Year after year, Art Horne and the gang at the Boston Sports Medicine and Performance Group host their anual Summer Seminar. Having heard nothing but positive feedback from colleagues who have attended in the past, I decided that this would be the year to finally attend. Living in Western Canada, it certainly isn’t easy to travel across the continent both from a time and financial perspective, but I felt that in order to continually better myself as a professional, attendance was a must. Like many of my previous educational endeavors, it was important for me to be 100% confident that this event was grounded in “educational conducivity” and not just a place where many of my friends were going to be. However, upon looking at the speaker lineup, it was more difficult to convince myself not to attend.
Perhaps the most challenging task however, was deciding which sessions to attend. So aside from the keynote lectures where all delegates were present, I found myself attending lectures from the following: Sean Skahan, Dr. John DiMuro & Mark Toomey, Art Horne & Dr. Pete Viteritti, Joel Jamieson, and Keith D’Amelio. So…
Continue to read this review by Jeff Cubos by clicking HERE
By Art Horne
With recent season ending ACL injuries to New York Knicks Iman Shumpert, and Chicago Bull’s point guard Derrick Rose coming on the same day, (not to mention Eric Maynor from the Thunder and Spanish Star Ricky Rubio earlier this season) discussion has arisen as to how these terrible injuries could have been avoided. Although the possible contributing factors are endless, ranging from previous injury to simply fatigue, one area worth shedding more light on, especially in the case of young Rose, is the implication of the kinetic chain as a whole.
Let’s start at the ground and work our way up.
I think we’d all agree that the big toe is a big deal. But how closely are we looking at this “pivotal” body-ground juncture?
In a study by Munuera et al, researchers found that “Hallux interphalangeal joint dorsiflexion was greater in feet with hallux limitus than in normal feet. There was a strong inverse correlation between first metatarsophalangeal joint dorsiflexion and hallux interphalangeal joint dorsiflexion.” (Munuera et al, 2012).
TRANSLATION: People with abnormally stiff or limited motion at the great toe had excessive motion at the joint just distal.
If you don’t have mobility where you need it, you’ll surely get it somewhere else.
Let’s move up the chain shall we?
In a study by Van Gheluwe and his group, researchers looked at how a stiff or limited great toe joint changes the way we walk. In their study, “two populations of 19 subjects each, one with hallux limitus and the other free of functional abnormalities, were asked to walk at their preferred speed while plantar foot pressures were recorded along with three-dimensional foot kinematics. The presence of hallux limitus, structural or functional, caused peak plantar pressure under the hallux to build up significantly more and at a faster rate than under the first metatarsal head. Additional discriminators for hallux limitus were peak dorsiflexion of the first metatarsophalangeal joint, time to this peak value, peak pressure ratios of the first metatarsal head and the more lateral metatarsal heads, and time to maximal pressure under the fourth and fifth metatarsal heads. Finally, in approximately 20% of the subjects, with and without hallux limitus, midtarsal pronation occurred after heel lift, validating the claim that retrograde midtarsal pronation does occur.”
TRANSLATION: if you have a limited motion in your great toe, pressure changes will occur – increase pressure changes will cause pain over time (think blister on your foot).
And pain changes the way we move – period.
Let’s take a look at the ankle.
In an article by Denegar et al, the authors outline the importance of regaining normal talocrural joint arthrokinematics following an ankle injury. The authors note,
“All of the athletes we studied had completed a rehabilitation program as directed by their physician under the supervision of a certified athletic trainer, and had returned to sports participation. Furthermore, all had performed some form of heel-cord stretching. None, however, had received joint mobilization of the talocrural complex. Despite the return to sports and evidence of restoration in dorsiflexion range of motion, there was restriction of posterior talar mobility in most of the injured ankles. Posterior talar mobilization shortens the time required to restore dorsiflexion range and a normal gait. Without proper talar mobilization, dorsiflexion range of motion may be restored through excessive stretching of the plantar flexors, excessive motion at surrounding joints, or forced to occur through an abnormal axis of rotation at the talocrural joint.” (pg. 172)
TRANSLATION: I repeat, Without proper talar mobilization, dorsiflexion range of motion may be restored through excessive stretching of the plantar flexors, excessive motion at surrounding joints, or forced to occur through an abnormal axis of rotation at the talocrural joint.” (pg. 172)
If you don’t have normal ankle motion, and specifically at the talus, your ankle motion (although appearing normal) is probably coming from other joints and/or in a combination with foot pronation.
Foot Pronation = Tibial Internal Rotation
Tibial Internal Rotation = Femoral Internal Rotation
Tibia and Femur Internal Rotation = Knee Valgus (or knee collapse)
Knee Valgus = BAD
But just because you have some extra motion doesn’t mean you’re doomed right?
But, excessive motion without the ability to control that motion certainly does. So where does knee control come from? The Hip!
But hip strength, control, and neuromuscular timing is seldom appreciated, and in the case of the basketball athlete it is certainly poorly measured, especially after ankle injury.
In a study by Bullock-Saxton, researchers investigated muscle activation during hip extension after ankle sprain and showed a changes in timing of muscle activation in the ankle sprain grouped compared to the non-injured group.
“the results highlight the importance of the clinician’s paying attention to function of muscles around the joints separated from the site of injury. Significant delay of entry of the gluteus maximus muscle into the hip extension pattern is of special concern, as it has been proposed by Janda that the early activation of this muscle provides appropriate stability to the pelvis in such functional activities as gait.” (pg. 333)
In another study examining ipsilateral hip strength/weakness after the classic ankle sprain, researchers demonstrated that subjects with unilateral chronic ankle sprains had weaker hip abduction strength and less plantar flexion range of motion on the involved sides (Friel et al., 2006)
“Our findings of weaker hip abductors in the involved limb of people with chronic ankle sprains supports this view of a potential chronic loss of stability throughout the kinetic chain or compensations by the involved limb, thus contributing to repeat injury at the ankle.” (pg. 76)
“If the firing, recruitment, and strength of the hip abductor muscles in people with ankle sprains have been altered because of the distal injury, the frontal-plane stability normally supplied by this muscle is lacking, and the risk for repeat injury increases. Weak hip abductors are unable to counteract the lateral sway, and an injury to the ankle may ensue.”
TRANSLATION: Ankle sprains cause neuromuscular changes up the chain and specifically in the hip. If this weakness is not addressed after an ankle injury,” frontal-plane stability normally supplied by this muscle is lacking.”
Lack of frontal-plane stability + Knee Valgus = Injury
Of course suggesting that the above points are exactly the reason for which Rose suffered his injury is certainly a stretch and not the intention of this post, nor is it to question the treatment that he or any other NBA player received prior to their devastating injury (for the record, the Chicago Bulls Sports Medicine and Strength Staff are regarded as one of the very best in the league). What I am suggesting however is that examining athletes and patients with the use of advanced technology to determine a state of readiness to participate, and/or examine more closely changes in gait and neuromuscular firing is certainly worth pursuing, especially in light of the ever-rising salaries within professional sports. A quick look is certainly worth the small investment.
One thing is for sure, ACL injury is not limited to teenage females or only seen on the soccer pitch.
The NBA Should Have Learned From The NFL - Injuries On The Rise
Did The NBA Lock-out Ultimately End Chauncey Billups' Career?
See lectures directly related to gait, injury prevention, and performance at the 2012 BSMPG Summer Seminar:
1. Dr. Bruce Williams: Hit the ground running: Appreciating the importance of foot strike in NBA injuries
2. Dr. Bruce Williams: Breakout Session: Restoring Gait with evidence based medicine
3. Art Horne and Dr. Pete Viteritti: Improving Health & Performance - Restoring ankle dorsiflexion utilizing a manual therapy approach
4. Dr. Tim Morgan: Biomechanics and Theories of Human Gait: Therpeutic and Training Considerations
5. Jose Fernandez: Advanced Player Monitoring for Injury Reduction
See the most advanced player monitoring equipment currently available at the 2012 BSMPG Summer Seminar:
Munuera PV, Trujillo P, Guiza L, Guiza I. Hallux Interphalangeal Joint Range of Motion in Feet with and Without Limited First Metatarsophalangeal Joint Dorsiflexion. J Am Podiatr Med Assoc. 102(1): 47-53, 2012.
Denegar, C., Hertel, J., Fonesca, J. The Effect of Lateral Ankle Sprain on Dorsiflexion Range of Motion, Posterior Talar Glide, and Joint Laxity. J Orthop Sports Phys Ther. 2002; 32(4):166-173.
Van Gheluwe B, Dananberg HJ, Hagman F, Vanstaen K. Effects of Hallux Limitus on Plantar Foot Pressure and Foot Kinematics During Walking. J Am Podiatr Med Assoc. 96(5): 428-436, 2006.
Bullock-Saxton, J. E., Janda, V., & Bullock, M. I. (1994) The Influence of Ankle Sprain Injury on Muscle
Activation during Hip Extension. Int. J. Sports Med. Vol. 15 No. 6, 330-334.
Friel, K., McLean, N., Myers, C., & Caceres, M. (2006). Ipsilateral Hip Abductor Weakness After Inversion
Ankle Sprain. Journal of Athletic Training. Vol. 41 No.1, 74-78
Smith RW, Reischl SF. Treatment of ankle sprains in young athletes. Am J Sports Med. 1986;14:465-471.
by Craig Liebenson
Mid-Thoracic Dysfunction: A Key Perpetuating Factor of Pain in the Locomotor System
Dysfunction involving excessive T4-T8 kyphosis is common. Symptoms arising from regions at a distance to the mid-thoracic area are often secondary to T4-T8 dysfunction. This article will discuss why (rationale), when (indications), what (skills), and how (practical integration) T4-8 dysfunction is addressed.
Mid-thoracic dysfunction involves increased kyphosis of the thoracic spine from T4-T8, usually the result of prolonged sitting in a constrained posture. Thoracic, lumbopelvic and cervicocranial posture are interrelated as links in a chain (see Figure 1). When excessive slumping becomes habitual, according to Brügger, it is called the sternosymphyseal syndrome (Lewit 1996, 1999, Liebenson et al., 1998, Liebenson 1999).
Mid-thoracic dysfunction affects the whole body's center of alignment and posture. Head and shoulder forward posture causes orofacial, neck and shoulder disorders; slumping affects breathing by leading to inhibition of the diaphragm and overactivation of the scalenes; and lumbar disc syndromes and nerve impingement have been shown to result from repetitive end-range flexion overload (Callaghan, McGill 2001).
Indications for treating the mid-thoracic region arise from postural analysis, passive joint mobility testing, and active joint mobility testing. The postural sign of increased thoracolumbar hypertonus is a classic sign of overactivity of the superficial "global" muscles and indicates poor "deep" muscle function (Janda 1996, Richardson 1999, Jull 2000, Hodges 2002).
Palpation of passive joint mobility and quality of end-feel is best performed in the seated position, as shown by Brügger (Brügger 2000).
The dynamic mobility screen of choice is the standing arm elevation test (Liebenson 2001).
Managing T4-8 dysfunction requires a broad skill set incorporating postural advice, manual manipulation, and therapeutic exercise.
Sample Exercises for Improving T4-8 Extension Mobility
- Brügger relief position - beginner
- Back stretch on the ball - intermediate
- Kolár's wall slide with arm elevation - advanced
Knowing why mid-thoracic dysfunction is clinically important, when it should be addressed, and what techniques are therapeutic is only the beginning point for successful management of the patient with a problem in this area. Satisfactory results will result from learning how to incorporate this knowledge and skill into patient care efficiently. A moment or two per session spent explaining the relationship between function and pain is one such step. Each exercise requires a unique "report of findings" to motivate the patient to incorporate it into his or her daily routine.
The Brügger relief position is an ideal workplace "micro-break." It activates an entire chain of muscles linked to the upright posture. To prevent the tendency to hyperextend the lumbar spine with this exercise, it should be performed with active exhalation.
The back stretch on the ball is comfortable and relaxing. It promotes improved respiration. It can cause dizziness at first, so the patient should be guided slowly onto it until he or she has learned how to balance on the ball.
Kolár's wall slide with arm elevation is a functional exercise, since it combines arm elevation, squatting and breathing. Patients typically feel a nice stretch in the lattismus dorsi with this exercise.
T4-8 dysfunction is a common source of muscle imbalance, trigger points, joint dysfunction, and faulty movement patterns. While often asymptomatic, it is nonetheless a key source of biomechanical overload involving the neck, TMJ, shoulder, arm, and even low back regions. Treatments which aim only at the site of symptoms are bound to fail if function is disturbed due to excessive kyphosis in the mid-back.
Rehabilitation of the upright posture is fundamental to optimization of function in the locomotor system. Neurological programs for maintenance of the upright posture are "hard-wired" into the central nervous system, making rehabilitation of the mid-thoracic area of central importance, both biomechanically and neurophysiologically. The mid-thoracic region is "linked" to a multitude of common musculoskeletal pain syndromes, and the simple assessment and treatments shown here are an excellent complement to chiropractic practice.
- Brügger A. Lehrbuch der Funktionellen Storungen des Bewegungssystems. Brugger-Verlag GmbH, Zollikon, Benglen, 2000.
- Callaghan JP, McGill SM. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clinical Biomechanics 2001;16:28-37.
- Hodges PW, Jull GA. Motor relearning strategies for the rehabilitation of invertebral control of the spine. In Liebenson CS. Rehabilitaiton of the Spine: A Practitioner's Manual (2nd ed). Lippincott/Williams & Wilkins, Baltimore, sched pub 2002.
- Janda V 1996. The evaluation of muscle imbalance in Liebenson CS (ed) Rehabilitation of the Spine: A Practitioner's Manual, Lippincott/Williams and Wilkins, Baltimore, 1996.
- Jull GA. Deep cervical flexor muscle dysfunction in whiplash. Journal of Musculoskeletal Pain 2000. 8:143-154,
- Lewit K 1996. The role of manipulation in spinal rehabilitation in Liebenson CS (ed) Rehabilitation of the Spine: A Practitioner's Manual, Lippincott/Williams and Wilkins, Baltimore.
- Lewit K 1999. Manipulative Therapy in Rehabilitation of the Motor System. 3rd edition. London: Butterworths.
- Liebenson CS, DeFranca C, Lefebvre R 1998. Rehabilitation of the Spine: Functional Evaluation of the Cervical Spine, Williams & Wilkins, Baltimore.
- Liebenson CS, Advice for the clinician and patient: The Brugger relief position. Journal of Bodywork and Movement Therapies 1999. 3:147-149.
- Liebenson CS, Advice for the clinician and patient: Self-treatment of mid-thoracic dysfunction: a key link in the body axis. Journal of Bodywork and Movement Therapies 2001. 5:90-100.
- Richardson C, Jull G, Hides J, Hodges P 1999. Therapeutic Exercise for Spinal Stabilization in Lower Back Pain, Churchill Livingstone.
See Craig Liebenson speak at the 2012 BSMPG Summer Seminar this May 19-20 in Boston MA.
LA Sports and Spine
Keynote Topic: Regional Interdependence: How Functional Pathology Limits Performance
Sunday Breakout Lecture: The Core as the Punctum Fixum in Sport: A Key to Making Movement Patterns More Efficient
Dr. Liebenson is an Adjunct Professor in the School of Chiropractic, Division of Health Sciences at Murdoch University, Perth Australia and consultant for the Murdoch University and the Anglo-European Chiropratic College M.Sc. program in Chiropractic Rehabilitation. The first ever chiropractic member of the McKenzie Institute (U.S.) Board of Directors, he serves on the editorial boards of numerous journals including the Journal of Occupational Rehabilitation; the PM&R Journal of Injury, Function and Rehabilitation; the Journal of Bodywork and Movement Therapy; and Journal of Manual Therapy.
Dr. Liebenson is the first health care provider to receive a Certification of Recognition from the National Committee for Quality Assurance (NCQA) on Achievement of Recognition for Delivery of Quality Back Pain Care. He is actively engaged in ongoing research on the spinal stabilization system as a Visiting Scholar at Pr. Stuart McGill’s Spine Biomechanics Laboratory at the University of Waterloo. He regularly assists Pavel Kolar in his courses and has worked with both Dr. Karel Lewit and Pr Vladimir Janda beginning in 1987. Dr. Liebenson publishes extensively and is the editor of the book/DVD Rehabilitation of the Spine: A Practioner's Manual (2nd ed), 2007.
He has had books published into Spanish, Greek, Korean and Japanese. He was the team chiropractor for the N.B.A. Los Angeles Clippers from the 2006-2007 season until 2009-2010 seasons and is currently a consultant for the M.L.B. Arizona Diamondbacks and Athletes Performance International.