Clinical Examination Article Archives

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Anterior Pelvic Tilt Influences Hip Range of Motion and Impingement

One of the most common postural adaptations that I see on a day to day basis is anterior pelvic tilt.  In fact, it’s getting more rare to find someone that isn’t in a large amount of anterior pelvic tilt.

I blame it on our seated culture.  The human body is excellent at adapting, and the seated posture produces an anterior pelvic tilt.

 

Anterior Pelvic Tilt Influences Hip Range of Motion and Impingement

Anterior Pelvic Tilt Hip Range of Motion ImpingementA recent research study published in the American Journal of Sports Medicine looked at the effect of changes in pelvic tilt on range of motion and impingement of the hip.

The authors looked at CT scans of the hips of  50 subjects with femoroacetabular impingement and simulated range of motion using 3D-generated models.

A 10 degree increase in anterior pelvic tilt, which I would say is something we see clinically, resulted in a significant loss of 6-9 degrees of hip internal rotation and increase in FAI.  This increase in anterior pelvic also resulted in a loss of 10 degrees of hip flexion.  Subsequently, an increase in posterior pelvic tilt resulted in greater hip internal rotation, less impingement, and more hip flexion.

 

Clinical Implications

The results of the study have several implications

  • Assessment of hip ROM should take pelvic position into consideration.
  • FAI symptoms may be reduced by decreasing anterior pelvic tilt.
  • People with limited hip internal rotation or hip flexion may have too much anterior pelvic tilt.  Focus on alignment before starting to torque the joint.  This is a fundamental principle I talk about in Functional Stability Training of the Lower Body.
  • People with poor squat mechanics, especially in the deeper positions, may have an underlying pelvic position issue.  People with excessibve anterior pelvic tilt that are squatting deep maybe impinging and beating up their hips.

 

I talk a lot about reverse posturing, my terminology for focusing on reversing the posture that you assume for the majority of your day.  But there is a big difference between reducing static anterior pelvic tilt posture and dynamic anterior pelvic tilt control.  You have to emphasize both with dynamic control being arguably more important.

Keep these findings in mind next time you see someone with a large amount of anterior pelvic tilt.

If you are interested in learning more about how I work with anterior pelvic tilt, I recently outlining my integrated system of manual therapy and corrective exercise in my Inner Circle webinar on Strategies to Reduce Anterior Pelvic Tilt.

 

 

The Influence of Pain on Shoulder Biomechanics

The influence of pain on how well the shoulder moves and functions has been researched several times in the past.  It is often though that impaired movement patterns may lead to pain the shoulder.

A recent two part study published in JOSPT analyzed the biomechanics of the shoulder, scapula, and clavicle in people with and without shoulder pain to determine in differences existed between the groups.  Part one assessed the scapula and clavicle.  Part two assess the shoulder.

The subjects with pain were not in acute pain, but rather had chronic issues with their shoulders for an average of 10 years.  Think of it like chronic recurring shoulder impingement.  The authors used electromagnetic sensors that were rigidly fixed to transcortical bone screws and inserted into each of the bones to accurately track motion analysis.

The studies were interesting and worth a full read, but I wanted to discuss some of the highlights.

The Influence of Pain on Shoulder Biomechanics

In regard to the scapula, the authors found:

  • Upward rotation of the scapula less in subjects with pain
  • This decrease in upward rotation was present at lower angles of elevation, not in the overhead position

It is important to assess scapular upward rotation in people with shoulder pain, particularly emphasizing the beginning of motion.  Realize that no differences were observed in upward rotation past 60 degrees of elevation, implying that the symptomatic group’s upward rotation caught up to the asymptomatic group.  This may imply that there is a timing issue, more than a true lack of scapular upward elevation issue.  They are upwardly rotating, but perhaps just too late?

The study also found the following in regard to shoulder motion:

  • Shoulder elevation was greater in subjects with pain
  • This increase in shoulder elevation was present at lower angles of elevation, not in the overhead position

Noticed how I intentionally presented it similar to the scapula findings?  if you put the two finings together, it appears that people with shoulder pain have a higher ratio of shoulder movement in comparison to scapular movement at the beginning of arm elevation.  The shoulder caught up again overhead, so it appears that the timing between shoulder and scapular movement may have an impact.

The Influence of Pain on Shoulder Mechanics

As you can see, it is important to assess both shoulder and scapular movement together, and not in isolation, as movement impairments at one join likely influence the other.  The brain is exceptionally good at getting from point A to point B and finding the path of least resistance to get there.

I should note that in studies like this, it is impossible to tell if the pain caused the movement changes or the movement changes caused the pain.  So keep that in mind.  Regardless of causation, our treatment programs should be designed with these findings in mind.

There are so many other great findings in the study that I encourage everyone to explore these further, but I thought these findings were worth discussing.  Based on these findings, it appears worthwhile to assess the relative contribution of scapular and shoulder movement during the initial phases of shoulder elevation.

Interested in advancing your understanding of the shoulder?  Join my extensive online program teaching you exactly how I evaluate and treat the shoulder at ShoulderSeminar.com.

ShoulderSeminar.com

Laxity Does Not Mean Instability

Several years ago, when Eric Cressey and I released Optimal Shoulder Performance, I discussed the Beighton Laxity Scale and how I use it to determine the amount of laxity that individuals may possess.  This is just one of the many factors that go into how I design my rehabilitation and performance programs, as an individual’s amount of laxity influences program design.

Since then, I have started to hear comments from people that their clients may have Ehlers-Danlos syndromeLoeys-Dietz syndrome or Marfan syndrome because of their Beighton score.

Laxity is Normal

Beighton Scale Laxity InstabilityIf you Google “Beighton Score,” you see that this is a scale often used to diagnose the above hypermobility syndromes, however each has their own specific features.  A Beighton score is not the only factor involved, and actually is probably not the most important finding in any of these syndromes.

Laxity is not a syndrome, in fact, laxity is normal.

We all have a certain degree of laxity, you’ve probably seen many people along this spectrum from the really tight to the really loose.  A high Beighton score does not indicate that they have a syndrome or problem, it just helps determine where they sit in the laxity spectrum.

Laxity Does Not Mean Instability

While joint laxity is normal, a high amount of laxity does not necessarily mean you have instability.  Stability is a combination of the function of your static and dynamic stabilizing systems.  Instability is when you have an issue with either (or both) of the static and dynamic stabilizers.  Functional stability is the ability to dynamically stabilize a joint during functional activities to allow proper control and movement.  This is the basis behind our entire Functional Stability Training programs.

Check out this video of my friend Sam’s Beighton score.

As you can see, Sam has a high Beighton score and a lot of joint laxity.  But Sam can deadlift over 2x her body weight.  That is laxity combined with functional stability.  She doesn’t have any problems because she can control her laxity.

Don’t automatically assume a lot of laxity is a bad thing, in fact many professional athletes possess a high amount of laxity.  Remember laxity is normal, does not mean instability, does not mean you have a clinical syndrome, and something you can control with the right program.

Assessing Scapular Position

The latest Inner Circle webinar recording on the Assessing Scapular Position is now available.

Assessing Scapular Position

Assessing_Scapular_PositionThis month’s Inner Circle webinar was on Assessing Scapular Position.  While I have openly stated in the past that assessing scapular position is not as significant as looking at dynamic mobility, I do feel it is worth starting your assessment with position.  You have to know where to start to know where to go.  This is a great follow up to my past talk on Scapular Dyskinesis.

Here is how I assess scapular position, but more importantly how I integrate it into my assessment.

To access the webinar, please be sure you are logged in and are a member 0f the Inner Circle program.

How Does Laxity Influence Program Design?

Today’s article is a guest post from Sam Sturgis regarding the influence of joint laxity on program design.  This is an important concept to understand when individualizing programs to achieve the best results.  People can fall on both ends of the laxity spectrum, from super loose to super tight.  Knowing this information will help you develop the best programs that are specific to the needs of each person.  Thanks for contributing Sam!

How Does Laxity Influence Program Design?

A heavily debated topic in the strength and conditioning world involves stretching.  It seems like there are never ending questions about stretching, such as “Who needs to stretch?,”  “When is the best time to stretch?,” “Does stretching even work?,” and many more.  Often times I will have clients mention to me that they “want to get more flexible” and that they “always feel tight”.  While this may be true in some instances, other times this feeling of “tightness” can be protective muscular tension since other structures aren’t quite working properly.

Being too tight obviously isn’t good, but neither is being too loose. It’s important to strike a balance of joint mobility and stability.

In our bodies we have two types of stabilizers: static and dynamic.  Static stabilizers are inert structures like bones, ligaments and joint capsules. These are non-contractile structures that do not create movements, they are simply there to create joint articulations and hold them together.  Dynamic stabilizers are the muscles. By contracting during a joint movement, they actively hold our joints in position so that they can move freely.  Laxity is a normal occurance.  Each joint has a certain amount of laxity.  However, in joints that have a lot of laxity, the static structures that hold the joints together may have a more difficult time keeping the joints in a neutral position.  Therefore, the muscles must work harder to create dynamic stability.

This laxity can either be congenital, meaning that you were born with it, or secondary to injury or repetitive activities.

During your assessment, one way to determine how lax a client may be is to use the Beighton Laxity Scale.  Mike Reinold and Eric Cressey mention this in their DVD Optimal Shoulder Performance and show how they use a Beighton Score when designing their programs.

The Beighton Score

The Beighton Scale is a 9 point scale that goes through a series of passive ranges of motion where a point is given for each indicator:

Beighton_scale

  • Hyperextension of the 5th finger MCP joint beyond 90 degrees
  • Apposition of the thumb to the flexor aspect of the arm
  • Hyperextension of the elbow beyond 10 degrees
  • Hyperextension of the knee beyond 10 degrees
  • Toe touch with the knees straight, touch the palms flat on the floor

A score of 0-4 would indicate an individual who is within normal levels of joint stiffness whereas a score of 5-9 would indicate joint laxity.  (photo from Physio-pedia.com)

Note From Mike: In Optimal Shoulder Performance, I teach how I actually use a 5-point scale.  In my mind if one of your elbows can hyperextend, for example, than you get a point.  If you perform a lot of unilateral activities, like throwing a baseball, you may have some chronic adaptations that may alter your score.  If you non-throwing arm has the laxity, then your throwing one probably had it too!

How to Use a Beighton Score

beighton-score-dynamic-stabilizationNow that you have determined how someone scores on the Beighton Scale, how should you change your program design?  Someone that scores 5 or higher on this scale should not be focused stretching! They need joint control and dynamic stability. For example, a baseball pitcher with a high Beighton score and 200 degrees of total ROM at the shoulder won’t get ANY shoulder mobilizations, they need to learn how to stabilize within those 200 degrees rather than try to gain more motion.

Conversely, someone who scores a 0 on the Beighton scale may be a candidate for more soft tissue and mobility work because they may need to create more range of motion to move freely and safely.

There is a continuum that clinicians should assess for and use to rationalize their decision making.  If a client presents with joint laxity outside of the normal limits, act appropriately and promote better proprioception and dynamic stability. Stretching or mobilizing someone who is already loose could make their issue worse. That protective tension is there for a reason, to keep the joint from getting injured! On the contrary, if someone presents as tight outside of normal limits, focusing on increasing their range of motion may be the most appropriate solution. If you can know which side of the fence each person falls on, this will help you individualize everyone’s program to maximize their training results.

About The Author

Sam SturgisSam Sturgis holds a Bachelor’s Degree in Athletic Training from Quinnipiac University and Master’s Degree in Strength and Conditioning from Springfield College.  A skilled Strength Coach and Athletic Trainer at Pure Performance Training in Needham, MA, Sam works primarily with baseball athletes and clients rehabilitating from injury.

Assessing Shoulder and Scapular Dynamic Mobility

Assessing Shoulder and Scapular Dynamic MobilityA thorough assessment of the shoulder must look at the posture and dynamic mobility of both the shoulder and scapula.  More importantly, we need to assess the interaction between the shoulder and scapula and not look at the two in isolation.

Assessing Shoulder and Scapular Dynamic Mobility

Altered scapular dynamic movement can be influenced by many things, so a thorough assessment is needed.  Here is a clip from my brand new educational program with Eric Cressey, Functional Stability Training for the Upper Body. This is part of a lab demonstration of Eric Cressey and I assessing overhead arm elevation and the quality of shoulder and scapular mobility.  In this clip you can clearly see a side-to-side difference and we discuss some of the potential implications:

This is just a very small clip of some of the great information we cover in our Functional Stability Training for the Upper Body.  Click here or the image below to order now before the sale ends!

Functional Stability Training for the Upper Body

Assess Don’t Assume

SFMAI was fortunate last week to swing by and watch my friend Mike Voight teach the SFMA in Boston.  I met Mike’s co-instructors Josh Satterlee and Brandon Gilliam and was impressed with the course.  I have been SFMA certified for some time but I wanted to hear Mike’s take on the system.

I wanted to share with everyone a key theme that was presented that I thought was worth expanding on and sharing.  During one of the introductory presentations, Josh talked about how important the assessment process was and without it, we are just guessing.  This goes along with what I always say, “assess, don’t assume.” [Click to Tweet]

One of the points that was made was that sometimes we get lucky.

Perhaps your client can’t touch their toes and you instruct them to stretch their hamstrings.  Now this person can easily touch their toes.  Take a guess what you are probably going to tell the next 50 people that can’t touch their toes to do?  Probably stretch their hamstrings, because it worked so well on that first person!

We have all been guilty of getting stuck in our box of techniques.  Every time we go to a new seminar or learn something new on the internet, we try it on everyone.  Perhaps we get lucky and hit a bullseye on a few of those people.

We all know there are dozens of reasons why you may not be able to touch your toes, and realistically, hamstring flexibility is not often the reason!  You can’t recommend hamstring stretching unless you have identified that this is the specific reason why your client can not touch their toes.

Don’t be guilty of being stuck in your box of techniques.  Just because it works on one person, doesn’t mean it will work on the next person.  Everyone is unique and has unique needs.

Don’t get stuck in your ways.  As Josh said, chiropractors are great at mobilizing already mobile people and physical therapists are great at stabilizing already stable patients.  I thought that was hilariously accurate!  It really comes back down to your assessment.  I do use the SFMA but also many other assessments techniques (you can see some of them in my Functional Stability Training system).  They help guide me towards what my client needs, I’m not satisfied with being lucky, neither should you.

 

 

Is Resting Scapular Position Important?

Scapular posture assessmentA common component of any shoulder or neck evaluation is observation of scapular position and motion.  Posture assessment is popular and attempts to identify any asymmetries between sides.

As our understanding of the mechanics of the shoulder and scapular improve, the reliability and validity of assessing resting scapular position have recently been challenged.  Many authors believe that we may be overassessing and assuming dysfunction based on resting scapular position, which would imply that many corrective exercise strategies for the scapula may be either ineffective or inappropriate.

I have really changed how I assess and treat scapular dysfunction over the last decade.  My research has led my change in thought process, but other studies have also been reported in the literature.

Does Poor Scapular Position Correlate to Poor Scapular Mobility?

My exploration of scapular asymmetries and dyskinesis led me to first assess scapular position.  In baseball players, asymmetries of scapular position are common, and perhaps a normal adaptation.

While these resting static asymmetries were noted, I started to observe that these asymmetries seemed to become much less obvious during active movement.  As an example of this, we noted that the resting static position of the scapula on the throwing side was 14mm lower, which was statistically significant.  However, when the arms were abducted in the scapular plane to 90 degrees of elevation, the scapula was now symmetrical with the nonthrowing shoulder.

Scapular position

This really made me start thinking about the validity of resting static scapular posture.

To further evaluate this, we then looked at 3D electromagnetic tracking to see if poor static posture correlated to poor scapular mobility, or dyskinesis.  We looked at this in a few studies and found that resting static position does not correlate to poor movement patterns.

Several studies have shown that these scapular asymmetries are common in the general population too, so I consider my findings in the overhead athlete relevant to any population.  In my experience these same results occur in other populations.

Does Scapular Position Correlate to Injury?

The validity of static resting posture of the scapula has come into recent debate as tests such as the Lateral Scapular Slide Test, described by Kibler, has been shown to find asymmetries in both symptomatic and asymptomatic people.  Static postural tests like this have been shown to have both poor reliability and validity, meaning that we are not sure how accurate they are or what these tests actually measure.

Probably more importantly, however, is the finding that static tests have been unable to identify people with and without shoulder injuries, such as in this systematic review from the British Journal of Sports Medicine.

in a 2-year prospective study of over 100 recreational athletes, a recent study in the International Journal of Sports Medicine showed that static resting scapular position did not correlate to the future occurrence of shoulder pain.  They did note that the people who developed shoulder pain demonstrated decreased scapular upward rotation at 45 and 90 degrees of elevation, further suggesting that dynamic mobility is more important that static.

These studies are difficult to conduct but it appears that scapular asymmetries are common in the general population and do not correlate to injury.  That does not necessarily mean they do not feed into dysfunction, but the correlation may not be as factual as many think.

Recommendations

So what do we know about resting scapular position?

Based on our current understanding of scapular posture, it is hard to place a lot of emphasis on static posture as it does not appear to be reliable, valid, correlate to injury, or correlate to poor movement patterns.

I think one of the worst things you can do is assume dysfunctional movement will occur based on a posture assessment.  For example, you would not want to cue excessive scapular movement during arm elevation just because the person is resting in a certain scapular position.  You have a very large chance of just further facilitating your compensatory pattern by forcing the motion instead of finding the underlying cause.

People often seem to forget one VERY important fact:

The scapula is part of the scapulothorax joint.  The position of the thorax and spine will greatly influence the position of the scapula.  [Click to Tweet]

Perhaps an anterior pelvic tilt is causing increased thoracic kyphosis and scapular anterior tilt.  Perhaps a forward head posture is causing shortness of the levator scapula and causing downward rotation of the scapula.  Cueing movement without addressing the alignment, soft tissue restrictions, and other real issues is going to make this a lot worse.

These are just two examples but hopefully demonstrate the complexity of assessing scapular position and mobility.

To learn more about my approach, I have a recorded webinar for Inner Circle members that reviews how I assess and treat scapular dyskinesis, click here to learn more about my Inner Circle.

Scapular Dyskinesis

Do I still look at posture and scapular position?  Sure.  I start there, but realize that dynamic movement is likely much more important to assess.  I would not recommend that you apply corrective exercises based solely on resting scapular position.