Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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It has been a while since my last post. To be honest, I have been busy with preparing/presenting my live seminar last week and webinars, as well as fulfilling my writing obligations and clinical role. So, I have been taking a “break” from blogging and recharging the battery so to speak.
Now I am getting back to it. The great thing about presenting though is that I am consistently reading and reviewing the latest research on topics related to my presentations and closely examine my rehab and exercise philosophy. In my clinic, I treat many runners for knee pain.
The average profile is an experienced runner b/w the ages of 25 and 50 who logs 20 – 35 miles per week and routinely competes in half marathons or some sort of triathlons.
Common injuries include IT band problems versus lateral meniscus tears versus patellofemoral pain. Often, I uncover the following things related to kinetic chain deficiencies:
- Elevated or rotated inominate
- Ankle dorsiflexion restriction (OH squat assessment)
- Poor single leg stance
- Weak lateral myofascial chain
- TFL dominance
- Excessive femoral internal rotation/adduction with single leg squats
- Tightness in hip flexors, ITB and soleus
Many currently debate the efficacy of foam rolling. Is it worthwhile? Some say yes, while others say no.
Let me start off by saying I have the privilege to assess and treat many avid runners on a weekly basis. Some of them are triathletes and others just dedicated runners. While the age and experience level varies, I see more female runners in all.
Recently, a woman in her mid thirties came in for PT after being referred by a physician’s assistant (PA) with a working diagnosis of hip flexor tendinitis. She had developed pain running in the past few weeks. It was now at a level preventing her from running despite using NSAIDS to reduce inflammation.
Specifically, she complained of increased pain with figure 4 sitting, difficulty and pain getting up from a chair, and increased pain with running. Her pain level at the eval was 2/10 but went as high as 9/10 with running. Lots of things can cause pain in the hip joint.
Summary of clinical findings:
- Poor single leg stance on the involved hip with mild pain
- No leg length discrepancy
- Subtle antalgic gait
- AROM for hip and L-spine are within normal limits
- No pain with quad or hip flexor stretching
- Manual muscle testing reveals 5/5 strength for hip flexion (SLR and seated), abduction and adduction
- Pain with FABER testing
- Positive hip impingement sign
- Pain with deep squat
It is no secret that proper scapula alignment and muscle activation makes for a healthy shoulder. There are many forms of dysfunction that may be present.
Generally speaking problems revolve around muscular tightness/weakness and faulty movement patterns. The term “SICK” scapula is often used and refers to Scapula Inferior Coracoid Dyskinesis. Common examples of a “sick” scapula include:
- Type I – Inferior border prominence. This is typically related to tightness in the pec minor and weakness in the lower trapezius. Keep in mind the upper trapezius will naturally dominate the lower trap in the force couple with the serratus anterior for upward rotation. You may also see increased thoracic kyphosis which will inhibit the normal resting position of the scapula.
- Type II – Medial border prominence. In this case the scapula is internally rotated or protracted and there is liekly weakness present in the rhomboids and middle trapezius. The serratus anterior may also likely be weak with evidence of scapular winging. This position places the humerus in relative internal rotation and increases risk of impingement with arm elevation.
- Type III – Superior border presence. Here the scapula appears elevated in the face of an overactive upper trap and/or levator scapulae. With active arm elevation, you may notice excessive shrugging or superior humeral head migration in light of the imbalance. Again, the lower trapezius is probably weak and being overpowered.
Click here for a great graphic display from the Journal of the American Academy of Orthopaedic Surgeons of how the scapular muscles work collectively as a force couple to promote optimal movement in the shoulder.
In many of the throwers and overhead athletes I see in the clinic, they often exhibit either medial border prominence of inferior border prominence. Additionally, I frequently observe GIRD (glenohumeral internal rotation deficit) values of 20 degrees or higher in those patients who come in with symptomatic shoulders (rotator cuff and/or labral issues). What does this mean?
Well, in a nutshell, it means addressing posterior capsule tightness in the throwing shoulder is important for avoiding internal impingement and SLAP tears. Tightness (or too much GIRD) can increase the load/tension in the late cocking phase of throwing thereby contributing to friction between the cuff and labrum, as well as excessive torsion on the proximal biceps tendon. Any excessive humeral head migration with repetitive throwing is a recipe for injury over time.
I have been a bit behind on blogging as of late. I try to aim for one per week, but I also strive to deliver sound and relevant content. Additionally, I do not seek outside contributors so finding time to write can be tricky with work and family life too. So, forgive me for any apparent inconsistency in posting. Just know that I will always try to provide valuable content. Today’s post centers around an article in the July 2012 edition of AJSM.
My work at the Athletic Performance Center has provided me an increased opportunity to work with FAI and athletic hip injuries. This is an area of evolution and growth in our field, so I find it particularly interesting to see rationale and thought processes centering around the timing, contribution and selection of hip exercises for active patients/athletes.
This article comes from the Steadman Philippon Research Institute in Vail, CO. The purpose of the study was to measure the highest activation of the piriformis and pectineus muscle during various exercises. The hypothesis was that highest pectineus activation would occur with hip flexion and moderate activity with internal rotation, whereas the highest activation with the piriformis would be with external rotation and/or abduction.
Methods: 10 healthy volunteers completed the following 13 exercises:
- Standing stool hip rotation
- Supine double leg bridge
- Supine single leg bridge
- Supine hip flexion
- Side-lying hip ABD with external rotation
- Side-lying hip ABD with internal rotation
- Side-lying hip ABD against a wall
- Hip clam exercise with hips in 45 degrees of flexion
- Hip clam exercise with hips in neutral
- Prone heel squeeze
- Prone resisted terminal knee extension
- Prone resisted knee flexion
- Prone resisted hip extension
All of these exercises have been reported to be used in hip rehab following arthroscopy or recovery from injury. The exercises were executed slowly and methodically with a metronome to reduce EMG amplitude variations.
Over the past several years, the trend in the health and fitness industry has been toward injury prevention and movement screening. Gray Cook and Lee Burton have given us the FMS. More recently, the Y-Balance test has emerged as another tool to assess asymmetry in the upper and lower quarter.
I am currently FMS certified and planning to attend the SFMA course next month in Durham. I routinely incorporate the FMS in both our rehab and sports performance work at the APC. I like many things about the screening exam. It provides a consistent tool to assess baseline movement and record asymmetry on a simple 4 point scale scale. It also has been shown to have good intra and inter-rater reliability. Click here for a recent study published in the Journal or Orthopaedic & Sports Physical Therapy.
For those unfamiliar with the screen, it is 7 tests scored on a 0-3 scale as follows:
- 0 = pain
- 1 = unable to perform the movement pattern (or perform with marked dysfunction)
- 2 = performs the movement with a mild compensation
- 3 = performs the movement correctly
I would say on average, most of the athletes I screen score between a 12 and 15. My highest score was a 19 (9 year old gymnast) and my lowest was a 9 (NFL lineman). As screeners, we are charged with uncovering asymmetry and faulty movement patterns. What do you see in the following picture?
Clearly, the dowel is not level, thus we score it a 2. She also had some ER in the right leg when stepping over the hurdle. She was a symmetrical 2 on the hurdle step test. This is a Division I soccer player who scored 17 on the exam.
Most of the movements seem straightforward. However, many question what the rotary stability test measures with respect to the ideal 3 score (ipsilateral movement)? It assesses an unnatural movement pattern to be sure. This athlete failed miserably on the ipsilateral pattern but scored a solid 2 with the contralateral pattern.
I have yet to test someone who can score a legitimate 3. I have seen some get a 3 on one side and 2 on the other (asymmetrical and a red flag in FMS land). As one who naturally questions things, I find myself questioning how many are truly capable of scoring a 3.
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