In the physical therapy world, we do a lot of listening (or we should … if you don’t, then you should start – there will be a post in the future about listening), but we also do plenty of talking – mostly educating our clients. However, not all words are created equal. We, as professionals, have to be very careful with our word selection because that can directly influence our outcomes with the client.
Words and language are a form of external, auditory stimulus. All stimuli (external, physical, etc…) are processed in the brain and then a response is sent out. If the stimulus is a touch of another person’s hand, the output response is that it is human touch. If the stimulus is a paper cut, the output response is pain. The same works for auditory stimuli – the brain has to decide how to respond to certain words and phrases. The output is usually emotion – how we feel towards hearing these words; do we feel happy/sad/neutral?
Think about this scenario: if you were a client (no healthcare background, unfamiliar with medical conditions or rehab guidelines in general like much of the populations we serve) and you found out you had a rotator cuff tear. You get an MRI and the MD tells you that you tore your RTC, you may need surgery, you may not be able to lift your arm without pain, they may ask “how much pain are you in?” etc… The same can be said of chronic pain clients. When these words are processed by the client, the brain’s output of emotion is negative and can heighten the pt’s perception of pain. There is an article published by Thomsen, R. et al in 2011 “Impact of emotion on consciousness” where they found that “participants were more confident and accurate when consciously seeing happy versus sad/neutral faces and words” with “evidence of interaction between emotion and conscious experience”.
If the client is predisposed towards having negative emotions with regards to their injury, we have to do better as PTs to change their overall outlook. We interact with the client on a more consistent and frequent basis than the MD does, so what we say matters more – if we are consistently conscious of our language use around the client, it can re-shape how they perceive pain. However, if we are consistently asking the client “how bad is your pain today?” or “do you have pain with overhead lifting?” or “don’t run/don’t lift heavy objects” – we are feeding into the client’s negative emotions towards their injury. Instead, ask these questions with different phrasing such as: “how’re you feeling today?”, “Are you able to perform any overhead lifting?”, “Modifying your run schedule or working on pacing during your run can decrease your discomfort”.
By turning some of these questions into “open-ended” ones, the client is forced to become more aware and mindful of their current status – over time, the client may start responding in a more positive manner. They may say “I still get a little pinching with overhead lifting” to which you can respond “that’s a positive improvement, when you started overhead lifting was a very difficult movement for you!” Positive language can help your client become more mindful of their current status. Luiggi-Hernandez et al published a paper in 2017 on mindfulness for chronic low back pain where they found that mindfulness helped participants decrease negative emotions towards chronic low back pain, decrease fear of pain, reduced significance of pain etc…
During a client’s first evaluation (especially chronic pain clients), I set the expectations very clearly – I know that pain will persist for a while, however, I don’t want the client to search for improvements on a day-to-day basis. Even if they still have the same level of “pain” or “discomfort” what I want them to look for, weekly/bi weekly, is if they can perform more functional tasks – tasks that they weren’t able to do prior to starting PT. This, in itself, is improvement. This sets the tone for all of my future sessions because the client won’t focus on the pain – they know it’ll still be there. Once they begin to follow through with my plan of care, they will – all of a sudden, usually – realize they have less pain with movements and it becomes an “A-HA!” moment for them.
Now, I don’t want people to read this post and think they can talk someone out of pain. The idea is to be aware of our choice of words and use guided mindfulness to decrease the client’s sensitivity and allow you, the PT, to treat their impairments and dysfunction. You still have to address their deficits and strengthen weak areas, cue proper movement patterns etc… but having the right word choice can open up new opportunities for gains.
We interrupt our regularly scheduled topic series (I promise Part 3: Interventions for tight hamstrings will be posted soon!) to bring you this article on principles for better treatment. This post is geared towards both new grads and veteran PTs alike, as I feel that even those of us who have been treating for a while could benefit from a refresher. Certainly this is not an end all be all guideline, but I felt that these 5 principles are a good foundation for improving your treatment outcomes with clients.
This post came about after much thought and reflection on what I felt made me successful with certain clients and what I could have done better with other clients. Enjoy!
1. Maximizing Your 1-on-1 Time
This is important, and all physical therapists know it, but it isn’t always executed well. With the pressure of increased productivity and decreased time spent with clients (i.e. traditional outpatient ortho clinics), it’s hard to perform a truly comprehensive on-going assessment/evaluation throughout your plan of care. And as a result, many times diagnoses are missed or you start on the wrong treatment path and have to back track.
Many clinics attempt to advertise that they find the “cause”/”source” of their client’s problem, however what I’ve seen in many clinics is that the therapist does not actually have time to find the source of the pain, and the client returns not too long after discharge and becomes a “frequent flyer”. So how are you supposed to find the source if you only end up with 20min of 1-on-1 time with the client?
When I worked in an insurance based model, I always tried to maximize my 1-on-1 time with clients. I had a check list of things I needed to check and each session I may only be able to check 1 thing, but I made sure to do it so that I would not have to back track. Here’s my list of items I need to check always when treating a client
- Check above and below the site of pain: Often times, unless there’s direct trauma to the area, the site of pain is not necessarily the source of pain. Don’t settle for only 1 joint above and below – make sure to treat holistically! Each session, test/check an area that could be influenced/influencing your client’s complaint. A good way to do this is to take a CEU on assessment; there are many out there, and I don’t believe that there is one that is better than all others, but the important thing is to use the assessment to it’s fullest potential. I use the SFMA and PRI for my assessments, but there are many out there such as Mckenzie, DNS, NKT etc…
- Don’t make it all biomechanical: what I mean by this is that as physical thearpists (read: movement experts) we HAVE to address the nervous system because the nervous system is what creates the movement patterns we see and treat. While we have to address the biomechanical side of issues, don’t get hung up on the roll/glide of specific joints, focus on the overall quality of movement and functional strength/patterns. Most/majority of injuries aren’t purely biomechanical in nature.
- “Every back has a front”: These wise words were spoken by my program’s director Dr. Kapasi, PT, Ph.D back on my first day of PT school in Anatomy. Remember, we are dealing with HUMANS, therefore not everything is about the bones and muscles. Sometimes back pain can be caused by inflamed kidneys, and it is important to know when to refer out. Utilize your differential diagnosis skills – the jump from a Master’s to a Doctorate was partly based on improving/increasing the differential diagnosis skills of clinicians. Don’t perseverate on a pure biomechanical model.
- Test/Re-test: Lastly, you need to know you’re on the right track, so make sure to test/re-test OFTEN! Not just on 30-day re-evals. Every session, you should be assessing and checking to see how your client is progressing, even through simple observation – it doesn’t have to be a formal objective test!
2. Motivational Interviewing/Listening
Many times as a PT I feel like I’m my client’s counselor more than a PT. However, part of our job is to LISTEN to our clients and their story. Knowing the right questions to ask and actively listening to their answers will lead us to the “why” of their problems. Our clients are very smart, and they will unknowingly give us the missing piece that we’re searching for. Make sure to always ask “how” and “what/when” questions – the “why” is for us to figure out. “How did you hurt yourself”, “When did this all start?”, “What makes it feel better/worse?”, “How are you coping with this, currently?”.
Sometimes we need to ask questions (through conversation, don’t be weird about it!) not directly related to their injury – are they currently dealing with any external stressors in their life?, any previous injuries growing up?, any pertinent past medical history (this is important because often times clients will only report history that is related to muscles/bones when they come to see a physical therapist).
And above all – LISTEN to their answers. A wise man (Dr. Kapasi, again) once said “God gave us 2 ears and 1 mouth for a reason – so we can do twice as much listening as talking”.
3. The Power of Positive Language
What we say to our clients matter! And directly affects their perception of their injury. This is especially important when dealing with chronic pain diagnoses. When I treat, I always try to re-direct my client’s focus from “pain” and what they can’t do towards positive outcomes such as functional improvement and what they are able to do now, even with the same level of pain (still demonstrates positive progress though pain is still present). When clients meet with MDs and they receive a “medical diagnosis”, many will research it on WebMD, and come in to our clinics with anxiety and fear due to what they’ve found on the internet – we need to break their pre-conceived notions!
Above, I mentioned that we need to address and treat the client’s nervous system (think biopsychosocial model). Using positive language/imagery/visualization can decrease our client’s anxiety levels, decrease their fear of movement, and subsequently change their outlook on their condition. Negative thoughts can indirectly increase pain perception, and therefore, the physical manifestation of pain within our client.
4. Don’t Over Treat
I think this one pertains more to new grads, though seasoned therapists could benefit from this one as well. When I was a new grad, I felt that every client needed manual therapy, every session. This is not the case. In fact, this leads to over treatment and can aggravate a client’s symptoms. Sometimes clients only need tactile cueing and proper movement coaching to improve. When a client is close to discharge, they should not require 30min of manual therapy – should they really be discharged if you have to “mobilize the distal tib/fib and tibiofemoral joints for an entire session?” (this is not including discharge for insurance reasons…). How do we know if we’re about to over treat? TEST/RE-TEST!
5. Confidence vs. Arrogance
Lastly, know the difference between confidence and arrogance. Clients can tell the difference, don’t be arrogant. You can be confident and assertive without sounding arrogant and pretentious. Again, verbal and body language matter. Make sure to not hold yourself as if you’re “better” than the client, build rapport and earn their trust – don’t be demanding, be empathetic. This can be frustrating when dealing with tough clients who aren’t adherent with your plan of care – where you know they could be progressing if they just followed through with your plan. Maybe you need to try another approach, maybe you need to find out why they aren’t adherent – what are their barriers to compliance? Don’t just assume that the client does not want to participate (you may have some who fall under this category but that should be a small percentage).
As an added bonus – don’t put down other professions to prove your point. It makes us (PTs) as a profession seem petty and desperate. Let your results speak for yourself!
Almost everyone, nowadays, you meet will say “I have tight hamstrings” and when you ask them to bend forward and touch their toes they’ll say “I’ve never been able to do that”. Many of these people will concurrently experience some form of low back pain – it may not be severely debilitating, but if it’s achy or intermittent, it’s still low back pain. In PT school, we were taught to always check directly above and below the affected target zone because it could be coming from elsewhere. Now, in my clinical practice I take it much further than just above and below 1 joint, but the idea is still the same – always find the source, don’t perseverate on the location of the pain!
I understand that in school and throughout the orthopedic world there are different classifications of LBP (i.e. extension/flexion based exercises, lateral shift, traction/manipulation etc…) but this post is meant to give a general insight into back pain and how hamstrings being tight might be playing a role.
Now, back to the topic at hand. Since we’re talking about tight hamstrings in this topic series, we’re going to work backwards and discuss how having these supposedly “tight” hamstrings can contribute to common ailments such as low back pain or hip pain (most notable FAI – which you can read about in the most recent topic series here).
Low Back Pain
I am about to explain one scenario in which low back pain exists, there are many findings and ways to develop LBP – this is not an end all be all.
The lumbar spine is connected directly to the sacrum, which is wedged between the two innominate bones on either side. So logically, there would exist a direct relationship between the L spine and the Pelvis. In fact, PTs talk about lumbopelvic rhythm, lumbopelvic stability, lumbopelvic ROM etc… By grouping them together many PTs would consider, and treat, this area as one area, which may cause some to miss the subtle influences that the pelvis may have on the L spine.
In the previous post, we discussed anatomical relationships of the hamstrings, internal/external obliques, and transversus abdominis. Addtional muscles that need to be added to the mix are the psoas, iliacus, adductor magnus, rectus femoris, and TFL.
The Psoas and iliacus muscles are often grouped together as the iliopsoas, but they are separate until their insertion. The psoas originate from the from of the vertebral bodies of T12-L5, and the iliacus covers the majority of the medial side of the iliac foss and joins the psoas on the lesser trochanter assisting in hip flexion and medial rotation. The adductor magnus is one that many tend to forget, it has an extension component because it starts on the ischial tuberosity and inserts into the linea aspera as well as the adductor tubercle. The TFL and rectus femoris assist in hip flexion due to their origin on the iliac crest and ASIS respectively.
As humans, many of us spend the majority of our days sitting at a desk leading to tight hip flexors (our nervous system adapts and overtime will allow us to assume this posture efficiently by effectively shortening certain muscles and lengthening others) and poor core engagement (how many people actually engage their core while sitting after 10 hours?). Take a minute and review the anatomy of the core muscles we discussed in the previous post and visualize how an anterior tilt can put these muscles on stretch and at a poor length-tension relationship.
With increased tightness (read: overactive, or increased neural activation of…) developing in your hip flexors pulling your pelvis into an anterior tilt, the glutes stop being as effective (or can also be overworked inefficiently trying to overcome the activation of hip flexors anteriorly) and the erectors posteriorly begin overworking for the lack of hip extension – effectively shortening and resulting in increased lumbar lordosis. This definitely makes sense visually and Smith et al (2016) found that there was increased activation of erector spinae during walking activities in those who were asymptomatic but had a history of LBP. They also found reduced endurance of the deep fibers of multifidus. The posterior wall of your core is not able to sustain a contraction for as long when you start having low back pain – this one piece should cue you into that the overall functional of an individual’s core is altered if htey have a history of LBP or are currently experiencing LBP.
What does this have to do with the hamstrings being tight? Remember that the hamstrings attach to the ischial tuberosity – an anterior tilt will result in the hamstrings on stretch while at rest. It also puts the hamstrings outside of their optimal length-tension (I warned you that this was a very important principle) for contracting and holding the pelvis in a neutral position. As a result, the hip flexors and erector spinae will dominate and result in a non-neutral spine; increasing the compressive forces through the spine, thus low back pain. The hamstrings are not the only muscles affected, the adductor magnus also attaches at the ischial tuberosity, so the extension AND adduction fibers are also affected.
After the previous discussion on low back pain – you may notice that many of the muscles mentioned have an attachment at the hip, and so you can imagine that there would be a direct relationship between low back pain and hip pain.
An anteriorly rotated pelvis (think the tight hamstrings we discussed just above) will disrupt the relationship between the femur and acetabulum. We will now skip to a tangent principle that is just as important as the length tension relationship mentioned in the previous post. It’s called Wolff’s Law. It essentially states that our body is constantly taking up and laying down new bone in accordance with where stress is. It’s our body’s way of adapting to the daily stresses we put our body through. As a result, if one side of a joint is consistently under more stress than the other, that particular side of the joint may become thicker overtime due to this principle. This can lead to potential problems over time however.
Picture this: A soccer player with tight hamstrings presents with groin pain. You find that they have an anteriorly rotated pelvis with excessive lordosis. The anteriorly rotated pelvis disrupts the relationship of the acetabulum and femur, and with the repetitive nature of soccer (running and forced/explosive hip flexion while shooting), the superior/anterior portion of the femur will bump into the acetabulum. Overtime, the body will adapt and the irritated part of the femur will become thicker with increased bone lay down. Now the femoral head is no longer spherical and the shear forces between the femoral head and acetabulum begin to wear away the cartilage – the athlete now has a Cam impingement and potentially the development of hip arthritis.
Many may argue that this post is focused on being able to achieve neutral, but life does not occur in a neutral spine or hip. I completely agree with that statement. However, because life is so dynamic, we must be able to achieve neutral before we can become dynamic. Otherwise we are perpetuating the dysfunction through inefficient movement. Life is about being able to move into and out of neutral, thus creating the dynamic nature of movement we see.
The third part of this series will focus on basic movement dills to help your athlete achieve neutral and then progress them into more dynamic exercises.
Smith, J. A. PT, PhD, Kornelia, K. PT, PhD Altered multifidus recruitment during walking in young asymptomatic individuals with a history of low back pain. JOSPT 46(5) 365-374; 2016
Harris-Hayes, M. PT, DPT, MSCI, OCS et al. Persons with chronic hip joint pain exhibit reduced hip muscle strength. JOSPT 44(11) 890-898; 2014
Prather, H. DO et al. Hip and lumbar spine physical examination findings in people presenting with low back pain, with or without lower extremity pain. JOSPT 47(3) 163-172; 2017
Megan Sions, J. DPT, PhD et al. Trunk muscle characteristics of the multifidi, erector spinae, psoas, and quadratus lumborum in older adults with and without chronic low back pain. JOSPT 47(3) 173-179; 2017
Ishizuka, T. et al Instantaneous changes in respiratory function induced by passive pelvic suspension in the supine position in relation to increased diaphragm excursion. J phys ther sci. Mar;29(3):432-437; 2017
Workman, J. C. et al. Influence of pelvis position on the activation of abdominal and hip flexor muscles. J strength cond res. Sep;22(5):1563-9; 2008.
Teichtal, A. J. et al. Wolff’s Law in action: a mechanism for early knee osteoarthritis. Arthritis Res. Ther. Sept;17(207); 2015
This topic series is meant to be applied holistically to any group of “tight” muscles. In this topic series we will be exploring why a muscle may develop tightness, using the hamstrings as an example.
Has a client told you that they have tight hamstrings before? Are your clients unable to bend forward and touch their toes because of “tight” hamstrings? What if I told you that the hamstrings may not be “tight”, but rather they are overstretched and compensating for dysfunction else where?
In order to understand why the hamstrings get “tight” we need to understand it’s anatomy first.
The hamstring is a group of muscles including the biceps femoris (long and short head), semitendinosus, semimembranosus. All aspects of the hamstring originate off of the ischial tuberosity except for the short head of the biceps femoris, which originates from the linea aspera of the femur. The semitendinosus and semimembranosus run along the medial portion of the posterior leg and attach to the medial portion of the knee. The biceps femoris attach to the lateral aspect of the fibular head.
When other muscles in the hip get tight, they can anteriorly rotated our pelvis and put our hamstrings on stretch at rest. Our muscles can operate and contract throughout an entire range, but work optimally within a certain range. When our muscles are too stretched out they are ineffective and when they are too contracted, they become inefficient. This is called the length-tension relationship.
In the above graph, 3 and 4 represent ranges where the muscle is too stretched out – the myosin and actin fibers do not overlap enough to pull effectively – and cannot contract effectively. 1 represents ranges where the muscle is already contracted – too much overlap between the myosin and actin, so it is not able to contract any further – this is often an explanation for muscle cramps; your muscles are already operating in a shortened range and it is unable to further contract, therefore it cramps up during a movement. 2 represents the optimal range for muscle contraction. This concept of “optimal muscle length” is an important one for all movement and can sometimes be forgotten in the clinical world while treating clients.
This is a lateral view where the L is “anterior” and the R is “posterior”. The image on the Left is normal pelvis positioning (neutral). The image on the Right is a forwardly tipped pelvis (anteriorly rotated). In the image on the Right, the hamstrings already “pre-stretched”. Many people judge whether or not they have tight hamstrings based on whether or not they can bend forward and touch their toes or sit with their legs in front of them and try to touch their toes. If they can’t, they deem themselves as having “tight” hamstrings. But what if your pelvis was rotated forward? Your hamstrings would be “stretched” at the start before your bend forward, and therefore it is unable to stretch much further.
IF you continue to stretch an already lengthened you may be weakening your hamstrings and creating an “over stretched” muscle – that will likely become ineffective at stabilizing your pelvis.
When your pelvis is rotated forward, your “core” and abdominal wall are stretched and not contracting well (think zone 3 and/or 4 in the previous image) and this can affect your overall movement (your core is where every movement begins) and it can affect your diaphragm/breathing (a post for another day!). The above images demonstrate how the core is involved. The top two pictures are of the Internal Obliques and Transverse Abdominis, and both attach to a substantial portion of your rib cage as well as the pelvis on either side. Together with the External Obliques (not pictured) they can help rotate your pelvis posteriorly (backwards). In the bottom image above, the middle figure is a posteriorly rotated pelvis. Knowing the attachments of these muscles, including the hamstrings, if contracted together, you can target the innominate and posteriorly rotated it.
The following posts will discuss exercise interventions – such as activating your muscles properly to control your pelvic range better – as well as how this poor pelvic positioning may influence other ailments you may have including low back pain, hip impingement, or knee pain.
The first two posts dealt mostly with understanding FAI as a pathology as well as assessing/differentially diagnosing the dysfunction. This post will serve to discuss mobility drills and interventions that can be implemented day one for the athlete with the limitations listed previously. This is not an all-inclusive list, just a few drills I like to give to help increase mobility of the hip. There are many aspects of the athlete that need to be addressed such as glute loading patterns, ankle mobility drills, and lumbopelvic motor control – these will be discussed in future posts separately, apart from diagnoses.
I’d like to also give a shout out to AnyTime Fitness in Quincy for letting me use their space for these photos.
Banded Hip Mobilization – Flexion
This is a great drill – and there are variations (one that is shown below) – that is great for increasing external proprioceptive input into the neuromuscular system. It can also serve to progressively increase motor recruitment for an athlete having a hard time with active hip flexion. This drill can also be progressed to other positions such as quadruped, tall kneeling, and standing (a la SFMA 4×4 progressions).
To start, have the client lay supine and take a resistance band (thera-band, j band, etc… get creative!) and anchor one end onto something sturdy and the other wrapped around the proximal femur of the affected joint. Have the patient bring the target extremity into 90/90 hip flexion/knee flexion. Make sure the client does not go into increased lumbar extension/lordosis – a verbal cue I give to clients is to make sure their back is flat against the ground; this will help increase deep core activation and put the client into a bit of a posterior pelvic tilt. Once they are able to assume the starting position, have the client bring their knee towards their chest into hip flexion – I also cue them to allow the band to “sink in” and pull down on their femur to increase inferior gliding; ultimately aiding them into hip flexion. Usually I’ll have them perform 10 repetitions and 2 sets at an even, slow pace – retest the client and see if there’s an increase in mobility.
Another reason I like this drill (and other banded mobilizations) is that the client is taught how to perform self-care at home and it allows them to take ownership of their rehab. This will result in increased compliance and improved overall outcomes.
Banded Hip Mobilizations – IR
This is a nice variation of the above banded hip mobilization. Same position as above, but now rotated 90deg to the R. Now the band is pulling laterally instead of inferiorly, which will aid in hip IR. There are two ways to perform this exercise. 1) Assume 90/90 of hip/knee and have the client internally rotate their leg while also allowing the band to “sink into” their medial femur and pull the proximal aspect laterally (gapping the joint and aiding in overall increased IR). 2) Have the client assume 90/90 and, just like the above drill, have them flex their hip and knee towards their chest and then internally rotate once max hip flexion is achieved. The first way is easier than the second, especially in the presence of progressive FAI.
Many times you’ll also find upon assessment that the anterior hip is restricted due to over activation of the hip flexors. Have the client assume a half kneeling position (airex pad is for comfort) with the target hip on the pad. Cue the client to keep their hips and shoulders square, drive the front knee over the 2nd and 3rd toes so that they feel a stretch in the anterior portion of the target hip. Now in this position, sometimes I’ll even have the client hold and perform a glute set with a 30sec hold to increase neural inhibition of the hip flexors.
The final image demonstrates another progression of the drill, where the client performs IR at end range hip extension and focuses driving the motion with their hips. I would instruct the client to rotate to their end range, or just before pain onset, hold for 10sec and then return to the starting position. Have the client perform sets of 10, and with each rep ask the client to see if they can push a little further.
The above mobility drills are designed to be implemented on the first day and the client should monitor their overall mobility in a long term fashion – results (as with all rehab) don’t happen overnight. As mentioned above, there are many, many other aspects of their dysfunction that would need to be addressed, but I will be saving those for future posts. For now, these mobility drills should help you get started in improving symptoms of FAI.
In this post, I will be covering some differential diagnosis and key aspects of the assessment when treating athletes with anterior groin pain that may be FAI. As mentioned in the previous post, there are a number of things that can cause “anterior groin pain” including athletic pubalgia (sports hernia) and trigger point referral patterns. So in order to differentiate FAI from these other diagnoses, you have to understand these other pathologies as well. I won’t be going into detail with each of the diagnoses but will provide succinct information as to the etiology of each.
Athletic pubalgia, also known as a sports hernia, is not a true “hernia” by medical definition. It can be a result of multiple injuries but most commonly it involves micro tearing in the rectus abdominis (lower portion, near attachment on public symphysis) and adductors (again, near their attachment on the pubis). Athletic pubalgia has commonly been viewed as sport and position specific, with the three more common sports being football, soccer, and hockey. Clients often will present with groin pain (often chronic), that increases with any exertional activity, and subsides with rest. Males are more commonly affected than females.
Muscle trigger points (MTrPs) can also cause referred pain patterns into the anterior hip. Due to their proximal attachments, the iliopsoas group/adductor longus and magnus can refer pain into the anterior groin. These can be present in an athlete with FAI as well due to their inefficient movement patterns and over compensation with certain muscles. However, it will be important to perform an in-depth assessment and not stop when you find MTrPs so that you don’t miss something more serious like athletic pubalgia or FAI.
Often times FAI can be traced by to some sort of non-specific groin strain, leading to muscular imbalances later in life, though there can be an acute precipitating episode as well. The athlete may recount “not being as flexible for as long as they can remember”. Though Dr. Byrd found that rarely is the flexibility a true impairment, as the lumbosacral and pelvic motions are increased to compensate for hypomobile hip joints. Most commonly athletes will use the “C sign” to describe the location of their pain when it’s deep.
I have mixed feelings about objective/special tests and the data that I can gather from them. I still perform them during my assessment because I feel that the more data you can gather on the initial visit, the better tailored your POC will be for that specific client. However, if a client comes in with an irritated hip, almost any test will surely increase their pain. Another thing to keep in mind is that while the client may have unilateral symptoms, the bony morphology may also be present on the asymptomatic side. The biggest deficit that should be spotted upon initial assessment is that the athlete will lack IR on the symptomatic side – however since I mentioned that the structural changes may also be present on the asymptomatic side, there will be cases where you will find no change side to side. You will need to continue to ask leading questions and find out if it reproduces THEIR pain or if the movement is just uncomfortable. Special tests that can be useful in cases of suspected FAI are the hip scour (if there is intra-articular damage already), passive flexion/adduction/IR (FADDIR), log roll test (IR and ER), ASLR*, as well as AROM/PROM and palpation.
ASLR has an * next to it because I don’t use it the way others do and it’s not necessarily validated by research (at least I haven’t found any – but who knows, I haven’t been looking too hard for that), just a clinical pearl. The classic ASLR test usually tests for lumbar disc pathology and/or posterior chain tension. Now, as I mentioned earlier, with any hip pathology that’s acute or moderate/highly irritable, movement WILL create pain for the athlete. I’ve found that those who aren’t symptomatic at rest but have some sort of FAI confirmed with other tests later, will have a positive ASLR with pain onset between 30-90 deg (large range based on severity and acuity of symptoms). It’s similar to the shoulders when you get an athlete with shoulder impingement and a painful arc. Now this is just something I’ve noticed in the clinic, so don’t quote me in your next presentation with this information, but give it a try and see what happens on your next assessment.
Some other things you may find upon initial evaluation is that they don’t really want to load the hip that is affected. With FAI, if it is in it’s early stages, the athlete may not have much trouble with weight bearing activities like walking but more explosive activities such as running and jumping may increase irritation. Therefore, the athlete may not have much pain when walking into your clinic. But in later stages the athlete may ambulate with an antalgic gait because they do not want to load the hip and want to get on and off of it quickly – effectively creating a functional leg length discrepancy during gait and can lead to lumbar spine problems if not corrected early on.
In athletes playing high risk sports (i.e. hockey, soccer, football etc…) some leading questions I like to ask include “when does the pain come on” during activity as well as “what movements exacerbate it”. Often times, the pain comes on during the swing phase of running (due to hip flexion ROM) or cutting away from the painful side. For hockey players pain can come on during their push off while skating AND when they bring the leg through. Pain during push off is usually noted when they are skating around a corner in the direction towards their painful side – i.e. L hip pain, when they push off to skate around a corner to their L. This is because they are adducting and IR their inside leg to stay in line while skating and can increase pain/pressure on that hip. Often times I will also ask the athlete to demonstrate the movement that brings on their pain.
If the patient has had radiographic imaging, you may be able to identify the lesion and type from the X-ray. You may also find other signs on the radiograph like the “cross-over sign”. The cross over sign indicates acetabular retroversion and is present when the anterior/superior border of the acetebulum extends more laterally past the posterior/superior border.
However – with all of these tests, no single test will tell you that the athlete has FAI, you will need to utilize a combination of tests, ROM, palpation, and most importantly history. If you ask the right questions, the athlete will, with out knowing, point you in the right direction. Palpation can often times help localize tender areas, but as mentioned before, your athlete may have a combination of impairments contributing to their symptoms, not just FAI (MTrPs, strain, articular damage etc…).
Ames, P. S. PT, SCS and Heikes, C., S. MD. Femoroacetabular impingement in the running athlete. JOSPT 40(2). Feb 2010
Austin, A. B. DPT, Souza, R. DPT, Meyer, J. L. DPT, Powers, C. M. PT, PhD. Identification of abnormal hip motion associated with acetabular labral pathology. JOSPT 38 (9). Sept. 2008
Byrd, J. W. T. MD. Femoroacetabular impingement in athletes Part 1: Cause and Assessment. SportsHealth 2(4) 2010
Rabe, S. B. MS, ATC, LAT et al Athletic pubalgia: Recognition, Treatment, and Prevention. ATSHC 2(1) 2010
Femoroacetabular impingement (FAI) is a common condition among sports where athletes utilize rotational forces or high levels of impact during hip flexion. FAI has been shown to lead to secondary breakdown of the acetabular cartilage within the hip joint overtime. Eventually, the athlete will likely develop osteoarthritis, sooner than their less athletic counterparts. Many times, FAI begins as non-descript groin pain and is treated as such with temporary relief, but as the athlete continues to participate in high risk sports (golf, baseball, hockey etc…) the pain will increase. As athletes continue their careers, increased breakdown occurs which can lead to increased joint damage, ultimately lowering the threshold for deterioration. This causes lower than normal loads to negatively impact the joint.
There are 2 types of impingement: pincer and cam. Pincer impingement is when there is an overgrowth or increased prominence of the anterolateral acetabular rim. The site of the impingement is usually anteriorly and occurs when the hip is brought into a flexed/adducted/internally rotated position. Normally the acetabulum sits and faces slightly anteriorly/laterally with differences between males and females. It can also be caused by an os acetabulum – a separate piece of bone along the anterolateral rim of the acetabulum. With hip flexion, the rim of the acetabulum begins to “crush” the labrum and with repeated motions, the labrum will start to fail leading to the typical anterior groin pain.
Cam impingements happen when there is a non-spherical femoral head rotating inside the acetabulum. Often times cam impingements are a sequela to Slipped Capital Femoral Epiphysis (SCFE) and can result in significant deficits into hip internal rotation. With hip flexion, the non-spherical shape of the femoral head eventually leads to increased deterioration of the cartilage inside the socket due to the shear forces placed on the surface – resulting in early onset arthritis. One theory on the cause of cam impingements, which has not be proven, is that there is early closing of the growth plate resulting in the non-spherical shape of the femoral head. Intense athletic activity may precipitate the premature closing of the capital physis, but it is unclear whether it causes the impingement.
As with all pathology, there is a chance for having both cam and pincer lesions present.
Differential diagnosis will be touched on in the next post covering assessments of athletes with FAI. However, I would like to mention that there are a number of diagnoses that can cause anterior groin pain in the subjective history including athletic pubalgia (sports hernia) and muscle trigger points in the iliopsoas, QL, rectus femoris, and obliques. As mentioned above, many times FAI is treated locally and symptoms will subside with rest/time, but it will be imperative to treat movement dysfunction that the athlete will present with in order to help them return to sport with decreased risk of re-injury/minimal flare up.
Stay tuned for follow up posts in this series that will cover in-depth assessments in athletes for FAI (including at risk sports) as well as treatment interventions.
For anyone who’s been wondering why this blog has not be updated as regularly as it had been when it first started, I wanted to first apologize as I know a lot of viewers look forward to the posts, but I’m here to clear this up. For the past 6 months I have been working full time in the clinic seeing clients as well as operating as the head Physical Therapist and Emergency Medical Responder (EMR) for the Boston Blades, a professional women’s ice hockey team that plays in the Canadian Women’s Hockey League (CWHL). Now, as physical therapist, in order to practice on the sidelines the way I did, I had to obtain my first responder (EMR) certification – a course that focuses on medical management in emergency situations. I am not an Athletic Trainer (ATC), nor did I provide athletic training services – I was a first responder during the event, and a PT before and after. I covered both practices (before, during, and after) and games (home and away).
The Boston Blades play in the CWHL, and so all of our opponents operate out of Canada – Toronto, Brampton, Montreal, and Calgary – and therefore required a lot of travel; thankfully one of the perks of working with the team meant all travel and lodging was covered. Practices were every Tuesday and Thursday night and games were Saturday/Sunday (always back to back scheduling for games).
Our roster consisted of girls who went to school in Boston and now live in the city (many BU, BC, and Northeastern alums) as well as girls who commuted from different states – most notably our two goalies Jetta Rackleff and Lauren Dahm who live in Rochester, NY and Syracuse, NY respectively as well as one of our defenders Maggie DiMasi who lives in Vermont – just to play hockey. The players are NOT paid during the season (only travel and lodging are covered for these girls, while staff are given a minimal stipend on top of travel expenses). Unfortunately there isn’t enough sponsorship or a big enough fan base to pay all of the players consistently. This experience has opened my eyes to just how differently women’s sports are treated compared to their male counterparts. It’s one thing to read about it, but to see and experience it first hand was shocking to say the least. I remember asking our GM at the beginning of the season why some of these players would travel so far just to play hockey and not get compensated for it, and her response was “Because they love the game”. These athletes play at the highest level possible for ice hockey, facing teams that have several Hockey Canada members and Multi-Olympians/Gold Medalists, including our captain Tara Watchorn, a 2014 Sochi Gold Medalist. Yet there still isn’t enough interest or money to pay these athletes a salary; besides our captain, every athlete on the Blades roster holds a full time professional job or is in graduate school full time. So they play internationally in Canada, get home at 4am on Monday morning and have to report to work or class in 5 hours – on a regular basis. All for the love of the game.
The overall experience working with the Boston Blades was truly amazing. I had never ice skated before the start of the season, let alone played high level hockey, but have treated hockey players in the past. I learned on the job, analyzed every player’s movement on the ice and posture at rest. I was fortunate enough to have gone through a PT program where I took a Sports PT elective taught by Dr. Melissa Baudo – who served on the Women’s Tennis Association tour for several years and has a wealth of experience with sideline coverage and therapeutic taping – and was able to apply EVERY BIT OF KNOWLEDGE that she taught me (for which I am FOREVER grateful), and then some.
In order to be successful as a sports physio working with a sports team (youth or professional) you have to be able to adapt on the fly. I never once had a treatment table available at the rink – practice or games – which made traditional manual therapy technique positions as well as taping positions unusable; you have to be creative and figure out new, innovative ways to treat on the go, including during 10 hour bus rides. You also have a budget for the season for medical supplies including tape (which can be expensive), so you have to have strategies to conserve the materials that you do have.
I remember a moment during the team’s training camp in September, my order of tape had not yet come in, and I had minimal tape that was left over from the previous season, yet I had to tape a player for patellar support and a valgus/varus knee block combo without Elastikon and minimal Leukotape and Lightplast. I had to think on the fly and modify my taping technique to make sure that player could skate and perform during tryouts. Now, this player arguably needs Physical Therapy/rehab and movement re-education – which I have referred her to. However, as a sports physio, you have to realize that during the season your job is to make sure that the player(s) make it through the season. Rehab is a long term solution, but it is not efficient or effective to shut a player down for 3 months to rehab shoulder impingement if it’s not serious. Athlete education is huge and I always make it clear to the athletes that more serious rehab would be warranted after the season ended but for now I would prescribe ther-ex and on the spot manual therapy to decrease the progression of their dysfunction. You have to step out of the “Rehab” mindset. Unless the player is unable to play due to fracture/concussion, it is unlikely they will sit out. Strains and localized pain from bone bruises or pulled muscles are not going to bench an athlete, and definitely not a hockey player.
Make sure they don’t compromise their physical fitness and make sure the condition isn’t progressing. You need to earn the athlete’s trust, they need to know that a strain is not going to make you go to the coach and bench them, because if they don’t trust you they won’t report an even more serious injury (concussion being the big one). It all comes down to education of the athlete, letting them understand the risks of continuing while injured. Concussions are not to be messed around with but a pulled groin will heal with time and taping/wrapping techniques can significantly help them play during the healing process.
I’m so thankful for this experience and have met such incredible, passionate, hardworking individuals along the way. This season was a huge learning curve for me – and I appreciate all of the players and staff members who’ve been patient and helped me along the way. Thank you for trusting me with your care this season, it was definitely an unforgettable one!
First post of 2017, and it’s a good one! I recently had the opportunity to interview Matthew Ibrahim, CSCS, LMT – a hybrid strength coach and therapist at Boston Physical Therapy and Wellness (Medford, MA) and Boston Underground Strength Training (Waltham, MA). He has an impressive resume and loads of experience in both the strength/training and rehab fields. He is the founder of “Movement Resilience” and co-leads the Hip Hinge 101 Workshops with Dr. Zak Gabor, PT, DPT. You can follow him on social media at the following links: Facebook, Twitter, Instagram, Youtube.
JC: How did you get started in the rehab/fitness field?
MI: I’ve worked in both the Strength & Conditioning and Sports Rehabilitation fields since 2008. I started out by going to UMass Boston for my undergraduate degree in Exercise & Health Sciences. However, my academics were not stellar and I didn’t really know what I wanted to do. While at UMass, I was fortunate to have had an internship at the world-renowned Mike Boyle’s Strength & Conditioning facility in Woburn, MA. It was a good blessing in disguise, really, because at the time I didn’t know what I was doing. I was under the direction of Nicole Rodriguez, and she really kicked my butt – in a good way. Overall, that experience sparked my interest into applying to PT schools. For the next 3 years I worked as a PT Rehab Aide at Bay State Physical Therapy (Arlington, MA), as I was also taking some pre-requisite courses applying to local PT schools. While I worked my way through school, I was observing treatments and evaluations. I was fortunate enough to have learned a lot under the direction of the PT’s there.
I also worked as a Strength Coach / Personal Trainer at few local Strength & Conditioning training facilities during that time. I was trying to prepare myself for PT school, and read up on a lot of books regarding movement and performance. Long story short, I applied to 5 PT schools for 2 years in a row, but never got accepted. I wasn’t ready to give up, so I tried to boost my resume and get some certifications. I wanted to show PT schools my commitment to helping the community and started what I branded as “Mobility 101” at the time as an educational resource. The goal was to make some content and videos and share what I had learned from my experience as well as learn from others. I never thought it would get to the point that it is now. I continued to network and meet other rehab professionals who, later, were connections that allowed me to write several articles here and there for various well-know fitness and rehab websites. I applied a third time, and yet again, was denied into PT school. At this point, I had considered other options such as PTA (PT Assistant) school – which I got into and turned down – just to have credentials to work with the rehab population. However, I had gained so much experience just from working and networking over the years that going back to PTA school just to have the letters seemed like a waste of time to me. Ultimately, I decided to go to Massage Therapy School (LMT) to gain hands-on experience for manual therapy and soft tissue skills, and utilize my knowledge and experience as both a Strength Coach and PT Rehab Aide.
Just prior to LMT school, I gained employment at Boston Physical Therapy & Wellness in Medford, MA, and began working as a Strength Coach and PT Rehab Aide – training all of their clients and also assisting the staff PT’s during rehabilitation of patients.
JC: Tell me a little more about your brand.
MI: As I mentioned before, I first created Mobility 101 as an attempt to boost my applications for PT school – I wanted to demonstrate to the admissions committee that I was committed to promoting better movement and wellness on the community level. I published content based on my experiences as well as things that I had learned along the way. I wanted to keep things simple – so to me, Mobility was a hot topic word at the time, and “101” to me has connotations of “introductory” and “entry level”. I started to build a large following on social media, including Facebook and Instagram – something that I had never expected when I first started. People started to see me as being knowledgeable in the field, so much so that about a year ago, I rebranded to “Movement Resilience”. I did not want any confusion with the public with my first brand of Mobility 101. I was getting emails at the time from professionals all over who were asking me for my advice and opinion on things that I was not qualified to answer, and instead were truly intended for physical therapists. I wanted to create clarity for my mission and ways in which I could help people – albeit, through in-person training or treatment, live workshops, or even via social media educational content.
JC: How do you feel like your unique background strengthens your rapport with your clients?
MI: I work out of 2 locations – Boston Physical Therapy & Wellness (Medford, MA) and Boston Underground Strength Training (Waltham, MA) – with mostly clients who are looking to increase their fitness and enhance their training. I picked up powerlifting as hobby of mine and to create focus in my own training. I wanted to compete and challenge myself. This background helped me to speak the same language as my clients, which gives them more confidence in me in terms of being able to help them. Walking the walk, to me, is something my clients look for, so it’s important to me to continue doing this. However, if someone were to have a more serious injury, I am not able to diagnose per my licensure and credentials; therefore, I use my team of physical therapists at Boston Physical Therapy & Wellness to refer a client to. In this sense, I am the “bridge” in the gap of training and rehab – acting as a liaison between the two. I’m very fortunate to work alongside intelligent and hard working professionals at both Boston Physical Therapy & Wellness and Boston Underground Strength Training.
JC: What is a typical treatment session like with you?
MI: What I offer now is treatment and training. I still work at Boston Physical Therapy & Wellness, working with athletes of all skill levels and ages. I utilize manual therapy techniques, soft tissue skills, IASTM, and also active cupping from the Modern Manual Therapy (Dr. Erson Religioso). I consult with our PT staff here and refer patients to them who I believe are out of my scope of practice. In my treatment sessions, I combine soft tissue mobilizations, movement education, and specific corrective exercises. The goal is to use the window of opportunity gained from the manual therapy to retrain and reload the area and improve their movement.
A normal session has what I call the “four pillars”. I want to see what’s going on. This process is similar to a PT treatment session – however, I am not diagnosing, and it’s important that I respect the scope that I’m in. Again, I refer out (aka walk into the next room to speak with our PT’s) when needed.
Here’s the breakdown of my treatment process, based on my four pillars:
Assessment – I’ll review the intake form and then perform a quick assessment to see what’s going on. I use my sports rehab experience and knowledge in assessment tools such as FMS, SFMA, and PRI to break things down a bit more. From these findings, I’ll tell my client the game plan for this specific treatment session.
Manual Therapy – I use specific hands-on treatment techniques to restore function and treat the specific condition. Some of the skills I use are based in manual therapy, soft tissue skills, IASTM, and also active cupping. My goal is to address the dysfunction found from my assessment and integrate localized manual therapy treatment where I see fit.
Movement – I’ll carefully select a few specific corrective exercises for my client to incorporate into their training to help address the problematic area and/or pattern. This process includes exercise instruction, lifting technique and form, pain-free movement, and recovery strategies.
Education – This is the most important aspect of my treatment approach, since my goal is to make sure that the positive changes we made during the treatment session continues into their daily life and activities. It is my goal to not only help clients get out of pain, but also teach them how to move well and build strength. I often find that helping them get into better positions during their training, and avoiding poor positions, typically gets them to train again, pain-free.
JC: Tell me a little bit about your new ‘Hip Hinge 101 Workshop’
MI: I started the Hip Hinge 101 Workshop with Dr. Zak Gabor (PT, DPT, CSCS, USAW), a dear friend and colleague of mine from Boston Physical Therapy & Wellness. There aren’t too many workshops with both a strong rehab and strong training background from the instructors. We both love the topic of low back pain and hip hinging (deadlifting), and saw a lack of understanding/efficiency in these areas, not only among the public, but also among both rehab and fitness professionals. The workshop focuses on creating spinal rigidity and maintaining a strong core that is necessary for hip hinge-based exercises and deadlifting. We break down the entire assessment and screen process, the research and pain science behind it all, demonstrate all of our progressions and regressions, and then get the attendees on the training floor as we provide hands-on coaching through their deadlifting.
We started in May 2016, and have had 6 workshops since then, each one averaging 15 attendees each time. After receiving positive feedback and requests for the 2017 year, we ended up booking 5 more workshops. For 2017, we want to spend more time on anecdotal evidence from the clinic/patients as well as evidence from the literature to support the how and why of breaking down the assessment/screen as well as various forms of cueing for proper movement. The 5 workshops booked for 2017 will be in an 8-hour full day format with CEU’s through NSCA. We want to teach people how to properly hip hinge and deadlift for long term resilience and training. Our goal is to make it open, educational, and easily applicable – all the while having fun.
JC: You’ve also been active on social media promoting education on low back and hip health.
MI: Yes, I have started the “30 Days of Low Back & Hip Health” series. I have had Dr. Zak Gabor as a guest on 3 of the days to lecture his thoughts on low back and pain science. I’ve created 30 one-minute exercise tutorial videos to explain the how and why behind the proper execution of certain exercises related to the low back and hips. I’ve also covered safe and effective ways to train hard and recovery intelligently. Since it’s hard to put it all together when the videos are all separate, there will be an article coming out on http://www.STACK.com at the end of the month that will summarize the whole 30 days in one spot!
JC: What are some tips/pieces of advice you’d give to someone looking to get into the rehab/fitness field?
MI: There are a few tips I’d give. We’re here to help people – people miss that point. We are here to change how they move within their bodies. We have the power to help make their movement efficient and get to a healthier place for long-term resilience.
- While it is important to do well in school and crush your academics, I think a lot can be learned at seminars and networking with those in the field, shadowing/visiting, and reading up on topics in the field. Have an entrepreneurial spirit. Form your own opinion. Keep your mind open and blend all of these aspects together. Above all, never stop learning. Apply what is useful and help your clients get stronger and healthier.
- Work on improving your interpersonal, intrapersonal, and social skills to enhance your level of communication with others – meet patients and clients half way, and help them get to where they want to be. Listen, understand and simplify the approach. At the end of the day, I always check in with myself to ensure that what I’m doing is simple, digestible, and easily applicable for the people I am working with.