A nice story to share with other health care professionals.  Support great athletic trainers by advocating for more of their time to be dedicated to specialty health care services such as emergency care and musculoskeletal evaluation, treatment and rehabilitation!

BSMPG is busy working on the final details of a continuing educational opportunity that you won't want to miss!

Pencil in this 3-day learning event coming March 30th through April 1st of next year. 

This event will only be open to 30 individuals and 30 individuals only.

NO walk-ins. NO casual learners. NO nodding off after lunch is served. 

This will be an intense 3-day course developed for those skilled clinicians looking to take their treatment approach to the next level and is the first of it's kind on the east coast!

Location: Northeastern University, Boston MA, USA

Details coming soon!

by Art Horne

Since squatting and the decision to squat or not comes up more often than any other subject when it comes to sports medicine and performance professionals, we decided to tackle this subject head on in this latest post.  Everyone should be able to squat - there I said it. So whether you'll be teaching it after surgery, or training it in the weight room it's important that the beliefs and concepts that you have pertaining to the squat is the same as those that you work with in order to achieve the highest level of athlete success. 

Below is an outline which we have used in a staff journal club to finalize our teaching progressions and teaching cues for the squat pattern while also getting everyone on the same page and on board with the importance of squatting.

Squat Goal: all athletes should be constantly working towards a score of three on their OH Squat test. Whether they initially present to Sports Medicine with back, knee, hip or other LE injury or pain, all care and performance training providers should be able to look at this movement pattern and address any movement concerns IN ADDITION to their traditional rehab or performance program regardless of initial pain or injury presentation.

FMS Squat Test:  see functionalmovement.com  for complete details
(Have a staff member certified or familiar with the FMS review testing criteria, followed by staff members from both staff’s testing and evaluating each other).

What if the student-athlete describes PAIN during the squat test?

Only qualified medical professionals should deal with pain and painful movement patterns.  If a student-athlete experiences pain they should be referred to the athletic trainer coordinating their care at the college level or another health care professional if you are working in the private sector.  Although many “painful” maneuvers are often neglected and played down by the student-athlete, seldom do those with pain during a simple bodyweight squat ever go on to compete at a high level without future injury and time loss.

Since PAIN is complicated, multifactorial and often unpredictable, a painful pattern should be “broken down” to its component parts so to find the underlying pain generator or limiting factor.  The Selective Functional Movement Assessment TM offers health care providers a systematic approach and a common movement language among all staff members.

(Have a staff member certified or familiar with the SFMA squat breakout present this algorithm to the remainder of your staff and then follow up by having individuals from both groups evaluate each other while identifying the limiting factor within each individual’s squat pattern.

SFMA Squat Breakout:

1. Overhead deep squatting pattern

2. Fingers interlocked behind neck into deep squat position
a. This position lowers the difficulty by not having the shoulders flexed vertical
b. Removes the upper body components and reduces the level of dynamic stability needed to perform the squat.

3. Assisted Squat from ATC into deep squat
a. Athlete holds hands of evaluator while performing squat.
b. Looks at the true symmetrical mobility of the lower body (hips, knees, ankles) without the requirement of dynamic stability.

4. Half kneeling Dorsi-flexion (test for ankle ROM)
a. Place foot on weight bench and lean forward over the foot as far as possible without the heel coming off the bench.
b. The knee should move forward out past the toes at around 4 inches.
c. Repeat for both sides.

5. Supine Knees-to-chest – test for anatomical limitations at hip in non-weight bearing position.
a. Looks at mobility of the hips, knees and spine in a non-weight bearing position.
b. Can help differentiate a mobility vs. stability problem
c. Have the patient grab both shins and attempt to touch their thighs to their lower rib cage.
d. If they can’t get their calves to touch their thighs due to knee tightness, have them grab their thigh instead and repeat thin maneuver. (This will help differentiate between hip and knee mobility issues. If in this position they still can’t get their thighs to touch their rib cage, then there is a potential hip dysfunction).

What’s Next?

Since so many of us sit on our butts all day it’s no surprise that our butts are rarely working to the level they should be. 

(Unless of course you use your butt for a simple paper weight – then your butt works just fine).

Because the squat is the end goal for all athletes in terms of both health and performance, it’s important for athletic trainers and other health care professionals to begin grooving this pattern early on in the rehabilitation process so that there is not only a seamless transition from one Sports Medicine to Performance Training, but also a clear message when it comes to cueing and technique among all professionals on staff.  In order to have everyone speaking the same squat language, starting everyone back on the ground and building a solid and logical progression from post-surgical all the way to high performance only makes sense while the entire staff is playing nice together.

Below is a starting point with a few teaching cues to get the conversation started and a solid progression built between the two groups.   (I have purposefully not included a complete progression below so to force the issue with your own staff.  People tend to complete tasks fully if they have had an opportunity to contribute to so be sure to ask for feedback from both staffs – Sports Medicine and Strength & Conditioning).

Back to Basics: (Supine Table Series)

1. Teach Glute Max w/ Bridge
2. Supine Bridge w/ Thera-band
3. Supine Bridge w/ Marching
4. Single Leg Hip Bridge

Teaching Points:

a. Squeeze Glutes to hold “gold coin” between butt cheeks or pretend to “crack a walnut” while bridging
b. brace core musculature as taught by Stu McGill
c. Ensure hamstrings are not dominate during exercise by palpating medial tendons.
d. Add a theraband around knees or create an ADDuction force to the knees to facilitate additional glute max contraction

– NEVER PLACE A BALL BETWEEN THE KNEES!

Teaching Progression for the Troubled Squat

1. Goblet Squat: hold Kettlebell by the horns and squat to depth (providing a weight to the anterior portion of body balances the athlete and gives an additional point of stability

2. Descend squat so that elbows touch VMO of each knee.

3. If depth is a problem “wedge” elbows inside of knees to mobilize the hips.

4. In the early stages be sure to stand behind your athlete to ensure safety – encourage thoracic extension and a flat back

5. ** use clinical judgment based on patient presentation and injury. If unsure, REGRESS activity and PERFECT – OWN THE MOVEMENT before progressing to more advanced alternatives.

READ:  Squatting - An Expression Of Health

Next week: Bringing both staffs together to learn and master the hip hinge – a must for avoiding and rehabilitating back pain and also pulling big deadlift numbers!

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.   

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.

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

by Art Horne

At the college level many times both assessment and intervention decisions are made based on time availability and simple manpower, and not on what the student-athlete requires for optimal health and performance.  Juggling study hall, practice, classes along with rehabilitation and performance training leaves little time for “additional” work for either the student-athlete or the staff professional in charge to provide additional auxiliary services in the form of corrective work, soft tissue manipulation or additional strength training.  With that said, this extra “work” is often neglected or pushed aside until either the student-athlete is no longer able to participate in practices or games due to an injury or becomes crippled due to some form of debilitating pain.  In either case, unfortunately the student-athlete has now become a student-athlete-patient within your facility and the little time you had to address her problem prior (which of course is why it wasn’t taken care of in the first place, or even looked at – ignorance is bliss after all) has now become a major investment and drain on your time and services. 

In order to avoid the initial trap that so many sports medicine and performance departments fall into each fall it is paramount that both departments (Sports Medicine and Strength Training) first reach an agreement to implement a comprehensive screening program TOGETHER to tease out dysfunction, evaluate for painful movement patterns and address these minor “tweaks” before they become major pains.

Where to start:

It’s hard to rank which movement pattern is more important over another as each of the “Big Three” (squat, lunge and step) are all integrated and hold value within the context of all sporting events and training.  However, the only pattern among the three that is universally tested among college athletes and Strength Coaches is the squat, and thus, at least with regards to an integrated approach takes precedent over the others if having to choose only one.  Administering the test takes under a minute and produces so much more than just a number via the traditional FMS scoring system.

1. There’s something powerful about having members of both your sports medicine and strength staffs stand beside each other while evaluating a student-athletes overhead squat pattern during a fall pre-participation examination.  Because the strength coaches typically tests each athlete’s squat either later the same day or the next, this “pre-screening” allows strength coaches to see the movement pattern in an authentic form, not to mention in a rare one-on-one format which is never the case in a collegiate weight room due to traditional low coach to student ratios. 

2. When an athlete scores a “1” which means they cannot achieve a proper squat, it’s always nice to see the strength coach cross the name off the list of kids to max test later that day.  If you cannot squat to at least a “2” in the FMS overhead squat test then you simply haven’t qualified to load the pattern and go balls to the wall during testing – PERIOD.  This will sometimes be an issue among sports medicine professionals and strength coaches if the athletic trainer simply tells the strength coach that the athlete shouldn’t squat; but this is never a problem when the strength coach sees for themselves the awful pattern that the student-athlete exhibits.  The strength staff must be involved in your yearly pre-participation screenings to ensure buy in from all those involved in the care and performance of the student-athletes.  Remember: squatting is not a weight room exercise, it’s an expression of health, and allowing a student-athlete to max test a pattern that they cannot perform with their own body weight is simply irresponsible – PERIOD.

3. So, with that said, what do you do with the kid that scores a “1” on the FMS overhead squat test? As we discussed prior, time is of the essence and thus the underlying deficiency needs to be “teased out” and an appropriate intervention applied.  Both the FMS and The Selective Functional Movement Screen (SFMA) allows the clinician and/or strength coach an easy algorithm to follow with suggestions for corrective  work once the underlying deficiency is discovered.  Often times it’s the usual mobility suspects – t-spine, hips and ankle but just as often, these mobility issues requires a skilled clinician’s assessment and intervention.  On the flip side, in the case of a neuromuscular-stability issue a Goblet squat progression can be implemented by a strength coach during a training time in place of the squat, to begin coaching them back towards their end goal of a “3” or at least a “2” prior to max testing. (more on Goblet squat progression in a future post)

4. For all those athletes that score a “0” during the test – which means they experience pain, a comprehensive follow up evaluation is scheduled either later that day or within the week by a skilled clinician, (most likely a member of your Sports Medicine Staff) to determine the pain generator along with a rehabilitation plan to properly address.  So many times athletes will state that they have no pain on intake but then suddenly realize that during a simple movement that pain is actually present.  I’ve never had an athlete experience pain during a simple movement test (“It’s not a big deal, I just put ice on it after I train”) not miss time during preseason due to this pain or another greater underlying problem.

Now, some would say that when evaluating the overhead squat pattern utilizing the FMS scoring criteria that we basically all fall in as a “2” and that only a very few athletes score a “1” or a “3” and therefore  the test may be a waste of time.  Although it is true that the majority of athletes that I’ve evaluated using this methodology score a “2”, the means certainly justify the end, especially when you’ve i. discovered pain in this simple pattern and were able to treat it immediately and ii. Discovered a poor movement pattern and provided corrections which over time allowed the athlete to squat normally (which always makes the strength guys happy) but most importantly allows the athlete to achieve success in their individual sport – the reason they showed up in August for pre-season in the first place.  In the end, the OH squat test really only takes a minute but the effects of this evaluation and correction last throughout their college career.

Next week we will talk about evaluating the Multi-segmental Extension Pattern and what to do when you find a problem.

Speaker at this past summer's, "Standing On The Shoulders Of Giants" Seminar, Clare Frank continues to educate the nations top sports medicine and rehabilitation clinicians in her upcoming 2012 speaking engagements.

See Clare's 2012 Speaking dates below.

Asuza - 2012 DNS Course

Janda Approach - Arcadia 2012