In Gray Cook's most recent podcast, he discusses the importance of going without shoes and the benefits that come along with going with less on your feet.

Click HERE to listen to Gray Cook.

For more information on going barefoot and how to implement a barefoot program safely click HERE to visit our web page dedicated to going with less on your feet or purchase BAREFOOT IN BOSTON today - your feet will thank you!

Barefoot expert and Harvard Professor Daniel Lieberman talks about the obesity problem in America.  This 13 minute presentation examines our evolutionary path to obesity and concludes with a radical idea to fight this growing problem.

Enjoy!

I have to admit I missed the boat on the importance of manual medicine for a long time.  After speaking to the best clinicians and therapists in the area there was one book that each and everyone of them, regardless of their current treatment approach, recommended I read - Greenman's Principles of Manual Medicine (Point (Lippincott Williams & Wilkins))   

After recently completing this book I now know why.  This book is a must for anyone treating musculoskeletal dysfunction on a daily basis.  Below is a short excerpt from this book.

The Manipulable Lesion

"The acceptable term for this entity is somatic dysfunction. It is defined as impaired or altered function or related components of the somatic (body framework) system; skeletal, arthrodial, and myofascial structures; and related vascular, lymphatic, and neutral elements. Notice that the emphasis is on altered function of the musculoskeletal system and not on a disease state or pain syndrome." pg 11

DIAGNOSTIC TRIAD FOR SOMATIC DYSFUNCTION 

"The mnemonic ART can express the diagnostic criteria for identification for somatic dysfunction.

“A” stands for asymmetry of related of the musculoskeletal system, either structural or functional.
“R” stands for range of motion of a joint, several joints, or region of the musculoskeletal system. The range of motion could be abnormal by being either increased (hypermobility) or restricted (hypomobility). The usual finding in somatic dysfunction is restricted mobility, identified by observation and palpation using both active and passive patient cooperation.
“T” stands for tissue texture abnormality of the soft tissues of the musculoskeletal system (skin, fascia, muscle, ligament, etc.). Tissue texture abnormalities are identified by observation and a number of different palpatory tests.

Some authors add one of two other letters to this mnemonic. “P” or a second “T”. “P” stands for pain associated with other findings, and “T” stands for tenderness on palpation of the area. Tenderness is particularly diagnostic if localized to a ligament. A normal ligament is not tender. A tender ligament is always abnormal. However, both pain and tenderness are subjective findings instead of the objective findings of symmetry, altered range of motion, and tissue texture abnormality. By the use of these criteria, one attempts to identify the presence of somatic dysfunctions, their location, whether they are acute or chronic, and particularly whether they are significant for the state of the patients wellness of illness at that moment in time. In addition to the diagnostic value, changes in these criteria can be of prognostic value in monitoring the response of the patient, not only to manipulative treatment directed toward the somatic dysfunction, but also to other therapeutic interventions."  Pg 11-12

By Art Horne

We’ve all done it from time to time – missed lunch to work with an athlete, stayed up late to write notes on the previous day’s work or ignored a pending physician or dentist appointment because we just didn’t have time.

And although it’s usually celebrated by those you care for and rewarded by the boss everyone knows this downward cycle of ignoring one’s own health in favoring of attending to the health of others can only be headed in one direction. 

So the next time you board a plane when traveling remember to listen to your flight attendant’s very important message,

“During a change in altitude, oxygen masks will drop down from the ceiling.  For patients travelling with young children, be sure to put your mask on first before helping your child.”

As busy as we all are it’s important to remember that the health of those we provide services for is inherently tied to our very own.  It’s tough to continue to help others if you haven’t first helped yourself. 

by Art Horne

Last week we discussed the importance of bringing all professionals who care for and provide performance services to your student-athletes together to develop a consistent teaching methodology and progression to mastering the squat pattern.  This week we look at the Hip Hinge.

Deadlift – Hip Hinge

Hip Hinge: all athletes should be able to separate their hips from a back strategy both in 2-legs and single leg stance -whether its knee, hip or other LE injury pain, we should be able to look at this movement pattern and address some overall concerns IN ADDITION to their traditional rehab program.

 
The hip hinge can be easily taught and standardized with our stick series.

Teaching Stick Series:

1. Stick maintains contact with three points (head, back and butt crack) throughout entire movement.
2. Reach butt backwards; knees should have slight bend.
3. Start with two feet on ground and progress to single leg stance.
4. This is not a squat pattern – be sure to hinge at the hips.
5. Maintain a packed neck (c-spine in-line with sternum throughout movement).

Start one foot away from wall (maybe just less) and reach back towards the wall with butt

1. Maintain three points of contact with stick on head, back and butt crack
2. This is not a squat pattern – first motion should be back towards the wall and not downwards.
3. Inch outwards from the wall with each successful repetition and repeat until you have found your end range.
4. ALTERNATIVE: face wall and touch with hands, move away from wall and repeat until you have reached max distance from wall while maintaining perfect form

Progression:

1. Two Leg Stick
2. SL Stick
3. 2-Leg – 2 hand Kettlebell Deadlift
4. SL 2-DB Deadlift
5. SL contralateral 1-DB Deadlift

When you finally get strength and sports medicine professionals together in the same room some amazing things begin to happen, especially when you start talking about hinging at the hips including:

1. Agreement to Pack the Neck: Packing the neck and maintaining a neutral cervical spine instead of admiring yourself in the mirror during a hip hinge stick series becomes a universal theme among both groups and taught and coached consistently – whether it’s pulling 300 pounds from the floor during a sumo squat or 4 weeks post ACL surgery during a simple stick series.  Knowing where an athlete is going and where they’ve come from is half the battle in my opinion.

2. Glute activation takes on a whole new meaning to athletic trainers when they see firsthand the work and technical coaching  that strength coaches employ with their athletes.  Sets of 3x10 for glute bridges and then discharge to full participation is no longer acceptable.

3. Bad Hip Hinge means Bad Back: In the same breath, strength coaches are able to discuss challenges with low back pain patients with sports medicine professionals and appreciate how important they are in the rehabilitation and care of those persons as well as how incredibly dangerous a poorly performed lift can be.
 

Read article on Hip Hinge by clicking HERE.

Missed this summer's BSMPG summer seminar?

Wished you could have seen the authors of these books and video speak while they were in Boston?

Well now you can - We captured three groundbreaking presentations from this once in a lifetime seminar.  Catch three of these Giants in action as they presented at the 2011 "Standing On The Shoulders Of Giants" Summer Seminar.

This conference was held in Boston, MA on June 3rd and 4th, 2011

Included: 3 DVDs with over 4.5 hours of Sports Medicine and Rehabilitation Information

Presentations by: Clare Frank - Muscle Balance and Stability, Tom Myers - Anatomy Trains and Myofascial Fitness and Charlie Weingroff - Trying to Define the Core.

Click HERE for complete details.

by Art Horne

I remember being taught in school that people have low back pain because their hamstrings are tight.  Therego, stretch the hamstrings and resolve the low back pain.  It was a simple solution to a very complex and often misunderstood problem and yet as a student it was a clean and direct resolution to an often nagging dilemma.

Further testing and evaluation always “proved” the hamstrings as the culprit since so many of the low back pain patients were never able to touch their toes, and of course toe touching was a direct result of hamstring length.  Again, this bore out to make sense since after spending an exhausting amount of time stretching these patient’s hamstrings, and then retesting, some measurable change were noted (sometimes) with the patient inching closer to their toes.  The only problem in this clean and concise “hamstring-LBP” relationship was that these patients, no matter how long I stretched them or which stretching technique I employed ALWAYS ended up coming back the very next day for the same stretching routine and the same unresolved back pain.

Insanity: Doing the same thing over and over again and expecting different results.

Of course, many of these patients really never had “tight” hamstrings after all, but instead had hamstrings that were preventing them from a place they no had no business being in the first place. 

What do I mean?

Well, many of these patients, or at least the majority of them,  were flexion intolerant which means both flexing their spine and/or moving into flexion caused a reflexive “tightening” of the hamstrings to essentially keep them from FLEXING FORWARD and moving into a region which would exacerbate their current condition, or “a place they have no business being.”  In addition, many of these “tight hamstring” patients were never ever feeling a hamstring stretch, but instead were experiencing a neural stretch, which unfortunately after stretching only continued their “tight-stretch-pain-tight” cycle. 

Soo… Should I Stretch or Not?

1. First distinguish between hamstring tightness and neural tension.  Neural tension is always described differently than muscular tightness – that is if you’re listening.  I had a professor who told me that your patient will always tell exactly what is wrong with them if you listen long enough.  And if you listen just a little bit longer, they’ll also tell you exactly how to make them better.  This case is no different – of course, if you’re too busy catering water you’ll never have enough time to listen long enough.

2. Neural tension is often described as “pinching” or with other words that clearly denote nerve origin such as “zapping” or “burning.”  Muscle tension doesn’t zap or burn.

3. Confirm neural involvement with a slump test – then STOP stretching and begin a nerve flossing regiment if indicated.

4. Does the patient need more mobility (hamstring stretching) or do they simply lack the appropriate stability (or neuromuscular control) which ultimately is limiting them from moving into a place where they simply didn’t have the requisite control? I’m willing to bet that more often than not that stability/neuromuscular control is the limiting factor and not hamstring length – especially in low back pain patients.

So what does this have to do with integrated care?

1. On evaluation during pre-participation screenings a simply toe touch as a gross indicator of both ability and willingness to forward flex will “catch” those athletes who either have had previous back pain, current back pain or a complete lack of understanding relating to lumbar spine/pelvis position and an ability to disassociate them during normal daily living.

2. Those with pain or previous pain should be referred to sports medicine for further evaluation – yes, even those that don’t currently have pain.

3. Those that have trouble separating hip and lumbar motion should be placed into a “teaching” group while in the weight room until they can successfully “stiffen” their spine while gaining mobility and motion throughout the hips; both which are essential if any type of squat or deadlift pattern are prescribed in their program.  But really more importantly, these two patterns occur each and every day of their lives and must be grooved before major lumbar spine pathology presents itself.

Click HERE for a quick note on establishing a hip hinge.

Next week: A quick in-service to get both Sports Medicine and Strength Training hinging at the hips and teaching all athletes a great squat pattern. 

BSMPG is proud to announce Sue Falsone to speak at Northeastern Univeristy on Sept. 22nd from 12-2 pm.  

In this lecture and lab, Sue will talk about the inter-connection of
the neck, upper back and shoulders and how these three areas are
dependent on each other. She will discuss anatomic and kinetic
connections, breathing and mobility issues as well as stability
needs. She will explore how upper quarter dysfunction is truly a
comprehensive integrated problem needing comprehensive integrated
solutions. You will leave this lecture with an improved understanding
of how the upper quarter segments relate to each other and you
will leave lab with integrated solutions you can implement Monday
morning with your clients.

Speaker: Sue Falsone

Topic: Cervicothoracic Junction: How the Head, Neck and Shoulders Inter-relate

When: Septemeber 22, 2011

Time: 12:00 noon - 2:00 pm

Cost: There is not cost associated with this program. In lieu of a program fee, attendees are encouraged to donate to InnerCity Weightlifting.

Location: THERE HAS BEEN A CHANGE IN VENUE - This lecture will now be held in the Matthew's Arena - Varsity Club, on the campus of Northeastern University.

Continuing Education: 2 hours of continuing education is awarded for this event for both Certified Athletic Trainers and Strength & Conditioning professionals.

Continuing Education: The Boston Sports Medicine and Performance Group is recognized by the Board of Certification, Inc. to offer 2 hours of continuing education for Certified Athletic Trainers. Provider Number P8108.

Contact Information:  For additional details please contact us at bostonsmpg@gmail.com. 

Listen to Sue on SportExpertRehab.com by clicking HERE.   

by Art Horne

As we mentioned last week, our society has clearly become hip flexion dominant. 

This is really no surprised as Janda identified this “epidemic” long ago and termed it, the Lower Crossed Syndrome.  Clearly ahead of his time, and well before Blackberrys and IPhones caused us to hunch over and run into people on the sidewalk, Janda also described and discussed the upper crossed syndrome which is more prevalent today than ever as well.  With that said, so many of the young “healthy” athletes that sign up to play collegiate level athletics no longer are able to express the fundamental movement patterns that we so often take for granted.  This of course is not always a mobility problem, as many athletes are not able to reach end range of these patterns simply out of a reflexive protective mechanism.

Your body will simply not allow you to go where you have no business going.  (Ever wonder why LBP patients can’t touch their toes? Hint: it has nothing to do with hamstring length and everything with your brain not letting you get to end range flexion, you know, the place you have no business going)
In other cases, mobility is the main culprit and can usually be addressed with a simple movement exam along with some corrective therapy and exercises. 

Let’s take a look at an example to see what I mean.

Case Presentation:

This athlete presented to me many years ago, and unfortunately the overall theme continues year after year despite our best efforts to educate our athletes and their high school and youth coaches.

Here’s the story:

On evaluation athlete complains of having a persistent anterior hip pain from day one of pre-season practice.  She states that she had a “significant” hip injury at age 13 which lasted about one year and limited her from all sporting activities including gymnastics where she originally hurt herself during a coach “assisted” stretch.  At the time of the stretch, the athlete’s injured leg was down and extended behind her pelvis, with knee at 90 degrees and the opposite limb forced into extreme flexion.  At that time she felt intense pain and was not able to return to any physical activities for about one year. 

She went on to a successful high school career and eventually earned a college scholarship for her efforts.

(not the same stretch - but close. OUCH!) 

On movement evaluation utilizing the SFMA, cervical and shoulder motions were FN (functional and non-painful), multi-segmental flexion FN, multi-segmental extension FP (functional but painful), multi-segmental rotation DN (dysfunction and non-painful) away from the injured side, single leg stance was DP on injured side, FN on uninjured side (NOTE: during this test athlete complained of pain with standing hip flexion.  She was however able to get her knee/femur past 90 degrees of hip flexion but had to first abduct her leg then lift it in front – so to basically avoid iliacus involvement and use only psoas with some help from TFL and Sartorius). Lastly,  deep squat was DN. 

(Now, according to the SFMA I should have “broke out” her multi-segmental rotation pattern and addressed her subsequent restriction but given her prior history and description of pain I decided to go directly to the prone hip extension test to confirm my suspicion that she had originally injured her iliacus some 5 years ago.)

On prone hip extension, athlete was unable to extend her injured leg to a minimum of 10 degrees.

Treatment Plan: evaluate and address tissue density changes and restrictions within the hip flexion musculature including both psoas and iliacus specifically.

If you aren’t familiar with manual therapy techniques to address soft tissue restriction within the iliacus consult a co-worker or expert in your area for help or training (If you’re in the Boston area one of the most talent manual therapist I’ve ever had the pleasure working with is Dr. Pete Viteritti.

Below are a few key technical points regarding treatment of the Iliacus utilizing a manual therapy release technique.  Remember: the iliacus is to hip dysfunction as the psoas is to lumbar dysfunction.

1. Begin with the patient lying on their side, hip and knee flexed and relaxed.

2. With the contact fingers extended, work the soft contact from the anterior superior iliac spine (above the inguinal ligament) medically onto the iliacus treating from proximal all the way distal to the lesser trochanter.  The adhesion can be anywhere in the muscle.  Also, be sure to move your hand contact treating medially until you bump into the psoas.  The junction of the iliacus and psoas is very important, be sure they are not adhering to one another. (adhesion's between muscles which cause them to adhere to one another is much more of a problem than an adhesion in a muscle itself).

3.The inguinal ligament should also be checked to be sure you can bow it both distal and proximal, as it can adhere to the iliacus underneath it.  Find the inguinal ligament at the ASIS and trace it as it moves medially and deep.  It is only the lateral aspect of it that comes in contact with the iliacus and can become entrapped.

4. As you begin, be sure to move the mesentary medially and not treat through it.  Use care to avoid putting tension on the mesentary as this will not only cause discomfort to the patient, but will significantly limit treatment effectiveness.

5. Once on the tissue, begin to put tension on the tissue superiorly with your inferior hand while the superior hand backs it up.

6. Have the patient extend the hip and knee straight and then extend the hip as far as possible.

Post treatment: Athlete was able to regain full prone hip extension, pain resolved with both single leg stance (athlete was able to lift knee/leg straight up in sagittal plane) and multi-segmental extension pattern.  Deep squat pattern improved significantly but was not yet perfect.  And most impressive post treatment was the look of shock and excitement on her face.

Whether you’re dealing with a shortened iliacus, a tight psoas major or a restricted rectus femoris (or perhaps even a shortened rectus abdominis thanks to the 2 million crunches you’d done), identifying the global limitation first (an extension pattern in this case), and then referring to an expert or addressing the underlying tissue restricting this pattern yourself before high levels of organized activity begins can mean the difference between weeks of treatment post injury or a few moments of your time prior, during your screening process.  Of course identifying the exact limiting factor/tissue/pain generator is the ultimate factor when it comes to whether your treatment will be a success or not.

“So what does this have to do with integrated care?  This sounds like a pure sports medicine problem and treatment approach to me.”

Perhaps – but all strength coaches can look at global movement patterns including extension and make the appropriate referrals.  Whether it’s during your pre-participation examination or during a simple recheck in the weight room – having all coaches, athletic trainers and therapists understanding the normal parameters of human movement and speaking the same language eliminates the language barrier and allows all parties involved in the care and performance of the student-athlete to be provide a unified care approach to the identified problem.  Although many strength coaches won’t be able to apply a manual therapy technique for this identified problem, appropriate strategies within the weight room can certainly maintain this new tissue quality and “cement” this new found range of motion with strength exercises appropriate for the athlete and previous injury.

Although the skill set or specific treatment modality between the two professional groups my vary slightly, the underlying philosophy should not and in this case addressing this extension limitation with whatever tools you are allowed to use will certainly pay dividends at the end of the day.

Next Week: When Not Being Able To Touch Your Toes Is Not A Hamstring Issue

Click HERE to listen to this interview.

In this interview, Art discusses his new book, "Barefoot in Boston: A Practical Guide to Achieving Injury Resolution and Enhancing Performance", as well as discussing some research on barefoot walking and training versus wearing shoes, what to look for in minimalist shoes, how he has incorporated barefoot training with his basketball team, and much more..(including how to take a hack saw to a basketball shoe!)