The latest Inner Circle webinar recording on 5 Tweaks to Make Shoulder Exercises More Effective is now available.
5 Tweaks to Make Shoulder Exercises More Effective
This month’s Inner Circle webinar is on 5 Tweaks to Make Shoulder Exercises More Effective. Over the years, you tend to pick up on the little things that can make a big difference. I’m always reading the latest research to find simple little tweaks that I can make to an exercise to change the desired result. Maybe I’m trying to optimize the mechanics of the scapula, or trying to enhance EMG activity of a certain muscle, or even change the ratio of activity between two muscles.
In this webinar, we discuss:
Why little tweaks can make a big difference
Why integrating the kinetic chain into a shoulder exercise may be effective
How altering hip and trunk movement during exercises change the muscle activity
How you can put this all together and make your own functional exercises specific to each person
https://mikereinold.com/wp-content/uploads/5-Tweaks-to-Make-Shoulder-Exercises-More-Effective.jpg8001448Mike Reinoldhttps://mikereinold.com/wp-content/uploads/MikeReinold-Small-Signature-Logo-2017-red.pngMike Reinold2015-08-31 06:49:572015-08-31 07:05:375 Tweaks to Make Shoulder Exercises More Effective
The latest webinar recording for Inner Circle members is now available below.
Enhancing the Balance Between Upper and Lower Trapezius
This month’s Inner Circle webinars discussed strategies to enhance the balance between the upper and lower trap, a common dysfunction I see. We’ll cover:
The impact on posture and trapezius balance
The relationship between imbalances of the trapezius and shoulder and cervical pathology
The relationship between imbalances of the trapezius and performance
Strategies for exercise selection
Coaching cues and programming considerations
To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.
https://mikereinold.com/wp-content/uploads/inner-circle-content.jpg200200Mike Reinoldhttps://mikereinold.com/wp-content/uploads/MikeReinold-Small-Signature-Logo-2017-red.pngMike Reinold2013-04-04 06:00:232015-03-02 07:35:35Enhancing the Balance Between Upper and Lower Trapezius
Baseball pitching appears to the general public to be mainly an upper-body movement. However, researchers have found that like many rotational movements such as golf swings and tennis serves, it involves the lower body and trunk musculature extensively. In fact, according to a theory known as proximal-to-distal sequencing, the pitching motion is actually initiated by the lower body and progresses through the core before accelerating the arm and finally the hand.
What is proximal-to-distal kinematic sequencing?
Researchers have suggested that rotational movements such as the baseball, golf or tennis swing follow proximal-to-distal kinematic sequence. Proximal to distal kinematic sequencing is where a motion is initiated by the larger, central body segments and then proceeds outward to the smaller, more distal segments, such as the arms.
While the concept is relatively clear, the terminology varies. Callaway (2012) has noted that researchers have referred to proximal to distal sequencing as kinetic linking or the kinematic sequence and in a recent article, Spaniol (2012) referred to the same principle as “sequential kinetic linking.”
In any event, where optimal proximal-to-distal kinematic sequencing occurs in sport, the pelvis is rotated using the leg and hip muscles. The pelvis accelerates but then quickly decelerates as it transfers energy to the torso. The same pattern is repeated with the torso and the arm and then the arm and the hand, club, bat or racket. Where the kinematic sequence is out-of-order, it is thought that energy is lost, performance decreases and other body segments step in to compensate, which can lead to injury.
What do we know about the role of the lower body in baseball pitching?
While the principle of proximal-to-distal kinematic sequencing indicates that there is a sound theoretical basis for the role of the lower body in baseball pitching, few studies have actually investigated either the forces or the muscle activity involved.
In fact, there are only four studies regularly referenced when discussing the role of the lower body muscles in baseball pitching: MacWilliams (1998), Yamanouchi (1998), Campbell (2010) and Oliver (2010). The studies by MacWilliams and Oliver investigated aspects of proximal-to-distal kinematic sequencing that are seen in baseball pitching, while the studies by Campbell and Yamanouchi looked more generally at the involvement of the leg musculature.
What does the research say about proximal-to-distal kinematic sequencing in pitching?
Is leg drive correlated with wrist velocity?
MacWilliams (1998) investigated the full-body kinematics and kinetics of 7 baseball pitchers using force plates to record leg drive and a five-camera motion analysis system for recording the joint angle movements. Most significantly, they found that wrist velocity correlated significantly with leg drive.
[quote]Pitchers with greater leg drive produced greater wrist velocities.[/quote]
The researchers therefore concluded that the lower body has an important role in increasing the speed of the throwing motion and supports the use of the proximal-to-distal kinematic sequencing model in any biomechanical analysis of baseball pitching. They therefore proposed that strengthening the lower body is important for enhancing pitching performance and avoiding injury.
Are the gluteals correlated with torso rotation during pitching?
Oliver (2010) investigated the muscle activity of the gluteals and explored the relationship of the gluteals to pelvis and torso kinematics during baseball pitching. The researchers found that the activity of the gluteus maximus was directly related to the rate of axial pelvis rotation and also that it was indirectly related to the rate of axial torso rotation.
[quote]Greater gluteus maximus activity increases rotational speed[/quote]
This study therefore also supports the use of the proximal-to-distal kinematic sequencing model in any biomechanical analysis of baseball pitching. Additionally, it implies that training the gluteals should be a specific focus of baseball pitchers. Optimal exercises for the gluteus maximus include the squats, trap bar deadlifts, hip thrusts, and back raises. However, the gluteus maximus can and should be strengthened in the transverse plane via core rotational movements such as the band hip rotation. See Mike’s article on training the glutes in multiple planes of motion.
What does the research say about leg muscle activity in pitching?
Are the adductors active during pitching?
Yamanouchi (1998) investigated the muscle activity of various upper and lower body muscles during a baseball pitch performed by 10 baseball players and 10 untrained subjects. He used surface electrodes to measure the electromyographical (EMG) activity and normalized the signal against a maximum voluntary isometric contraction (MVIC). He separated the baseball pitching movement into just two phases divided by the point at which the non-pivoting leg landed. The activity of the thigh muscles reported by Yamanouchi is shown in the chart below. Unfortunately, he did not record the activity of the gluteals or hamstrings.
Yamanouchi concluded that his findings were consistent with reports that pitching can lead to problems with the adductor muscle group. He therefore suggested that strengthening the adductor and the antagonist abductor groups could therefore be useful for enhancing pitching performance and avoiding injury.
Most leg muscles are very active during pitching
Campbell (2010) investigated the muscle activity of the biceps femoris, rectus femoris, gluteus maximus, vastus medialis and gastrocnemius during the baseball pitching motion. The researchers used surface electrodes to measure the EMG activity in 11 highly skilled baseball pitchers and normalized the data against MVICs. Rather than the two-phase division used by Yamanouchi, they divided the pitching action into four phases, although the data can be restated to be comparable with the two phases used by Yamanouchi, as shown in the chart below.
The researchers concluded that muscle activity in both the stride and pivot legs reached extremely high levels during the baseball pitch and was generally very high throughout. They therefore suggested that since pitchers must perform over 100 pitches per game, this implies that pitchers need a high level of maximal strength/power as well as a high degree of muscular endurance. They therefore recommend training the lower body of baseball pitchers to increase strength, explosive power and muscular endurance.
What can we conclude?
From this admittedly small body of research, we can suggest that:
Proximal-to-distal kinematic sequencing seems to occur during baseball pitching, with the movement being initiated by the legs, transferred through the pelvis to the torso, through the arm and finally into the hand.
Leg drive is therefore important for pitching velocity. Improving the strength and power of the legs should consequently transfer to faster pitching performance.
Since pitchers may have to perform approximately 100 pitches per game, some degree of muscular endurance training for the legs could be beneficial.
While all leg muscles are very involved in the pitching action, the activity of the gluteals is strongly correlated with pelvic axial rotation velocity, suggesting that specific gluteal training may be worthwhile. A variety of gluteal exercises from multiple vectors is needed for optimal performance.
The adductors may be more involved in the pitching movement than in most standard resistance-training exercises, suggesting that specific exercises should be used to focus on these muscles to help improve performance and avoid injury.
Mike’s Thoughts
Chris wrote an outstanding article as usual. Obviously, as you can see, the leg strength and power is pretty important to baseball pitching. The concept of the proximal to distal kinetic chain sequencing is likely one of the many important factors involved with baseball pitching. Why is it that some of the brightest people in the world can flawlessly understand baseball pitching biomechanics yet can’t pitch successfully! Heck, I am one of the guilty! It’s not that I do not understand how to throw, it’s that I have an imperfect sequence of events that result in a less than ideal fastball! So, while leg strength and power are important to baseball pitching, we can’t forget about training this sequence. This is why proper coaching at a young age and proper strength and conditioning programs that understand this concept are necessary.
In regard to our training programs, these studies demonstrate the need to emphasize the legs, and should give guidance on what specific muscles to focus on. Chris states it well, however, I will further reinforce his comments that we need to train the legs, but also focus on leg work outside of the sagittal plane.
About the author
Chris Beardsley is a biomechanics researcher and author of a book about scientific posterior chain training. He also writes a monthly review of the latest fitness research for strength and sports coaches, personal trainers, and athletes. Thanks for contributing this article on Why are Leg Strength a Power Important in Baseball Pitching!
[hr]
https://mikereinold.com/wp-content/uploads/Leg-Power-Baseball-Pitching1.jpg328550Mike Reinoldhttps://mikereinold.com/wp-content/uploads/MikeReinold-Small-Signature-Logo-2017-red.pngMike Reinold2013-02-18 06:00:002013-02-19 07:33:27Are Leg Strength and Power Important to Baseball Pitching?
Today’s guest post comes from Dean Somerset discussing 4 things he thinks we are doing wrong with rehab. Great job Dean, I always love reading your stuff! If you want to hear more from Dean (and you definitely should!) I recommend you check out Dean’s new Post-Rehab Essentials program. It is over 12 hours of great content. I am still reviewing but have enjoyed it so far, I’ll try to post a full review once I get a chance to finish it all!
4 Things We Are Doing Wrong With Rehab
I’ve built up a profession working the grey zone between where physiotherapists and traditional rehabilitation professionals leave off with their patients and where strength coaches and persona trainers begin. There’s a definite gap between the two, and hopefully more and more trainers and rehab professionals will be able to bridge this gap to effectively help their clients and patients, respectively, through the entire continuum of wellness. Today’s post will hopefully show a few ways to bridge the gap in a more practical sense for some of the common things that aren’t being adequately addressed by either side.
#1. Not looking at foot mechanics – For Everything
A simple test I use with a lot my classes: I get everyone to put their arms overhead as straight and high as possible with a tall and upright posture. Then I have them make their upper back kyphotic, and try to do the same thing, and watch everyone’s expression as they wind up getting half the range of motion necessary. Then I have them do both a posterior and anterior pelvic tilt and see what happens. Yep, you guessed it, less range of motion. As the grande finale, I have them stand tall, and then simply pronate their feet to see what effect it has on their shoulder range of motion. Most if not all involved, will have some reduction in their ability to abduct their arms. Give it a try and see what happens.
Mike made an excellent post a few months back about the kinetic chain ripple effect versus the kinetic chain, and this is an excellent example of that concept. When the spine was kyphotic, it had the most dramatic effect on shoulder mechanics than when the foot was pronated, but the effect was still there, much like ripples in the lake from a stone hitting the surface on the other shore. This shows that even if the foot isn’t directly involved in a lot of issues with the body that it may in fact be indirectly involved with issues of the knee, hip, spine, and even shoulder and neck.
By checking to see if the foot has a fallen, normal or high arch structure to it, as well as if any arch alterations are structural in nature (the bones are formed that way) versus postural in nature (the muscles holding the ankle are weak) can allow a practitioner to get one more piece to the puzzle. If the arch has fallen due to weak muscle support through both the tibialis posterior and the compound effect of a weak greater hallicus longus, you can train the muscles of the foot to stabilize and resist collapsing, which would prevent the internal rotation of the tibia, and everything that would result up the chain.
Altered foot mechanics can affect every movement, from heavy deadlifting (my drug of choice) to how you throw a fast ball, to how at risk you are of low back pain.
#2. Not watching runners’ stride and technique
I’m fortunate enough to have been able to work with a lot of distance runners, even though I consider distance running one of the most pointless activities you could ever do. Seriously, if you have that far to go, drive there. You get a cup holder and air conditioning. Be that as it may, I’ve been able to do hundreds of run stride analyses clients, from beginners looking to complete their first 5km race, to elite marathon and ultra marathon runners looking to shave time, and even those who had repetitive strain issues with their legs and needed to know why. You can see amazing things happen when you use even a basic digital video camera and slow down the replay to watch things like calcaneal eversion, midfoot pronation, valgus collapse, tibial rotation (both internal and external), pelvic stability on impact, foot strike mechanics, knee position and angle on impact, stride length and frequency, and even whether they are in the right shoe for their stride or not. We could debate barefoot versus shod running forever, but I’ll just leave it to say that barefoot isn’t for everyone, and typical running shoes aren’t for everyone either.
A lot of repetitive strain injuries in runners could be corrected by simply altering their run mechanics, much like a golfer can reduce their incidence of golfers elbow and low back pain by receiving coaching on proper swing mechanics. This could be as simple as using a hand-held video camera to show real-time feedback about performance, or as complex as using a DartFish software package to analyze force vectors and angle and rate of pronation, but in each situation it would result in an improvement in run stride, which would reduce the stress on the involved tissues, and allow runners to keep running with less pain, and probably while going faster.
It’s one thing to watch someone in static posture, and another entirely different beast to watch them move in their desired activity. By simply working on the muscles, joints, and fascia, we’re missing the boat on how their activities are impacting those tissues and what can be done about it. Athletes in most sports that involve running in one way or another (basketball, soccer, field hockey, and to a lesser degree football and baseball) would benefit from having someone analyze their gait and see where there may be some energy leaks and ways to decrease risk of injury.
#3. Not checking breathing mechanics
With the majority of upper body muscles attaching in one way or another to the rib cage, it would be common sense to think that an alteration in breathing mechanics could alter not only core function, but also scapular, glenohumeral, cervical, and potentially even lumbopelvic and lower leg function. If a client isn’t breathing properly through one side of their lungs, they may wind up getting side stitches on the opposite side as it works extra hard to compensate during forced heavy breathing. If they aren’t using their diaphragm properly, they may get neck cramping as their scalene compensate for the short-comings, and so on. On top of that, if the ribs cannot expand and contract properly, it will affect the ability of the thoracic spine to extend and rotate, which will affect the mechanics of the above-mentioned body parts. If they are collapsing into kyphosis, it will alter breathing capacity, which will alter performance and lead to further postural and repetitive strain issues.
Here’s an example of a runner who came in to see me with shoulder pain during her runs.
Notice how the rib cage elevates, but doesn’t actually expand width-wise? Here’s what she looked like after two weeks of doing three breathing exercises each day.
She’s still restricted, but using her lower ribs more instead of just relying on scalenes and upper ribs to do her breathing. This is a woman who can run at 10 miles an hour for ever and hold a conversation with you, and has won marathons, Death Races, ultra marathons, and 50-100 mile trail running races galore, all while only using about one third of her lungs. She shaved 6 minutes off her personal best marathon time by only altering her breathing mechanics and stretching her thoracic spine through extension and rotation.
#4. Not communicating with everyone involved
I’ve been able to work with a lot of good rehab professionals who have been willing to discuss their patients’ status and ways to help them out in our training sessions, and also take my observations and questions in stride. I’ve also worked with a few who weren’t so willing to work with me, and as a result the quality of care wasn’t as good, and the results that the client was able to get were less than optimal.
One of the first questions I ask any rehab professional when it comes to any workouts I’m going to have them do is quite simply “What do you want me to focus on, and what should I avoid?” Essentially, I’m always going to defer to the direction of the doctor or physiotherapist or chiropractors’ directives, and work my program around their guidelines. I may question certain aspects based on the results of my assessments, and occasionally can give them some new information, but most of the time my questioning is to get more information and to learn more from another set of eyes and educational background.
The same could be said in the reverse direction. If your patient is working with a personal trainer or strength coach, reach out to them and ask to discuss their training program. Odds are you can both come to a collaborative conclusion that will only benefit that patient, and result in them getting healthier faster and make you look good to everyone involved. One example stands out in my mind of a client who came in with really severe brachial plexus impingement in both arms, had been to physiotherapists and chiropractors, and seen no relief. I wanted to talk with her neurologist to see if there was anything that I should work on or avoid, and his response was amazing.
“I don’t know, just get her to lose some weight and increase her flexibility. If she says it hurts, move on to something else.”
I then proceeded to refer her on to a really good physiotherapist in my area who checked her out and gave some very good and specific recommendations, and within 6 weeks her pain was nearly half of what it was. The combined approach will always work best.
Strength coaches and personal trainers who don’t have an established network of health care practitioners scare me, and they should scare anyone who is willing to work with a trainer, especially if they already have specific medical or injury concerns. I’ve had countless situations where I needed a second opinion and referred a client out to get an assessment and report back on what they can and can’t do, and as a result we’ve been able to train longer and avoid aggravating issues further. I’m paranoid about making client safety an issue, because if that client isn’t able to train and I can’t find a way to make them better, it affects my bank account at the end of the month, and my reputation as a whole. Having medical referral networks makes trainers money, and increases their respect and reputation. Not having qualified professionals they can ask for help makes them a liability.
For more great information from Dean, be sure to check out his Post Rehab Essentials Program. It’s a 12-hour program that goes over great topics such as above. It is a great resource for the personal trainers that deal with people coming off of injuries.
https://mikereinold.com/wp-content/uploads/four.jpg150150Mike Reinoldhttps://mikereinold.com/wp-content/uploads/MikeReinold-Small-Signature-Logo-2017-red.pngMike Reinold2012-02-20 06:00:142012-02-11 16:40:124 Things We Are Doing Wrong with Rehab
I remember when I first heard about the kinetic chain concept when I was in undergraduate physical therapy school. It was the first introduction to the concept that joints in the body can be causing dysfunction elsewhere. Simply put, brilliant. We just spent the last year talking about anatomy and physiology and learning how to evaluate a joint. Now we realize that while we do have to evaluate the joint, the answer probably lies elsewhere!
[quote]A chain is only strongest as its weakest link.[/quote]
The last two decades or so has really seen a large push towards understanding human movement and dysfunction. We have made many significant breakthroughs in understanding things such as:
How the scapular influences the glenohumeral joint
How pelvic tilt influences the thoracic spine, scapula, and shoulder
How the hip and foot influences the knee
This is obviously just a small glimpse into these concepts, and there have been many more, but I remember learning about treating the symptoms of patellofemoral pain and how “challenging” these patients were. Well, I would agree, if we all just simply treated the location of the symptoms rather the the source of dysfunction. To me that is really always our goal:
[quote]Treat the source of dysfunction rather than the location of symptoms[/quote]
The Problem with the Kinetic Chain Concept
Just like anything else, the more I experienced and the more I learned, I realize that my original understanding of the kinetic chain concept was probably not ideal. There were two important pieces that I had originally not fully grasped, but feel like I better understand now.
Not all Links in the Human Body Kinetic Chain are Equally as Important
The first thing that I quickly realized was that unlike the actual “chain” analogy, where if you break one link, the chain is pretty useless, the human body did not act this way. Not every link in the kinetic chain is equally as important. How many times have we heard about a story about someone that stubbed their toe and then started having contralateral shoulder problems?
While I agree this MAY be possible… I get it. You limp, change your gait, changes your hip, pelvis, spine , scapular, and whammy you hurt your shoulder. This CAN happen. But this is pretty extreme to me and the person probably had some underlying issues going on prior to the dreaded stubbed toe incident that drastically altered the course of the rest of their life.
That stubbed toe can have a huge impact, but I would say it’s biggest impact is actually at the joints closest to it, the rest of the foot and ankle. Those areas are going to be influenced by the stubbed toe a lot more than the shoulder.
This is why I like to think of the kinetic chain as more of a ripple in water than an actual chain. So, not a chain, but a chain reaction. I have talked about the kinetic chain ripple effect in the past, but in general, the joints closest to the area of dysfunction are going to be most impacted. Take the hip as an example. Any tightness, weakness, or imbalance of the hip is going to have a large influence on the low back and knee, and a much less impact on joints the further away you get from the hip.
This may not change your thought much, but it does impact the way I evaluate. Using this concept, I always start from the center of the ripple and branch outward from there. Using this method, you will find the areas of imbalance and dysfunction that are having a large influence on the area of pathology. Basically, work from the center outward. Once you address areas closest, re-evaluate and assess if the problem is better or if you need to move further away in the kinetic chain.
The Kinetic Chain Needs to Include what is Between Each Link
The other big omission I often see people make when considering the kinetic chain is that they think of each link in the chain as a joint. This is a simplistic version of the kinetic chain in purely the sense of biomechanics an arthrokinematics. Instead, realize that there are many influence on the kinetic chain between each joint.
[box]This includes the muscles, fascia, ligaments, tendons, and anything else you can think of. Basically, it’s not just the joints, but also everything in between.[/box]
We have made great strides in this area over the last decade, especially with concepts like Myers’ Anatomy Trains, Stecco’s Fascial Manipulation, Sahrmann’s Movement Impairment Syndromes, and Cook’s Functional Movement. (Photo by pratanti)
The kinetic chain shouldn’t be just how the neck influences the shoulder, which influences the elbow, which influences the wrist. It should be all encompassing include things such as how:
The plantar fascia influences the Achilles tendon and calf
The psoas influences patellofmoral biomechanics
Pec minor tightness influences lower trapezius weakness
A joint doesn’t have to just influence a joint and a muscle influence a muscle. All these structures work and interact together. A great example of this is the upper body cross syndrome.
This is a great example of how both tightness and inhibition influence different areas around a joint. This is the real kinetic chain concept. Not simply joint to joint, but structure to structure. Something to consider next time we think about how the body functions and how motion is achieved. These factors related to the kinetic chain concept should be applied when discussing functional movements.
https://mikereinold.com/wp-content/uploads/kinetic-chain-muscles.jpg198300Mike Reinoldhttps://mikereinold.com/wp-content/uploads/MikeReinold-Small-Signature-Logo-2017-red.pngMike Reinold2011-11-29 06:00:442013-11-12 08:15:23The Problem with the Kinetic Chain Concept
Last week we talked about the kinetic chain ripple effect theory and how the kinetic chain has an impact throughout the body, but more of an impact closer to the source of dysfunction. For this week, I wanted to discuss 3 common injuries that we all see that may actual just be a symptom, and not the actual injury or source of dysfunction.
As a general rule of thumb, we should probably consider that many of our traditional “injuries” that seem to be relentless and not responsive to treatments may actually be coming from elsewhere in the body. Think back to how patellofemoral pain has been referred to as “the black hole” of orthopedics and how surgery and rehabilitation to correct patella alignment is often unsuccessful. Perhaps patellofemoral pain is actually just a symptom and not the source of dysfunction.
Below are what I have found to be 3 common “injuries” that may actually just be symptoms from dysfunction somewhere else within the kinetic chain. There are many more than 3, but these are likely to be some of the most common that you may encounter. Feel free to leave a comment of more examples that you have encountered. Furthermore, all three fit into the kinetic chain ripple effect theory as the source of dysfunction is pretty close to the location of symptoms
Groin Pain – Source: Hip Joint
I have to admit that in my career I have been stumped by groin strains that seem to be difficult to treat or frequently reinjured. I am sure we have all seen this in our practices, groin pain that doesn’t really look like a groin strain, but what is it? As our understanding of the hip has improved, we find that many people with intra-articular hip joint pathology present with groin pain, which is a common pain referral pattern from the hip joint.
Next time you have a patient with groin pain, clear the hip, you’ll be surprised how many times we find that the symptoms are coming from the hip and that will drastically change our treatment program.
Lateral Epicondylitis – Source: Cervical Spine
Another commonly misdiagnosis that I have seen involves lateral epicondylitis. The C6 nerve root is one of the most commonly involved nerve roots involved in cervical radiculopathy as it exits between the 5th and 6th vertebrae. Any radiculopathy from this nerve root can cause weakness in wrist extension. I have seen even a subtle loss of strength of wrist extension cause a raging lateral epicondylitis. Sometimes this weakness is so subtle that the person doesn’t even realize they have weakness until it is too late. We continue to function and use our hands with this weakness and overload the area. So, we can treat the heck out of the lateral epicondylitis, but if we don’t solve the nerve root issue at the cervical spine we will never regain the wrist extension strength that is needed to decrease the symptoms of lateral epicondylitis.
Patellofemoral Pain – Source: The Hip
We’ve spent a lot of time discussing the contribution of the hip has on symptoms of patellofemoral pain. [If you haven’t yet, this would be a great time to sign up for my newsletter and receive a bunch of goodies, including my eBook on Solving the Patellofemoral Mystery.] Over the last several years, we have made a giant leap in our understanding of why some forms of patellofemoral pain occurs. More often than not, weakness and dysfunction of the hip muscles, specifically the abductors and external rotators, is a leading cause of biomechanical faults at the knee and subsequent patellofemoral pain. Similar to lateral epicondylitis above, you can treat the symptoms all day but you aren’t going to solve the problem if you don’t address the source, weakness and dysfunction of the hip.
Take Home Message
I’m sure that many of my readers have observed all of the above findings. Please do comment and add more examples. So what is the take home message? For the younger clinicians in the audience, I guess it would have to be that we should probably take a step back a rethink all of the injuries that we see that we consider “difficult to treat” or “unrelenting” such as lateral epicondylitis and patellofemoral pain. Maybe we need to think of the bigger kinetic chain principle. Perhaps we are only treating the symptoms and not the true source of the dysfunction. So next time you seem to have a patient that is not responding to your treatments, take a step back, re-evaluate and assess elsewhere in the kinetic chain and make sure that you haven’t missed the true source of the person’s symptoms.
https://mikereinold.com/wp-content/uploads/image44.png336558Mike Reinoldhttps://mikereinold.com/wp-content/uploads/MikeReinold-Small-Signature-Logo-2017-red.pngMike Reinold2011-06-13 06:00:002012-05-07 00:15:52The Difference Between the Location of Symptoms and the Source of Dysfunction
Several months ago, I first mentioned my theory on the kinetic chain ripple effect. I discussed my thoughts on how certain areas of the body may influence other areas throughout the kinetic chain, but have different impact based on how far away the two areas are. The kinetic chain concept in itself is nothing original or exciting, as this has been popularized for almost two decades now by several people in the form of functional rehabilitation and manual therapy techniques. Two very influential people in this area have been Chris Powers and Tom Myers, who have shown the influence the hip has on the patellofemoral joint and the influence of the fascia throughout the body, respectfully. But the differing impact based on proximity is something that I think is often overlooked.
While the kinetic chain concept is both simple yet profound, I sometimes feel like the concept is taken to the extreme at times. I have had a recent conversation about this on Facebook, which prompted me writing this post. One could certainly argue that since everything is connected, a small adaptation at the big toe of the left foot could lead to an injury of the left shoulder. But before we jump to conclusions, I think we should consider what I call the “kinetic chain ripple effect.”
Kinetic Chain Ripple Effect
The kinetic chain ripple effect is a really simple theory. To simply summarize, the kinetic chain can transfer influence throughout the body, but the effect is minimized the further away from the source that you get. This is exactly like the ripple that occurs after throwing a rock in the water. The closer you are to the area of impact, the larger the ripple. As the ripple travels, it’s effect is reduced the further it gets away from the origin. Hence the name, the kinetic chain ripple effect.
The Kinetic Chain Ripple Effect and the Human Body
How can we apply this to the human body? Any dysfunction (and that is intended to be vague and include weakness, inhibition, instability, tightness, hypomobility, fibrosis, and many other dysfunctions) is going to have it’s biggest impact on the joints closest to it’s origin. Take a look at the photo to the right (which I tinkered with in Photoshop for an hour!).
In this photo, the “ripple” is occurring in the left hip. As you can see, this will have a much greater impact on the lumbar spine and left knee than it would the left foot or right shoulder. This is why there are numerous studies that have been published discussing the influence of the hip of patellofemoral pain and low back pain while the influence of the hip on shoulder and upper extremity pathology has been mostly theoretical and difficult to demonstrate definitively.
I think that the majority of us now understand the kinetic chain concept and know that we need to evaluate more than just the location of symptoms, but also the related areas within the kinetic chain. That was one of the first aspects we all learned about evaluation skills, right? Assess both proximal and distal?
Based on the kinetic chain ripple effect, we should probably work our way both proximal and distal along the kinetic chain away from the source, identifying any contributing factors. While our emphasis should be placed on identified dysfunctions that are closest in proximity, we shouldn’t stop at the closest joints.
Once we have address dysfunctions close to the symptoms, we can then reassess both the the symptoms and dysfunctions along the kinetic chain. If symptoms are resolves than we know that we have likely alleviated the current problem. If symptoms are simply reduced, we may need to go further along the kinetic chain.
So next time you have someone with right shoulder impingement and a tight left hip, carefully assess the joints in between before jumping to conclusions. I am sure you’ll find that dysfunctions closer in the kinetic chain, such as the scapula and thoracic spine, are contributing more to the shoulder dysfunction than the hip. Address these first and work your way through the body like the ripple in the water, embracing the kinetic chain ripple effect concept.
This month’s Inner Circle webinar is on 5 Tweaks to Make Shoulder Exercises More Effective. Over the years, you tend to pick up on the little things that can make a big difference. I’m always reading the latest research to find simple little tweaks that I can make to an exercise to change the desired result. Maybe I’m trying to optimize the mechanics of the scapula, or trying to enhance EMG activity of a certain muscle, or even change the ratio of activity between two muscles.
Chris Beardsley is a biomechanics researcher and author of a book about 
The other big omission I often see people make when considering the kinetic chain is that they think of each link in the chain as a joint. This is a simplistic version of the kinetic chain in purely the sense of biomechanics an arthrokinematics. Instead, realize that there are many influence on the kinetic chain between each joint.
Last week we talked about the 
Another commonly misdiagnosis that I have seen involves lateral epicondylitis. The C6 nerve root is one of the most commonly involved nerve roots involved in cervical radiculopathy as it exits between the 5th and 6th vertebrae. Any radiculopathy from this nerve root can cause weakness in wrist extension. I have seen even a subtle loss of strength of wrist extension cause a raging lateral epicondylitis. Sometimes this weakness is so subtle that the person doesn’t even realize they have weakness until it is too late. We continue to function and use our hands with this weakness and overload the area. So, we can treat the heck out of the lateral epicondylitis, but if we don’t solve the nerve root issue at the cervical spine we will never regain the wrist extension strength that is needed to decrease the symptoms of lateral epicondylitis.
We’ve spent a lot of time discussing the contribution of the hip has on symptoms of patellofemoral pain. [If you haven’t yet, this would be a great time to sign up for my newsletter and receive a bunch of goodies, including my eBook on Solving the Patellofemoral Mystery.] Over the last several years, we have made a giant leap in our understanding of why some forms of patellofemoral pain occurs. More often than not, weakness and dysfunction of the hip muscles, specifically the abductors and external rotators, is a leading cause of biomechanical faults at the knee and subsequent patellofemoral pain. Similar to lateral epicondylitis above, you can treat the symptoms all day but you aren’t going to solve the problem if you don’t address the source, weakness and dysfunction of the hip.
How can we apply this to the human body? Any dysfunction (and that is intended to be vague and include weakness, inhibition, instability, tightness, hypomobility, fibrosis, and many other dysfunctions) is going to have it’s biggest impact on the joints closest to it’s origin. Take a look at the photo to the right (which I tinkered with in Photoshop for an hour!).
