instability patient, someone with internal impingement will not fell apprehension of anterior symptoms.  Rather, they will have a very specific point of tenderness in the posterosuperior aspect of the shoulder (below left).  WHen the examiner relocates the shoulder by giving a slight posterior glide of the humeral head, the posterosuperior pain diminishes (below right).

DSC01930 DSC01931

3 Keys to Treating Shoulder Impingement – How Does Treatment Vary?

There are three main keys from the above information that you can use to alter your treatment and training programs based on the type of impingement exhibited:

  1. Subacromial Impingement – Differentiate between acromial and coracoacromial impingement: Treatment is essentially the same between these two types of subacromial impingement, however, with coracoacromial arch impingement, you need to be cautious with horizontal adduction stretching.  This is unfortunate as the posterior soft tissue typically needs to be stretched in these patients, but you can not work through a pinch with impingement!  A pinch is impingement! Also, I would avoid elevation in the sagittal plane or horizontal adduction exercises.
  2. Primary versus secondary impingement – This is an important one and often a source of frustration in young therapists and trainers.  If you are dealing with secondary impingement than you can treat the persons symptoms all you want, but they will come back if you do not address the route of the pathology!  This is where a more global look at the patient, their posture, muscle imbalances, and movement dysfunction all come into play.  Break through and see patients in this light and you will see much better outcomes.
  3. Internal impingement – One thing to realize with internal impingement is that it is pretty much a secondary issue.  It is going to occur but any cuff weakness, fatigue, or loss of the ability to dynamically stabilize and the athlete will show some hyperlaxity in this athletic cocked shoulder position.  Treat the cuff and it’s ability to dynamically stabilize to relieve the impingement.

Mario, hope this helps.  If you are interested in learning more about this and some of my other thoughts on the shoulder impingement, I have an Inner Circle webinar on shoulder impingement that discusses all of this and more in detail.

Or if you are really serious about learning the shoulder, my 8-week online CEU program at ShoulderSeminar.com is even more detailed.  Both are loaded with clinical pearls like this to take your knowledge of the shoulder to the next level!

 

ShoulderSeminar.com

 

These are just some of my thoughts on shoulder impingement examination, classification, and rehabilitation – what do you think?