Boston Sports Medicine and Performance Group, LLC Blog

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

So often ankle dorsiflexion or should I say a lack thereof, is pointed at as the underlying culprit for a variety of movement impairments … and rightfully so. A lack of true talocrural motion can cause havoc up the chain involving itself in a variety of impairments including anterior tibial pain, patellofemoral pain and general low back pain to only name a few.

However, the actual limiting factor causing this lack of osteokinematic motion may be multi-factorial and if clinicians are hoping to address this limitation over the long haul with permanent change the exact location and tissue responsible for this restriction must be clearly identified and addressed with a specific intervention to match the specific tissue.

With regards to soft tissue restrictions there are only 6 possible structures that can limit this motion, and these are:

1. Soleus
2. Posterior Tibialis
3. Flexor Hallucis Longus
4. Flexor Digitorum Longus
5. Posterior Talofibular ligament
6. Posterior Tibiotalar Ligament

The gastrocnemieus, although probably the very first structure that comes to mind, does not limit true dorsiflexion in function (that is unless you participate in ski jumping or speed walking, and then you need to include this in your assessment), since the knee is almost always flexed when the ankle is asked to express dorsiflexion in function, such as walking, running, squatting, lunging, stepping, jumping and landing.

 
 
Now that’s some dorsiflexion!

Remember, in order for your tibia to pass over your talus, and your talus to move between the tibia and the calcaneus we need to think of what pathology or dysfunction is not allowing the above mentioned tissues to lengthen.  More often than not, fibrotic adhesions within the muscles or fascial restrictions are to blame, with the filet mignon of tissue treatment choice being an Active Release Technique.  Although lesser cuts of treatment choices allow tissues to mobilize at times, rarely can a foam roller or tennis ball address a specific adhesion like a skilled clinician and the appropriate manual release technique.  That’s not to say one is wasting their time or shouldn’t employ the soft tissue mobilization techniques that they are allowed to use given their credentialing or state laws, but understanding when to refer to a specialist with a very specific skill set is the difference between a butter knife a ninja – both may get the job done but we all know which one we’d rather have on our side.

So how does one differentiate between these tissues?

Because the Soleus and Posterior Tibialis are the two usual suspects and responsible for the majority of problems when it comes to ankle dorsiflexion limitations, these two will usually require the majority of your focus both in evaluation palpation and treatment.

However, both the Flexor Hallucis Longus and the Flexor Digitorum Longus can limit dorsiflexion and should be excluded to be sure that they are not involved.  To exclude these two structures from your list of possible dysfunctional contributors simply ask the patient to maximally dorsiflex their ankle while keeping their heel on the ground.

 
1. Gently pick up the great toe off the ground into extension. If there is slack and the patient does not indicate an increase in symptoms then the FHL is more than likely not involved.
2. Repeat tissue testing by selecting the toes and pulling them into extension.  If there is slack and the patient does not indicate and increase in symptoms then the FDL is more than likely not involved.

To identify the underlying tissue whether it be the soleus or posterior tibialis requires some discernable palpation skills.

Did I make a permanent change?

Charlie Weingroff calls it the “Audit Process”  while others such as good friend and colleague Pete Viteritti simply calls it, test-treat-retest.  If the correct treatment choice was matched to the correct tissue choice and location then a marked improvement in range, function and/or pain levels should occur. 

If minimal or no improvements were made than the following may have occurred:

1. You applied the correct treatment to the wrong tissue (tissue adhesion was within the posterior tibialis and you treated the soleus for example), or
2. You applied the incorrect treatment to the correct tissue (pressure was too light and thus was not sufficient to break up the underlying scar tissue), or
3. The limiting factor was not soft tissue but instead an osteokinematic “misalignment” or a position fault as described and made famous by Brian Mulligan (more Mulligan in a future post).

Summary: The most important step in any treatment approach starts with first identifying the correct pain generator or dysfunctional tissue involved.  Without a correct place to start, all treatment options will fail to make a lasting change.

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.

Missed this summer's BSMPG summer seminar?

No Problem - 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.

We asked what the Giants in Sports Medicine & Rehabilitation, Basketball and Hockey performance training have read or are currently reading and we brought their list to you.  

Click HERE to view our recommended library with an ongoing list from these speakers who presented at the BSMPG "Standing On The Shoulders Of Giants" 2011 summer seminar.

by Keke Lyles, DPT, CSCS

I had a conversation with someone the other day who was telling me about how he has started to train with a guy who is currently in school with aspirations to become a strength coach. He was telling me about all the different books, websites, and articles that his guy has been reading. It is always refreshing to hear about any professional who is trying to do all they can to better themselves. He continued on to tell me how his guy started to use Graston tools on him to help with his soft tissue issues, and then shared with  me how he got all “jacked up” from the Graston. He had to seek medical help to deal with the consequences.

My question to all professionals is at what point is it okay to read about different techniques or skills and then decide you are capable of performing such skill? I don’t want to sound like a bitter physical therapist who doesn’t like the idea of strength coaches trying to expand their knowledge, but as a strength coach myself, we MUST operate within our scope of practice. Even as a physical therapist, I would not recommend anyone just picking up Graston tools or any other such tool without proper training and education beforehand. Yes, it is true that given impairments would greatly benefit from such techniques, but our job as strength coaches, physical therapist, or athletic trainers is sometimes to swallow our pride and refer our clients/athletes to the people who are experts and trained properly to use specialized techniques.

Many techniques are certainly beneficial but at the same time can be very destructive to the tissues that we think we are correcting. As a result, serious consequences may arise from practitioners who are trying to do the right thing, but without the proper skill set. I urge us all to continue to read and learn about the advancements we are making both in the strength world as well as in the rehab world. However, just because I read about how great some patients responded to PRP injection in their patella tendon, doesn’t mean I am going to try to perform injections myself to everyone that comes to me complaining of patella tendon pain.  That is not my decision to make and certainly not the person to perform it.

Be responsible with your actions and continue to read to learn about the current evidence-based practices so that when you come across someone who may benefit from such technique, you can do you part of informing them of the options and then refer them to the right person who is suitable to perform such technique.

We asked what the Giants in Sports Medicine & Rehabilitation, Basketball and Hockey performance training have read or are currently reading and we brought their list to you.  

Click HERE to view our recommended library with an ongoing list from these speakers who presented at the BSMPG "Standing On The Shoulders Of Giants" 2011 summer seminar.

Keynote Speakers Pete Viteritti and Shirley Sahrmann

Happy Canada Day to our readers north of the border!

by Shaun Bossio

I had a colleague recently come to me out of frustration. Their position grade was below that of several other people in their department that they felt were not as valuable. In addition, they felt as though both title-wise and salary-wise they should be receiving more consideration than these folks that they felt had received some undue advancement. After about three years in their position, they felt as though they deserved more than the token merit increases that they had seen over that time.

In actuality, there are two different problems here. The first is that they felt as though they were not receiving the proper recognition. The second and most important though is that they were measuring themselves against the performance of others within their department. Therein is where the problem lies for you. Unless these staff members are reporting to you, there is not a whole heck of a lot you can do about their perceived performance vs. yours. Equating yourself to other comparable employees within your organization is a lot like playing golf. You cannot control what your opponents are shooting, so your best option is just to concentrate on shooting the best score that YOU can. Focusing on comparisons between your coworkers and yourself is a trap that many people fall into and really it is energy that could be better spent making yourself an even better employee.

Many of us at one time or another have felt as though we were not receiving the proper amount of credit (compensation, title, accolades, etc). It is important to remember that while this may be the case, it is a matter to be handled between your employer and yourself and has nothing to do with your coworkers. If you are truly underappreciated in your organization, then it is time to approach your supervisor and let them know why and remind them of the value that you provide to them. In some cases it may be as simple as making a solid case for your yourself and in others the possibility exists of setting goals that, if met, will yield increased benefits to you. Sometimes however, your opportunity lies elsewhere. In many organizations (universities in particular come to mind), unfortunately your best chance is in taking a promotion with another company. In these cases, if you revere your organization, the chances of returning at a higher salary/title have already increased.

Regardless of how you perceive your future, know that the best thing for you is to simply focus on yourself and to do the best job that you can do. If you get to a point where you feel as though you are not being properly appreciated, take some time to remind your employer what they have and why they need you around. The folks that are busy comparing themselves to each other are the ones that are only concerned with doing their job as well or slightly better than their coworkers. In the meantime, you can be the one excelling and getting people to notice.

Shaun Bossio is the Assistant Business Manager at the Boston University FitRec.

Caring

No organization cares about you. Organizations aren't capable of this.

Your bank, certainly, doesn't care. Neither does your HMO or even your car dealer. It's amazing to me that people are surprised to discover this fact.

People, on the other hand, are perfectly capable of caring. It's part of being a human. It's only when organizational demands and regulations get in the way that the caring fades.

If you want to build a caring organization, you need to fill it with caring people and then get out of their way. When your organization punishes people for caring, don't be surprised when people stop caring.

When you free your employees to act like people (as opposed to cogs in a profit-maximizing efficient machine) then the caring can't help but happen.