Clinical Examination Article Archives

Check out all my articles on clinical examination and evaluating injuries.  Explore the archives below or click the button to subscribe and never miss another post.

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Did We Really Discover a New Ligament in the Knee?

This week’s Stuff You Should Read is about the “new” discovery of the anterolateral ligament of the knee.

Inner Circle and RehabWebinars.com Updates

My next live Inner Circle will be an evening live Q&A which is always fun, ask me anything!  This was a big hit last year so I expect it to be even better this year.  It will be Monday December 16th at 8:30 PM EST.  Looking forward to this one.

RehabWebinars.com has a bunch of awesome new webinars coming up over the next few months.  Michael Mullin had part 1 of a webinar on Integrating Postural Restoration Institute Concepts into Training, part is coming in January.  This was a great webinar and a great intro into the PRI concepts!  This month, David Weinstock, the developer of Neurokinetic Therapy, discusses some of the principles of NKT.

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The Discovery of the “New” Knee Ligament – The Anterolateral Knee Ligament

anterolateral knee ligamentFor this week’s stuff you should read, I thought I would piece together a few articles that go over the press received over the “discovery” of the “new” anterolateral ligament of the knee.  Notice all my “quotes!”  Here is a link to one of the many sensationalized articles from the media on this new ligament:

Pretty exciting title, right?!  The media cracks me up.  Sensationalizing everything.  The news report is in reference to a paper published in the Journal of Anatomy regarding the anterolateral ligament.  Here is the abstract of the paper, which ironically, starts with the phrase “In 1879, the French surgeon Segond described the existence of a ‘pearly, resistant, fibrous band’ at the anterolateral aspect of the human knee.”

The website io9 did a good job highlighting these facts in their article:

But Dr. LaPrade from the Steadman Clinic did an even better job talking about everything you want to know about this “new” ligament!

Here is a video of the ligament:

So, nice articles and video, but no, not a new ligament.

Can Tight Hip Flexors Cause Tight Hamstrings?

I like the title of this article – Can Tight Hip Flexors Cause Tight Hamstrings?  It is sort of like a riddle, isn’t it?

I was working with a client recently that is knowledgable and understands anatomy fairly well.  He came to see me for several reasons, but high on the list was “my hamstrings are tight” followed by a poor attempt at touching their toes.  His hands were about 3 inches from the floor with his knees bent!  He added, “I don’t know why I can’t touch my toes, I have been stretching and working on my hamstrings for months!”

After spending time assessing him from head-to-toe, I shared with him that I thought his hamstrings were “tight” because his hip flexors were tight.  He thought about it for a second and then tried to call BS, stating “If my hamstrings are tight, shouldn’t my hip flexors be loose?”

My answer was “I don’t think your hamstrings are tight.”  At this point, he was about ready to leave the session, thinking I was the craziest person in the world, stating “but I can’t touch my toes?!?”

 

How Tight Hip Flexors Can Cause Tight Hamstrings

I bet you’ve had clients like this in the past.  They know just enough to be dangerous.  The answer to my riddle is more semantics than anything else.  Yes, hamstring tightness can limit your ability to touch your toes, but that isn’t the only cause.

We have actually done a great job understanding this concept over the last several years.  People like Gray Cook, Lee Burton, Brett Jones, and others have done wonders teaching many people that sometimes there are other reasons why you can have a limited toe-touch, specifically because of poor motor control and core stabilization.

However, hip flexor tightness can be a contributor as well, as backwards as that seems.  Again, it comes down to semantics.  I am actually talking about anterior pelvic tilt limiting your ability to touch your toes.

Here is an interesting an example.  Which hamstring is shorter in the below image?

hip flexor hamstring tightness

If you answered the left leg, you are guessing!  Without a comprehensive exam, you are just guessing.  What if his left pelvis was anterior tilted?  This would cause the proximal attachment of the hamstring to move superiorly and look just like a tight hamstring, such as in this example:

tight hamstring anterior pelvic tilt

Whenever someone appears to have tight hamstrings or can not touch their toes, I look first at pelvic alignment to see if they are in excessive anterior tilt.  Everything revolves around assessing your starting point.

As you can see in the example below, if you are starting in a large anterior pelvic tilt, then you are theoretically starting with the hamstrings long.  I used the simple math numbers of 45 degrees and 90 degrees, which is pretty excessive, but you see what I mean.  In a large anterior pelvic tilt, your normal starting position in this example would already be close to 45 degrees!

Anterior Pelvic Tilt

So, can having tight hip flexors cause tight hamstrings?  I’m not sure about that.  But I know that being in anterior pelvic tilt can limit your ability to touch your toes.  Again, it always comes down to:

Functional-Stability-Training-Lower-Body

Assess, Don’t Assume

This is one of my major concepts from the Functional Stability Training for the Lower Body program.  Assess alignment before you just start treating.  Resist the urge to just foam rolling, massaging, and stretching your hamstrings without truly assessing if this is the reason why you can’t touch your toes.  Sometime having tight hip flexors and an anterior pelvic tilt can limit your ability to touch your toes just as much.

Scapular Dyskinesis

Scapular DyskinesisThe latest webinar recording for Inner Circle members on Scapular Dyskinesis is now available below.

Scapular Dyskinesis

This month’s Inner Circle webinar discussed Scapular Dyskinesis.  This is a diverse topic and I think a lot of people get confused when trying to figure out what to look for, how to assess, and how to treat scapular dyskinesis.  My goal was to simplify what to look for and give you the steps I follow to develop a thorough treatment program.  Many people struggle with scapular dyskinesis because they miss one or more important portions of the treatment process.  In this webinar, I will discuss:

  • What exactly is scapular dyskinesis?
  • Why some of the most common ways to assess are not reliable or valid
  • How to best assess and classify
  • A 4-step process to treat the entire spectrum of scapular dyskinesis

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

What You Need to Know About GIRD: What It Is and What it Isn’t

GIRD Mike ReinoldGlenohumeral internal rotation deficit, or GIRD, continues to be one of the most polarizing topics in baseball sports medicine.  It has become so popular that even athletes and the general public know about GIRD, often exhibiting fear and anxiety with just the mention of GIRD.

How many times has a baseball player come back from the doctor with their head down saying, “I have GIRD,” as if the world has just ended?

I do not feel that everyone truly understands GIRD, how to assess GIRD, or how to treat GIRD.  There are a lot of theories and assumptions out there that may or may not be true.

Here is my take on GIRD, and it is not exactly how everyone would describe GIRD.

What is normal range of motion in an overhead athlete?

Before we can have any discussion on what is considered abnormal range of motion in the thrower’s shoulder, we should make sure we understand what is considered “normal” in overhead athletes.

Throwers have very unique adaptations from the demands of throwing. Numerous articles over the past 15 years have consistently shown that the dominant shoulder in overhead athletes exhibits an increase of external rotation and a subsequent decrease in internal rotation.  However, if you take the total rotation motion and combine ER and IR measurements the numbers are almost identical.

I remember when we first started discovering this phenomenon many years ago and it is uncanny how you find essentially the exact same total motion arc on both sides.

Here is an illustration of what this looks like.  In this figure.  You see the nondominant shoulder on the left and the dominant shoulder on the right.  You see the shift in the arc of total rotational motion, however if you break down the components of ER and IR, you see that both sides total 180 degrees.

GIRD glenohumeral internal rotation deficit

This adaptation has been shown in too many publications to list here, but I’ll add a few:

GIRD total rotational motion

This is a brief list but you can see that the total rotation motion on both the dominant and nondominant shoulders is almost identical in every study.  Statistical analysis revealed no significant differences in range of motion side to side.

Why the Adaptation in Shoulder Range of Motion?

Since the first discovery of this loss of internal rotation on the throwing arm, there have been several theories as to the specific reason for the adaptation.

The first theory centered around the fact that since there was a loss of internal rotation, there must be a subsequent tightness of the posterior capsule.  In actuality, this is really a long shot of being the isolated reason for the loss of IR, assuming a very specific cause for GIRD.

With so many potential factors contributing to the altered range of motion, it is surprising to me how popular this theory became.  If IR is less on the thrower shoulder, we now jump straight to recommending aggressive internal rotation and posterior capsular stretching.  I guess whatever theory comes out first gets the most traction and popularity!

The major flaw of the posterior capsule tightness theory is that it does not take into consideration the very specific increase in ER that is also seen in overhead athletes, let alone the fact that total rotational motion is still the same side-to-side.  If the posterior capsule was the cause of the loss of IR, would we then assume that the anterior capsule has loosened precisely the exact same amount to allow the exact same increase in ER as the posterior capsule does to restrict IR?

That sounds pretty unrealistic to me.

Shortly after the posterior capsule tightness theory was presented, many researchers took a more scientific look at what could be causing this very precise shift in the arc of motion in baseball pitchers and other overhead athletes. Several studies have now been published that have assessed boney changes that could be associated with GIRD.  Using both MRI and CT scans, it is now well documented that the humerus of the throwing arm is more retroverted than the nondominant arm.

What this means is that the actual bone of your upper arm torques and adapts.

Imagine twisting and wringing out a towel.  This is exactly what happens to the humerus during throwing while your growth plates are open.  The body, bones especially, do a great job of adapting to stress.  Essentially, the humerus bone of your upper arm twists at the growth plate and causes permanent adaptations to your bones.  Newer research is also now showing that the other end of the socket, the glenoid, also shows retroversion.

Based on these studies, the exact amount of retroversion observed appears to be approximately 10 degrees on average.  Now go back up and look at the table above.  Notice how the loss of IR is approximately 10 degrees and the gain of ER is approximately 10 degrees?  This boney adaptation makes the very specific shift in range of motion make more sense.  I have shown a simple and fairly effective way of measuring humeral retroversion in the clinic.  Try it in your throwers and you’ll see.

Pretty cool, right?  Still think the posterior capsule is the cause of loss of IR?

I was also a part of two studies that looked at glenohumeral translation in the baseball pitcher that both showed that posterior translation was twice that of anterior translation.  This was even present in baseball pitchers with as little as 10 degrees of IR.  They still had a large amount of posterior translation, not posterior capsular tightness.

Taking all of this into consideration, if there is one thing you take away from this article, it should be:

[quote]The thrower’s shoulder is supposed to have less IR on the dominant side.  This is normal.[/quote]

Determining What is Clinically Significant GIRD

A threshold to determine what can be considered a clinically significant loss of IR is vitally important to the implementation of programs designed to prevent and treat GIRD.  As previously discussed, a loss of IR itself can be considered a normal anatomical variation observed in overhead athletes.

Despite this finding, the term GIRD has continued to have a negative connotation, implying that any side-to-side loss of IR may be pathological.  This has resulted in a trend towards assuming many of the hypothesized theories of why loss of IR occurs are present in each person.

This unfortunately leads to a standardized prescription of stretches and exercises based on assumption and not a thorough assessment.

After reviewing the literature, it appears that most authors have been arbitrarily defining GIRD as a loss of IR greater than 15-20 degrees in comparison to the nonthrowing arm.  Some authors have even published studies showing that your chance of getting injured is increased if you have GIRD of more than 15-20 degrees.

Correlating GIRD to injury is too simplistic at best and again has too many flaws to consider this valid.

You can not accurately state why an increase in injury was observed.  Was it the loss of 17 degrees of IR?  Or perhaps the subsequent gain of 17 degrees of ER?  You can’t make a definitive conclusion either way.

[quote]Perhaps the increase of injuries in baseball pitchers is due to the gain in shoulder ER, not GIRD and the loss of IR?[/quote]

I am thinking this more and more everyday.

Another major flaw with defining GIRD using an arbitrary number is that the published amounts of range of motion have a very large standard deviation.  If you look through the published studies on GIRD, you’ll see that the standard deviation of measurements is large, ranging from 8 degrees to over 15 degrees.  That means the “normal” amount of internal rotation on a shoulder is approximately 50 degrees, but plus or minus 15 degrees.  Thus both 35 degrees and 65 degrees of internal rotation should be considered “normal.”

I can say that I have observed this first hand in professional baseball pitchers.  I have seen just as many players with 140 degrees of total rotational motion than I have with 200 degrees of total rotational motion.  Sure, this averages out to 170 degrees.  But not all baseball pitchers have 170 degrees of total rotational motion.

With such a large standard deviation and variability in measurements, assigning an arbitrary number to define GIRD is too simplistic.

A New Definition of GIRD

These findings have caused me to alter the way I define GIRD and stimulated me to propose a new definition of GIRD based on total rotational motion.

Previous definitions of GIRD based on arbitrary numbers have resulted in generalized treatment programs that are not specific or individualized enough to be utilized in clinical practice.

I propose that a loss of side-to-side IR is actually a normal anatomical variation in overhead athletes and should not be considered pathological GIRD unless there is a subsequent loss of total rotational motion in the dominant arm as well.  

This definition essentially takes the large variability in ROM that has been observed in athletes into consideration and allows for a more individualized approach to treating GIRD. So:

[quote]GIRD is a loss of internal rotation range of motion in the presence of a loss of total rotational motion.[/quote]

In this new definition of GIRD, a pathological condition of GIRD is defined as a loss of IR in the presence of loss of total rotational motion.

Lets looks at this as both an illustration and an equation.  In the figure below, you see the normal arc of motion in an overhead athlete, and to the right, an altered total rotational range of motion due to a loss of IR.

a new definition of GIRD

You can observe this yourself by assessing the specific range of motion measurements.  To calculate GIRD, use this equation:

GIRD = (Side-to-side difference in ER) + (Side-to-side difference in IR)

Here is an example of two baseball pitchers with a loss of IR:

  • Player 1 = (D ER 120 deg – ND ER 100 deg = +20 deg ER) + (D IR 60 deg – ND IR 80 deg = -20 deg IR) = 0 deg – Despite a loss of 20 degrees this is not pathological GIRD because total motion is the same bilaterally
  • Player 2 = (D ER 120 deg – ND ER 100 deg = +20 deg ER) + (D IR 35  deg – ND IR 80 deg = -45 deg IR) = -25 deg GIRD – This represents a pathological GIRD because both IR and total rotational motion are limited

I would suggest that the first player above should not be considered or even called GIRD, despite the fact that there is 20 degrees less IR on the throwing shoulder.  Because the total motion is the same, this is a normal adaptation in this athlete.

In fact, I would comfortably say in my experience that if you tried to reduce that 20 degrees loss of IR when total motion is symmetrical, you would essentially be increasing the total rotation motion and creating instability in an already vulnerable joint.

I believe this causes more injuries than it helps.

Because of the negative association that we have established with the word GIRD, I would propose that we stop calling everything GIRD and reserve GIRD for when it is truly pathological.  This helps clear up confusion.

I strongly feel that this new definition of GIRD takes the individual variability of range of motion as well as the total rotation motion into consideration and is a much more accurate calculation to base treatment recommendations.

Why is this important?

The goal of this article is to share my experience treating baseball pitchers.  I have rehabilitated 1000’s of injured baseball pitchers and managed 1000’s of healthy baseball pitchers.  This unique experience really opened my eyes to what is “normal” in baseball players.

When I first started working in Major League Baseball, I quickly found out that much of what I believe to be “facts” were not always accurate.  I’ll be the first to admit this.  If you only treat injured baseball pitchers, you start to assume that some normal adaptations may be pathological.

While my experience has been with baseball pitchers, this information can be extrapolated to all overhead athletes as these findings have all been established in other sports, such as tennis and handball.

There are far too many people who see a loss of IR and immediately label it GIRD.  Furthermore, there are far too many people who label any loss of IR as GIRD and blindly treat the posterior capsule.  I’m not saying that posterior capsular tightness does not exist, I am just saying it exists far less than we are diagnosing it and there are many other reasons that we need to consider before we start challenging the integrity of the stabilizing structures of the thrower’s shoulder.  I even dedicated an entire webinar to showing you 5 ways to gain IR without stretching the posterior capsule.

Blindly assuming GIRD is pathological, stretching the heck out of IR, and treating the posterior capsule is harmful.

Assess, Don’t Assume

Even with a pathological GIRD using the above equation, you can not assume you know why they have a loss of IR.

I have previously published a study showing that there is an immediate loss of IR after pitching.  We theorized that this was too acute to represent any changes in the capsule and most likely represented muscular stiffness from the eccentric trauma associated with pitching.  This was even more apparent when we also noticed that there was a loss of elbow extension, which is also subject to extreme eccentric forces during throwing.

You can’t assume they need to be stretched to gain more IR or that the posterior capsule is tight.  Maybe it is.  Maybe it isn’t.  Regardless:

Assess, don’t assume.

There is a specific way to assess the posterior capsule, which I will share in an upcoming post.  In fact I am going to write a series on how to more accurately assess GIRD, internal rotation, and the posterior capsule.

By changing the way we assess and define GIRD, we can start to more accurately understand what is happening to these overhead athletes and provide the best care possible.

Breathing Pattern Disorders

Breathing Pattern Disorders WebinarThe latest webinar recording for Inner Circle members on Breathing Pattern Disorders is now available below.

Breathing Pattern Disorders

This month’s Inner Circle webinar discussed breathing pattern disorders.  There has been a lot of talk lately regarding breathing and the function of the diaphragm.  But what is important and what is just “hot air?!”  In this webinar, I will discuss:

  • The difference between voluntary and involuntary breathing
  • Why simple breathing retraining doesn’t usually work
  • The effect of breathing pattern disorders on your body
  • Why focusing on breathing can help you with some of your other goals
  • What exactly to focus on to put the body in a better position to breath more efficiently

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

Teres Major: An Important Muscle that is Often Overlooked in Throwers

There is no doubt that baseball pitchers and other overhead athletes get tight from throwing.  We originally showed this in my study published in AJSM, pitchers had an immediate loss of shoulder internal rotation after 45 pitches on the mound.

I often say that this loss of motion can easily become cumulative if not addressed, and unfortunately, the majority of baseball pitchers I see tend to need work on their soft tissue mobility.  I believe this is directly related to the cumulative trauma to the muscles that has been left unaddressed for some time.

I am a firm believer that regular soft tissue maintenance work is important for baseball pitchers, but I also understand that having access someone like me isn’t very realistic for many athletes.

We have come a long way with tools to work on your own soft tissue, like foam rolling, massage sticks, and trigger point balls.  For throwers, we have been recommending the use of these tools for some time and you often see people focused on a few key areas like the posterior rotator cuff, lats, and pecs.  This is for good reason!

But there is another spot that I bet you are missing that I think is pretty important and will help you feel better quickly.

Teres Major

The teres major just doesn’t get enough respect.  It’s not lucky enough to be included as one of the “rotator cuff” muscles.  It’s not a big guy that you can read how to strengthen in Men’s Health, like the pecs or lats.  Sometimes I think it is forgotten!

The teres major is a pretty important muscle to focus on.

The teres major acts as an internal rotator and adductor of the arm.  Guess what the arm does as you accelerate through your mechanics to generate velocity on the ball?  That is right, you internally rotate and adduct the arm!

But unlike the pec and the lat, who also contribute to the same motion, the teres major has a more intimate relationship with the scapula and humerus.  When you look at baseball pitchers, you tend to see a large, overdeveloped, hypertrophied teres major.  This again tells me it is an important muscle for throwing.  (photo from wikipedia)

teres major tightness

As the teres major gets tight and shortened from overuse and throwing.  you can start to see changes in scapulohumeral motion.  When assessing someone, you may see that the scapula looks like it wants to upwardly rotate more on the throwing side, which I often attribute to the teres major shortening not allowing proper separation of scapula and humeral arm movement.  Essentially the tight teres major drags the scapula up with the arm because the two can’t separate

It looks like the person is achieving good arm elevation but realistically they are just compensating with more scapular upward rotation.  If you look closely, you’ll even notice that they are elevating the arm less and upwardly rotating their scapula more.  This is probably going to cause some impingement and irritation to the shoulder.  Here is a great example:

teres major tightness

Self-Myofascial Release and Soft Tissue Work for the Teres Major

So as much as I want to help you and work with you, I also want you to be able to manage this yourself a little bit.  Remember, we said earlier that you will lose motion after throwing, it’s all about managing this as best as you can.

A simple way to work on the teres major is to perform self-myofascial release to the muscle with a trigger point or lacrosse ball.  We often recommend you roll the back of the shoulder or posterior rotator cuff, but in my experience, we do not emphasize the teres major enough.  To do this you simply need to understand the anatomy of the muscle and adjust the placement of the ball.

I should note that I do not think foam rolling your lats will get your teres major very well.  The muscle is too short and situated up towards your armpit that it just doesn’t work well.  You need to get in there more focal with a smaller trigger point ball.

You can also read my article and video demonstration on self myofascial release for the teres major.

Self-myofascial release teres major

What Trigger Point Ball to Buy?

I typically use a couple of different trigger point balls, depending on how firm I want the ball to be.  I would recommend the softer balls for beginners and firmer for advanced users.  Here is what I recommend:

  • For Beginners: Trigger Point Therapy Massage Ball.  These are a little more expensive than lacrosse balls at about $15, but they are softer and have a little nub than you can wedge into different areas, which I like.  This is a good starting point, but the newer Trigger Point Therapy X-Factor Ball is a little larger and more firm.  I use these a lot.
  • For Advanced Users: SKLZ Reaction Ball.  You know those little yellow reaction balls that you drop and bounce all over the place?  A friend just recently turned me on to these as trigger point tools!  They work great!  They are firm and have great little nubs to really get in to the tissue.  Plus you can usually find them for under $10.
  • You can always just go with a simple lacrosse ball as well.  I think lacrosse balls are great, but they are pretty firm and don’t have a small nub to use, making them less than ideal for some areas.  That being said they are under $2!

Try working on the teres major or recommending this to your athletes, I bet you see improvement pretty quickly.  Working on the teres major soft tissue with some self-myofascial release techniques is an important, yet often overlooked, area to emphasize in baseball pitchers and other overhead athletes.

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The Dale Carnegie Approach to Assessments

We are often guilty of making a big mistake when we are performing assessments.  This applies to both rehabilitation and fitness specialists.

Imagine this scenario, your throat hurts so you go see your doctor.  Your doctor takes pride in being thorough and “getting to the root of your dysfunction.”  Over the course of the next 30-minutes you find out you have high blood pressure, are technically obese, maybe pre-diabetic, have psoriasis on your scalp, and maybe even a little athlete’s foot.

Your next question has to be, “but what about my throat?”  Your doctor responds, “Oh it’s nothing, probably a little post-nasal drip from seasonal allergies.”  Do you leave the doctor’s office happy that you don’t have strep throat or are you depressed that your throat is fine but that your health is a ticking time bomb?

Now I am obviously a fan of thoroughness and preventative medicine, however sometimes we are guilty of overloading our clients with everything that is “wrong” with them.  How many times do you think we do this in our professions?

How many times has a shoulder patient come to you and you find 40 things wrong with their arm, spine, and legs?  How many times has a fat loss client come to you and you are focused on their poor rotary stability and shoulder mobility?

The problem with these three scenarios is not your thoroughness or your findings from the assessments, it is with your delivery.  We recently were all guilty of this when we all discussed my article on assessing overhead arm elevation.  We found a lot of flaws but not a lot of positive findings!

The Dale Carnegie Approach to Assessments

dale carnegie approach to assessmentsI started to teach the concept of what I call the Dale Carnegie approach to assessments (If you don’t get the reference, you have some reading to do).  I mentioned this briefly during the lumbopelvic assessment I perform in my Functional Stability Training of the Lower Body program but wanted to expand on this topic.  (photo from Wikipedia)

Here are a couple of key principles of how I implement the Dale Carnegie approach to assessments.

Sandwich The Negatives with Positives

Next time you are assessing someone, try this simple task – start and end with something positive.  Try to avoid just bombarding your client with all their flaws, which is really easy to do.  Let’s be honest, we are trained to see the negatives, and you are probably really good at it, right?  Your assessment should not be about finding everything that is wrong with your client to show off your intelligence.  There need to be some positives as well.

What about someone who really has a lot of flaws?  In this case, perform your thorough assessment, take detailed notes, but try to limit what you share with your client to what is only needed to 1) help them reach their goal, and 2) allow you to perform your job as best as you can.

If you can’t find any positives (you really should…), compliment them on their haircut, new sneakers, or anything else, but find something!

I also try to explain that no one is perfect and talk about some of my own flaws.  This seems to relieve a little tension, but your client is still going to focus on themselves.  So try to give them some positive to shift their focus.

Arouse in the Other Person an Eager Want

A little earlier in this article we mentioned the fat loss client.  My friend Pat Rigsby and I were talking recently and he asked an interesting question, “Do you think someone who comes to you for fat loss really cares about their shoulder mobility?”  This was a pretty great thought.  I think we sometimes get a little caught up in what “we” want to do with our clients instead of what our clients want.

Again, this doesn’t mean to avoid assessing their shoulder mobility, but rather, talk in terms of your clients’ interests.  You need to connect the dots, as Ryan Ketchum likes to say, and help your client see how addressing your assessment findings are going to help them achieve their goals.

Taking this another step, don’t forget more classic Carnegie wisdom by using encouragement and praising any improvement.  This is important for each session and during re-evaluation periods.  If your clients are seeing gains in “their” goals and “your” assessment, they are going to make the correlation.

Next time you have a new client, try using my Dale Carnegie approach to assessments and see what happens – Let me know in the comments below!

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Groin Injuries in Hockey Players

Today’s guest post on Groin Injuries in Hockey Players is from Peter Nelson.  Peter is currently working in collegiate hockey and has shown great interest in understanding why groin injuries are so common and what we can do about it.  Peter does a great job thinking outside the box and taking a look at the bigger picture.  Thanks Peter, great article, I’ll add some of my own comments at the end.

 

Groin Injuries in Hockey Players: An All-Too-Common Problem With a Not-So-Commonly Known Solution

going injuries in hockey playersBeing a former competitive hockey player (admittedly not a very good one—fourth line for life!) and working predominately with hockey players in a strength and conditioning capacity for the last few years, it has become clear to me that hockey players and groin injuries go together like the artist formerly known as Ron Artest and his psychiatrist.  Gold star if you get the reference.   (photo by David Shane)

 

Examining the Prevalence of Groin Injuries Among Hockey Players

While this relationship exists at almost all levels of the game, it has been particularly well documented in elite players.  Several studies have been conducted to assess the prevalence of this specific injury at the professional level.  The results have been consistent, and they are troubling.

A 1978 study by Sim et al. concluded that “ice hockey players are at high risk for noncontact musculoskeletal injuries because of the excessive force generated during the acceleration and deceleration phases of skating.”

A 1997 study by Molsa et al. reported that 43% of muscle strains in elite Finnish hockey players were involving the groin region.

A 1999 study by Emery et al. found that “the impact of groin and abdominal strain injury at an elite level of play in hockey is significant and increasing.”  According to their data, the rate of groin/abdominal strains in the NHL increased from about 13 injuries per 100 players per year during the 1991-1992 season to almost 20 injuries per 100 players per year during the 1996-1997 season.  Furthermore, the recurrence rate was 23.5%, meaning that injuries of this nature went on to plague a significant percentage of players for an extended period of time.

More recently, a study by Tyler et al. found that out of 9 NHL players evaluated, all of whom had suffered from groin injuries, four had sustained multiple strains.

 

The Long and Short of Groin Injuries: Muscular Imbalances in Athletes

With the strong correlation between hockey players and groin injuries established, it becomes important to understand why this is the case.  Many would be quick to attribute it to the violent nature of the sport, but research indicates that this is unfounded.  The study by Emery et al. found that upwards of 90% of all groin injuries were non-contact in nature.  Others posit that strains are due to the muscles involved being too short and lacking flexibility.

Sports physicians, physiotherapists, and strength coaches who fall under this category often prescribe stretching of the groin musculature to remedy the issue.  The study by Tyler et al., however, found that preseason flexibility of the hip adductors, the primary muscles that make up the groin region, did not differ between NHL players who went on to sustain groin strains and those who did not.  This indicates that stretching of the groin is probably not an effective approach toward preventing or treating this type of injury.

What the Tyler et al. study did find was that preseason hip adduction strength of the players who sustained groin injuries was 18% lower than that of the healthy players.  They also found that adduction strength was 95% of abduction strength in the uninjured players, compared to only 78% in the injured players.  This suggests that a muscular imbalance between the weak adductors and the relatively strong abductors plays a large role in groin issues.  The Sim et al. study also supports this view, suggesting that “in ice hockey players, adductor strains may be caused by the eccentric force of the adductors attempting to decelerate the leg during a stride.”  The researchers further went on to state that “a strength imbalance between the propulsive muscles and stabilizing muscles has been proposed as a mechanism for adductor muscle strains in athletes.”

 

Detective Work: Delving Deeper to Identify the Root of the Problem

The logical conclusion then should be that the solution is to strengthen the adductors and stretch the abductors, right?  Well, yes, but a more in-depth look at the problem is necessary to determine exactly why this imbalance is present in the first place, that way we can most effectively remedy the issue.  As a sports physician, physical therapist, or strength coach, you are not truly solving the problem unless you address the root cause.

In order to identify the root cause, it is important to first consider three main concepts.  First, it is imperative to understand the biomechanics of skating.  This brief excerpt from the study by Sim et al. sums it up very well:

“During the powerful skating stride the hip extensors and abductors are the prime movers, while the hip flexors and adductors act to stabilize the hip and decelerate the limb.”

 

Janda Lower Body Cross SyndromeThe second concept to understand is that these specific movement patterns have a profound effect on the relative strength—and consequently length—of the muscles involved.  Because hockey players, like most athletes, spend so much time in extension, the spinal erectors become extremely tight.  The same is true of the hip flexors, which become tight due to the constant forward lean seen in an “athletic stance” as well as the strength required to overcome the aforementioned eccentric force needed to slow down the leg in the recovery phase of a skating stride.

Consequently, since the hip flexors pull the pelvis down from the front and the spinal erectors pull the pelvis up from the back, the pelvis becomes tilted anteriorly.  This lengthens the hamstrings, putting them at a leverage advantage and forcing them to take on more of the load in extending the hips than the glutes.  The glutes then become relatively weak, as does the anterior core.  The end result is a player with what Janda called “lower-crossed syndrome”, illustrated below, who is at risk for both low back and hamstring injuries.

How does this play into groin injuries?  In order to make that connection, you need to understand the third concept, which is a central tenet of the Postural Restoration Institute (PRI): while muscles are often prime movers in a single plane, they must actually be considered as having an effect on movement in all three planes—sagittal, frontal, and transverse.

The perfect example of this is the hip extensors.  While the hip extensors are mostly responsible for movement generated in the sagittal plane, these same muscles—most notably the gluteus maximus—function as external rotators and abductors.  This is relevant to hockey because the nature of a skating stride requires players to have strong abductors—they are prime movers in this movement—as well as spend a lot of time in external rotation.  This tightens both the external rotators and abductors and pulls the hips into chronic external rotation and abduction, or in other words causes them to become “flared”.  Adductor muscles like the adductor magnus, which also contribute to internal rotation, become lengthened and, like the hamstrings in the sagittal plane, are put at risk for injury.  This clearly fits the theory of a muscle imbalance as the potential contributor to groin injuries, and it becomes clear from the analysis above that pelvic alignment is important in understanding the root cause of this imbalance.

It also makes it apparent that stretching the groin is not only ineffective; it can actually feed right into the problem!

 

Shifting Into Neutral: Correcting Pelvic Positioning

That brings us to the million-dollar question: how do we fix it?  After coming to the understanding that groin issues are caused by pelvic misalignment in all three planes of movement, you can see why I suggested that strengthening the internal rotators and stretching the external rotators is not a comprehensive solution to the problem.  We must address muscular imbalances with the triplanar perspective in order to effectively prevent injuries of this nature.

The first plan of attack should be to rectify the imbalances in the sagittal plane.  The reason being is simply that extension limits rotation, and since I already explained that hockey players—and athletes in general—tend to live in chronic extension, it makes sense to resolve that problem first in order to maximize the effectiveness of attempts at repositioning an athlete in the other two planes.  I group the frontal plane with the transverse plane, even though I am talking about rotation being limited, because there is significant overlap between the prime movers in abduction/adduction and internal/external rotation.

Addressing the imbalances in the sagittal plane is fairly straightforward.  I like the approach Mike Robertson takes in identifying two “force couples”.  The posterior force couple consists of the anterior core and the posterior chain (primarily the glutes and hamstrings), and these two will be weak in athletes living in extension, as I previously mentioned.  Hammering the glutes and hamstrings with exercises like hip thrusts (demonstrated by Bret Contreras below) and Romanian Deadlifts, respectively, will strengthen the posterior chain and tilt the hips posteriorly by pulling them down from the back, the net result being a more neutral alignment since the athlete was in anterior tilt to begin with.  With the anterior core, it is important to note that it is the internal obliques, external obliques, and transverse abdominis that are usually weak, as opposed to the rectus abdominis.  Strengthening these muscles will tilt the hips posteriorly by pulling them up from the front, also resulting in a more neutral alignment.

The anterior force couple consists of the spinal erectors and the hip flexors, and these two will be tight.  Stretching the hip flexors is crucial; this can be accomplished with stretches like the Bench Hip Flexor Stretch, illustrated by Tony Gentilcore.  Self-myofascial release can also be useful.

groin injuries

With the Bench Hip Flexor Stretch, the harder the athlete squeezes the glutes and extends at the hips, the greater the stretch on the rectus femoris.  Be careful, however, not to allow the athlete to extend at the lumbar spine, as this reinforces the incorrect movement pattern we are trying to move away from.

Stretching the spinal erectors can be accomplished with “prayer position”-type stretches.  Self-myofascial release with a lacrosse ball peanut can also be effective.  In working with Head Strength Coach Rob McLean and the Pennsylvania State University Men’s Ice Hockey team, we tend to use exercises with movement patterns that inhibit the paraspinals while also activating the anterior core, such as the exercise from the Postural Restoration Institute shown below, demonstrated by Kevin Neeld.

 

In this case, we are killing two birds with one stone in strengthening the weak muscles and teaching the athletes to inhibit the tight muscles (notice how Kevin’s back is rounded; this helps to inhibit the spinal erectors) at the same time.  You can also see that in the video there is a ball between Kevin’s knees—this is to activate the internal rotators/adductors, which I will discuss next.

Addressing the frontal and transverse planes when it comes to fixing pelvic alignment is overlooked too often.  Again, we want to strengthen the internal rotators and adductors—the muscles might largely overlap but it is important to pattern both movements individually—and stretch the external rotators and abductors.  For internal/external rotation, med ball crushes is a good one to strengthen internal rotation (note that this exercise can also pattern the adduction movement, depending on how it is performed), and knee-to-knee mobilization is good for both activating the internal rotators and stretching the external rotators.  Any exercises that target the semimembranosus (the most medial hamstring muscle) will also help strengthen the internal rotation movement.  An easy modification to an already great exercise, which I mentioned earlier, that will help in this regard is having athletes internally rotate the legs during the hip thrust.  Here at Penn State we have started doing band-resisted hip thrusts with internal rotation, and Coach McLean and I both like how it hits the internal rotators.  Considering that it also strengthens the posterior chain, you’re really killing two birds with one stone in repositioning the pelvis with this small tweak.

There are also a number of good exercises for patterning and strengthening the adduction movement.  Adductor Side Bridges, demonstrated below by Kevin Neeld, are great in this regard.

 

The adductor pullback exercise from PRI, demonstrated below also by Kevin Neeld, is another good one.

 

 

We have our players perform the adductor pullback exercise only on the left side (so they would be lying on their right side, as Kevin is in the video) to address the left AIC alignment that I mentioned earlier.  Doing the opposite by lying on your left side and shifting your right hip forward and externally rotating it (since the right leg tends to be internally rotated) also helps correct this particular alignment.

 

Conclusion

Simply put, pelvic positioning is an important piece in preventing groin injuries, which affect athletes in all sports, but are especially a problem amongst hockey players.  The three main concepts to remember in assessing pelvic positioning in any athlete are 1) understanding the biomechanics of the sport, 2) identifying the effects these movements have on the muscles involved, and 3) considering muscles as contributors to movement in all three planes, even if they are not prime movers in one or more of those planes.  These concepts can be applied in order to identify imbalances in an athlete and the effects they have on the position of the pelvis. Once this is accomplished, a program can be designed so that the imbalances can be corrected and the pelvis returned to neutral.  After all, neutral is where we want our athletes to be, as that puts them at the lowest risk for injury.  And any reputable strength coach knows that keeping athletes healthy is the primary objective in any program.  You can’t translate gains in strength and power to the playing field if you’re stuck on the sidelines.

 

Mike’s Thoughts

I think Peter did a great job with this article, highlighting the need to start thinking about alignment and triplanar function of the body.  These are often missed in our critical thinking.  The only thing I would add to this great article is that the real goal of working to enhance alignment is to then allow you to train the body in better neutrality.  We may not function in neutral, but you don’t want to be stuck in our poor alignment.  You want to be able to get out of your asymmetry when needed.

Every athlete I have worked with that is “stuck” in their asymmetry is prone to recurrent injuries.  We’ve all had them, right?  The person that just keeps straining their groin, or hamstring, etc.  Take a step back and think of the 3 principles that Peter summarizes in his conclusion.

If you like information like this, I’ve discussed concepts like triplanar training of the glutes.  These are some of the fundamental principles in my Functional Stability Training of the Lower Body program with Eric Cressey.  We discuss a lot of concepts related to alignment, triplanar function of the body, and training the body in 3D.

Functional Stability Training for the Lower Body

About the Author

Peter Nelson is a Strength and Conditioning Staff Intern with the Pennsylvania State University Men’s Ice Hockey Team.  He graduated in 2012 from Phillips Academy Andover, and is currently a sophomore at Penn State’s University Park Campus.  Peter is a former competitive hockey player, having played for Andover’s Varsity Hockey Team for three years in Division 1 of the New England Prep School Ice Hockey Association.  While he no longer plays competitively, his longtime involvement in sports has driven his interest in research fields such as nutrition and strength and conditioning.  He has previously interned at NIKE SPARQ-affiliated Athletic Evolution in Woburn, MA.  Peter is greatly looking forward to continuing to work under Head Strength and Conditioning Coach Robert McLean of the Penn State Men’s Hockey Team and continuing his education in pursuing a career in the health and fitness realm.

Note: I’d like to thank Coach Rob McLean, Head Strength and Conditioning Coach for the Pennsylvania State University Men’s Ice Hockey Team, for taking me under his wing and introducing me to and helping me understand important concepts like those presented by the Postural Restoration Institute.  Much of this article reflects what I have learned over the course of the past year while working with him and the hockey team as an intern.  I sincerely appreciate the opportunity.

 

Referenses

  • Sim FH, Simonet WT, Melton LJ III, et al: Ice hockey injuries. Am J SportsMed 15: 30–40, 1987.
  • Molsa J, Airaksinen O, Näsman O, Torstila I. Ice hockey injuries in Finland: a prospective epidemiologic study. Am J Sports Med. 1997;25(4):495-499.
  • Emery CA, Meeuwisse WH, Powell JW. Groin and abdominal strain injuries in the National Hockey League.. Clin J Sport Med. 1999;9(3):151-156.
  • Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility on the incidence of groin strains in professional ice hockey players. Am J Sports Med. 2001;29(2):124-128.
  • Robertson, Mike. March 3, 2007. “Hips Don’t Lie: Fixing Your Force Couples.T Nation.