Lateral Ankle Sprain series, Part 2: No Such Thing As A Minor Ankle Sprain

With all of the hype surrounding the upcoming Olympics, I felt like this was a great time to bring in some real life examples. This past week wrapped up the US Gymnastics and Track & Field trials – and what an exciting week it’s been. So far between Gymnastics, Track & Field, and Swimming it seems like in order to make the US Olympic team you have to start breaking some records.

Given that we are on the ankle sprain series, I wanted to draw everyone’s attention to the 200m Finals of the Track and Field Trials on July 10. Below is a video of the finals heat, many top contenders in the field vying for 1 of 3 spots on the Olympic roster. In lane 5, is Allyson Felix, the reining 200m Olympic champion from 2012. Prior to the 200m qualifiers, Felix had already qualified for Rio in the 400m, winning the 2016 trials a few days ago. Coming into the trials this year, Felix has been dealing with an ankle injury to her R leg after a misstep in a training session back in late April – forcing her to pull out of a couple meets in May and June. In an interview with her coach following the injury, he said “(The injury) is 80 percent better in less than a week”. I’m not sure that a grade 2 ankle sprain is 80% better in less than 7 days (some public education may be needed for this coach). Felix, herself, said “The speed wasn’t there” for her in the 200m trials.

If you’ve been keeping up with the news, you’ll know that Felix missed making the Olympic team for the 200m by .01s (what a photo finish), still running a blistering 22.50s. Take a look at the video below (excuse the woman yelling in the background):

The slow-motion play back begins at about 4:35. If you pay attention to Felix (in all blue, lane 5) as she’s pushing towards the finish line, you’ll notice that she does not get the same push with her R leg as she does with her L leg, she has asymmetrical strides bilaterally, and her hamstring prematurely contracts on her R side reducing her quad contraction that she needs for her push (leading to less hip extension as well).

Following an ankle injury, there is a change in neuromuscular activation and firing due to the body’s mechanism of protection. Peroneal activation is delayed, glute med activation is impaired, increased MTrPs develop in the  lateral gastrocs, increased activation of hamstrings. I’m assuming that with Felix being a high profile athlete, she’s getting/gotten some of the best rehab since her injury, but this just goes to show that even 2 months out, she is STILL dealing with the residual effects of an ankle sprain – grade 2.

Friel et al. found that not only is ipsilateral hip abductor weakness noted following an inversion ankle sprain, but that plantarflexion ROM is also limited on the involved side. This also means that the force that can be generated from the involved side is significantly less. As you can tell from the above video, that is exactly what happened to Allyson Felix in the 200m finals.

How many of you are reading this thinking: “She missed it because the other girls were faster” or “it was just bad luck”? Just a week ago, she blew away the competition in the 400m with a time of 49.68s. She had the speed for the 400m, however after 3 rounds in the 400m and 2 rounds in the 200m trials, by the time the 200m finals came around, she could no longer compensate and hide her ankle injury and it’s residual impairments.

On the flip side, she has been dealing with injuries (like most athletes) for a good part of her career, may also have chronic ankle instability. In 2010 she had to pull out of a meet due an ankle injury. She tore her hamstring in 2013 during the 200m event. Who’s to say that these past injuries did not contribute to her “misstep” 2 months ago?

Felix missed Rio in the 200m by .01s not simply because she didn’t have the speed. She didn’t have the most efficient movement pattern down the stretch. From the start, she was placing a lot of pressure on her R ankle – it’s her first “pull” step out of the blocks (she pushes off with her L). Down the stretch, she was not able to make the final push with her glutes and quads/gastroc-soleus, and the asymmetry of her stride decreased the amount of force she could generate.

For those who think ankle sprains don’t affect your performance, even months/years down the line: Allyson Felix missed the Olympic roster by .01s …. all because of an ankle sprain.


Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle sprains. Journal of Athletic training. 2002;37(4):364–375

Friel, K et al. Ipsilateral hip abductor weakness after inversion ankle sprain. J Athl Train. 2006; 41(1): 74–78.





Lateral Ankle Sprain series, Part 1: An Introduction to Anatomy of the Ankle

It might seem odd to jump from the shoulder/overhead athlete in one topic series to lateral ankle sprains at the other end of the body in the very next, but I promise there is a connection – there always is. Many overhead athletes rely on the hip opposite their dominant side for power generation and stability – L hip (stance hip) for R handed pitchers, L hip adduction in R handed javelin throwers etc… Therefore, if the opposite hip is important, then so too is the opposite ankle. After all, the contralateral hip relies on the ankle to remain upright. 

Lateral ankle sprains are among the most common in sports injury. The ankle joint is comprised of three separate articular surfaces: the talocrural, subtalar, and distal tibiofibular joints. The talocrural joint is the articulation between the dome of the talus and the distal ends of the tibia and fibula, while the subtalar joint comprises of the anterior and posterior articulations of the talus and calcaneus, and distal ends of the tibia and fibula join together to form the final piece of the ankle in a syndesmotic joint.

The talocrural joint sits on an oblique axis and is the hinge joint that is responsible for dorsiflexion. This joint is crucial during weight bearing, as it allows any torque in the lower leg (internal/external rotation) to be transmitted to the foot (supination/pronation). The subtalar joint, an articulation between the calcaneus and talus is responsible for rear foot eversion/inversion and also participates in this force transfer. The subtalar joint is made up of two separate joint cavities and therefore, 2 separate joints, the anterior subtalar joint (talocalaneonavicular) and the posterior subtalar joint. The sinus tarsi and canalis tarsi separate the anterior and posterior components. Due to the location of the sinus tarsi, it is vulnerable to overuse injuries and ankle sprains, resulting in sinus tarsi syndrome – impingement of fatty tissue.

The distal tibiofibular joint makes up the last piece of the ankle joint. The tibia and fibula have two articulations, one distally and one proximally, and are connected along their shafts by a syndesmosis. Due to two points of contact between the tibia and fibula, as therapists, we need to address both in an ankle sprain. In normal dorsiflexion ROM, the fibula should glide superiorly and a little posteriorly. Most commonly, the distal tibiofibular joint can be anterolaterally shifted in chronic ankle injuries, reducing overall ROM in dorsiflexion – this is also due to reduced ligamentous stability from the anterior talofibular ligament (ATFL). Therefore, assessment of symmetry bilaterally of the fibula position following a lateral ankle sprain is paramount.

The main ligaments involved in stabilizing the ankle include the ATFL, posterior talofibular ligament (PTFL), calcaneofibular ligament (CFL) – all responsible for lateral stability – and the deltoid ligament – for medial stabilbity. The former three are more commonly injured due to their role in lateral stability and the prevalence of lateral ankle sprains, however the deltoid ligament can be pinched during grade 3 lateral ankle sprains.

Aside from rehabilitating the site of pain and addressing joint mobility/strength/proprioception deficits locally, it is vital to search up the chain for impairments – namely, the glutes/hip (including adductors) and anywhere along the lateral – including the peroneals and TFL – and functional lines. We are all familiar with the functional relationship between the glutes-lumbosacral fascia-lats (aka. Hip to contralateral shoulder relationship), however that is only on the posterior side, but there exists a similar relationship anteriorly. This relationship links the adductors and the contralateral lateral sheath of the rectus abdominis and pectoralis major.

When treating an athlete with an ankle sprain it is important to note not only the site of pain but to also address the core and hips higher up in the chain. This is due to the alterations in motor recruitment during gait following an ankle injury – antalgic gait often leads to mild Trendelenburg gait pattern and reduced activation of hip stabilizers in single limb stance secondary to pain. In the previous topic series, I’ve discussed how important it is for overhead athletes, and the demands of their sport, to have functional glute and core strength – it generally is a good idea to assess in any athlete. In one study it was also shown that any individual with a history of ankle sprains have reduced glute function. In the following segments I will address some manual interventions including taping and neuromuscular interventions, and return to sport testing.


Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle sprains. Journal of Athletic training. 2002;37(4):364–375

Kobayashi, T. Fibular Malalignment in individuals with Chronic Ankle Instability. JOSPT. 2014; 44(11): 872-878


Featured Professional: Nicole Canning, PT, DPT

Dr. Nicole Canning, PT, DPT is our first featured professional on #NotYourAveragePhysio. She was a classmate of mine while at Emory University and is also the author of the blog: Check it out! Dr. Canning is also a former NCAA D1 soccer player at St. Johns University in Queens, NY, and is also a soccer coach with experience in strength and conditioning as well. Recently I’ve had the opportunity to catch up with her and pick her brain a little:
JC: Where do you currently work and what population do you treat?
NC: I currently work at Competitive Athlete Training Zone (CATZ) Physical Therapy Institute in Pasadena. Since we are also attached to a Sports Performance Center, I see mostly youth, high school, and collegiate athletes, as well as active adults. I also see a small mix of general orthopedic cases.
JC:What are your top treatment philosophies when treating athletes?
NC: My main priority is getting the athletes I treat back onto their respective field/court as safely and quickly as possible, making them a better athlete in the process, and preventing future injury. My two biggest philosophies are promoting efficient movement, and education.
At CATZ, we draw primarily from the Gray Institute and the philosophy of Applied Functional Science. Essentially in this philosophy, movement in all three planes (sagittal, frontal, and transverse) is addressed, with respect to ground reaction forces, center of mass, gravity, momentum, reaction, and relevance, in order to enhance functional movement. For example, when I am working with an athlete, I need to know what movements are specific to his/her sport, what internal and external drivers of movement are utilized, what types of movement do they need to be able to react to, etc. I then look at how they are currently moving and performing these tasks, figure out where the dysfunction is occurring, and then address those impairments in a sport-specific, movement-based, and meaningful way for each individual.
I also like to draw from the Strength and Conditioning world when prescribing exercises for my athletes. Since many of these athletes are currently working, have worked, or will eventually work with a Strength and Conditioning Coach, I believe it is helpful to incorporate those principles as well, and tie it in with whatever pathology or impairments a given individual presents with. I also think it’s important to understand periodization when working with athletes, especially with college athletes. It’s imperative to understand how you need to challenge them differently based on what point of their season (or off-season) they’re in. The Strength and Conditioning world has also helped me in my prescription of exercise dosage. There are different rep and set variables to work with based on what you are trying to achieve. I don’t think I can truly do my job to the best of my ability unless I incorporate essential Strength and Conditioning principles.
Another philosophy I tend to get on my soap box about is the mental/emotional aspect of treating athletes. Competitive athletes possess a very different mentality than the general population. They will over train, play through pain, and do whatever they feel they need to do in order to stay at the top of their game. It’s crucial to understand that in order to help it work for the patient and their rehabilitation rather than working against them.
Finally, the most important thing I do for my patients is education! My goal is to never see my patients again (as a patient) once they have returned to their sport. I educate them on how to maintain ideal movement, how to prevent future injuries, and how to listen to and respect their bodies when they need rest.
JC: What are your clinical interests?
NC: Although I love treating any and all athletes, my main clinical interest is in treating conditions of the lower extremity. I particularly enjoy treating patients with ACL injury because I can take the athlete and basically build them back up from scratch. Aside from gaining range of motion and improving strength and neuromuscular control, I can also take a look at what impairments may have put them at risk of that ACL tear in the first place, and then address those risk factors to decrease the risk of re-injury, or injury to the contralateral side. With patients with ACL injury, you get to literally teach them how to walk, climb stairs, squat, run, jump again. What better way to address dysfunctional movement and inefficient movement patterns and teach the athlete ideal movement instead?
JC: How has your background as an NCAA D1 soccer player helped you in treating athletes?
NC: The ways in which my background as an NCAA D1 soccer player helps me treat athletes are countless! Probably the biggest aspect it helps me with is the mental/emotional facet of treating athletes. Not only do I have insight into the mental and emotional roller coaster that goes along with being a competitive athlete (especially one sidelined with an injury), but I feel that it also helps my patients to connect with me and feel more comfortable when they learn that I was once in their shoes and, to some extent, can understand what they’re going through. This helps me understand when I can push them a little harder, and when I need to back off a bit and allow them to experience success. I think generally, there’s a high level of mutual respect and understanding between my patients and me, and when a patient truly believes that you’re the Physical Therapist who’s going to get them better, and help them become a better athlete, then you’ve already won half the battle.
JC: I know you conducted research, and presented a platform talk at CSM 2015, on implementation of ACL injury prevention programs, can you tell me a little more about that project?
NC: Yes, as a female soccer player, I have always been interested in ACL Injuries. Also, aside from being a Physical Therapist, I have been coaching youth soccer for nearly 10 years now. While I was in PT school, I noticed that many of the research articles I read had great ways of helping to identify and reduce risk factors for ACL tears. Actually, considering how common ACL tears are among female soccer players, I was surprised at how much research I was finding on the topic, especially in the past 5-10 years. This made me wonder how there could be so much research on preventing ACL injuries, and yet the number of ACL injuries per year kept increasing. I realized that there is a huge gap between clinical research and its actual implementation into the population it addresses. I also realized that Physical Therapists, Orthopedic Surgeons, Professional and Collegiate Strength and Conditioning Coaches and ATC’s all have access to this information, but by the time an athlete gets to any of these people, it is often too late. This information is staying at the collegiate and professional levels and has no way of being accessed by youth athletes. I find this to be extremely surprising and important because nearly every researcher, MD, PT, ATC, Coach, S&C Coach will tell you that this stuff needs to be introduced and implemented while the athlete is still developing and growing. I decided to delve a little more deeply into where this breakdown of information was occurring, why it wasn’t being implemented, and how to bridge that gap between clinician/researcher and youth soccer player so that the research can be utilized in a meaningful way.
Thank you to Dr. Nicole Canning PT, DPT for taking the time to chat. Hope you all enjoyed this new segment!

Overhead Athlete series, Part 3: Biomechanics and Movement Patterns of the Overhead Athlete

Understanding anatomy is very useful when treating any client population, however, when treating an athletic population, it is imperative to understand the sport in question, as well as the associated movement patterns. As mentioned previously, most studies are conducted on baseball athletes, but an overhead athlete can play a number of sports, and the mechanics of a baseball pitch/throw can be extrapolated to each of these sports with minor changes. To start, we will outline the mechanics of a baseball player’s pitch.

There are 5 distinct phases of a baseball pitch – wind-up, cocking/stride, acceleration, deceleration, and follow-through. The wind-up phase sets up the pitcher to transfer his weight from their hind leg to their front leg, and is essentially a single leg stance, with opposite knee march. In this phase the hands are together; when the hands break, we enter the cocking/stride phase. In the early cocking phase, the scapula is retracted, the humerus is abducted/externally rotated/horizontally extended – placing maximal stress on the anterior joint capsule. At the same time, the stride leg (contralateral to the throwing arm) begins to extend at the knee/hip and internally rotate. The body’s center of gravity also begins to lower due to the support knee and hip flexing and anteriorly rotating – this is accompanied by extension of the lumbar spine to assist in the shoulder’s external rotation. During this phase, the deltoid and RTC sequentially become active. Internal rotators activate during late cocking to decreased external rotation. Tensile forces are increased in the abdominals and spine to stabilize the trunk. This puts the body in the best position to transfer weight from the support leg to the stride leg as well as energy from the hips and core to the ball.

Acceleration takes place from maximal humeral external rotation/abduction/extension and scapular retraction to when the ball leaves the hand, at which point the scapular has protracted and the humeral position is in internal rotation/flexion along with elbow extension. This is also the point at which the energy stored from the cocking phase is transferred to the ball – therefore successful weight shift from support to stride leg as well as trunk rotation (i.e. thoracic rotation) are necessary for a successful pitch. The Lats and subscapularis muscles are highly active during this short period of time to allow for full internal rotation of the humerus. This ties into the final 2 phases of the pitch – deceleration and follow-through. During these phases, all muscles are active to either slow down the arm or bring it into increased internal rotation. The infraspinatus, teres minor, and posterior deltoid are all active eccentrically to slow down the humerus, while the lats and subscapularis continue to bring the humerus into internal rotation. Elbow flexors including the biceps brachii are active to prevent excessive extension of the ulnohumeral joint. To complete the motion, the trunk continues to rotate contralateral to the throwing arm and flexes. By now, the pitcher should have already transferred all of his weight from his support leg to his stride leg, ending in, again, single leg stance.

baseball pitching phases

Given the above phases of a pitch, the same can be applied to other sports. In volleyball the arm swing phase – when the hitter is in the air – is almost identical to a pitcher’s throw. However it is not as extreme in ROM and the weight shift occurs without rotation in preparation for jumping and can be combined with the hitter’s wind-up phase, while the trunk rotation occurs in the same phase as a pitch, acceleration-deceleration. The other distinction between a pitcher’s arm and an outside hitter’s arm is that the volleyball hitter will swing with decreased abduction and increased flexion through the acceleration phase – their hitting arm will attempt to pass over their head rather than to the side and contact the ball (equivalent to ball release in baseball) with full elbow extension.

In track and field, a javelin thrower’s arm goes through very similar motions as a volleyball hitter. There isn’t much of a wind-up, rather, when the thrower pulls the javelin back, they are already in their cocking phase. Due to the demands of the sport, these throwers also have their arm pass through an arc that is less abducted than a baseball pitcher – they need to achieve height on their throw. The key in this sport, however, is in their legs. The javelin thrower begins with the arm at 90-90, holding the javelin, and starts with a straightforward sprint. During the final steps (when the thrower enters the cocking phase), the thrower moves forward with cross over steps, requiring increased activation of the contralateral adductors followed by contralateral trunk rotation and flexion.

javelin throwing phases

During a tennis serve, again, there is a very similar sequence of movements. There is a windup phase that consists of knee flexion and the toss with scapular retraction of the racquet arm (cocking phase). In order to contact the ball, the athlete must generate power through their lower extremities and core and accompany it with trunk rotation. From here, the movement sequence is similar to the above sequences of acceleration, deceleration, and follow-through.

While a softball pitch presents with different mechanics, the throwing of a softball for positional players is the same. A more thorough breakdown of softball pitching mechanics will be addressed in the future.

By now, hopefully I’ve convinced you how important hip and core stability are in an overhead athlete – it is not enough to only address the shoulder, many times if you solve the deficits in the hips and core, their shoulder impairments will also resolve or reduce in severity. If you don’t believe me, here’s a good article that also discusses hip stability and it’s role in the pitching motion: Understanding movement patterns inherent to the athlete’s sport can help direct your manual therapy and neuromuscular re-education, addressed in Part 4: Treatment interventions.

Overhead Athlete series, Part 2: Physical Characteristics of the Overhead Athlete

All athletes will develop special physical characteristics that are specific to their sport due to repetitive use of certain muscle groups as well as movement patterns required of that sport. Overhead athletes are no exception to this observation. Here are some of the physical characteristics to keep in mind of an overhead athlete upon initial evaluation – summarized from Wilk et al’s clinical commentary on shoulder injuries

Range of motion

In PT school, we’re all taught that normative values for external rotation and internal rotation (when measured in supine at 90° abduction) are 90° and 70°-90° respectively. That gives us a 160°-180° of TOTAL motion. It is important to keep the concept of total motion in mind, especially when dealing with overhead athletes. In baseball pitchers, there tends to be increased external rotation and decreased internal rotation. In a Wilk et al (2009) clinical commentary piece, Bigliani et al found that on average pitchers exhibited 118° of external rotation. Similarly, Reinold et al state that baseball pitchers ranged from 129°-137° of ER and 54°-61° of IR for a combined arc of 183°-198° of total motion. When looking at range of motion, I tend to stress the TOTAL arc of motion because the dominant/throwing arm will tend to have increased ER and decreased IR, but if the total arc of motion remains the same bilaterally then there isn’t a deficit; throwing tends to reduce IR. However in a baseball pitcher, if the total arc of motion is decreased when compared side to side, usually it will be due to a pathological loss of IR.


Laxity and Osseous Adaptations

Most throwers will have some form of acquired laxity that can be noted through a physical assessment. Most of it is due to repetitive stress on the capsule – increased posterior capsular laxity when compared to anterior capsule.

In Wilk et al’s clinical commentary on shoulder injuries they bring up osseous changes in the humeral head that I found interesting. They stated that in most studies, there was on average a 17° of humeral retroversion in the throwing arm. This can have impacts on posture as well as the relationship between the humerus and scapula. This can also explain the differences in ER/IR ROM when measured R vs. L, though the total arc of motion may remain the same.

Muscular Imbalances

Due to repetitive motions, every athlete has muscle imbalances somewhere along the kinetic chain. With baseball pitchers, often times their internal rotators on their throwing side are stronger than their external rotators and tend to have strong adductors as well. Proper balance between antagonist and agonist is crucial to providing dynamic stability around any joint. There is a theory that proposes the external rotators should be at 65% of the internal rotators strength for optimal stabilization around the glenohumeral joint.


Due to the aforementioned muscular imbalances, overhead athletes often will have changes to the resting position of their scapula and thoracic spine. The two more common postural changes include an anteriorly tipped scapula when the shoulder is at rest and an upwardly rotated shoulder when the shoulder was abducted to 90° due to increased activity of the adductors (pec minor) and protractors/internal rotators (subscapularis, serratus anterior, latissimus dorsi).

 It is great to be able to identify these impairments and deficits, but if you are unable to treat them, then what’s the point? Treatment, including neuromuscular re-education and manual therapy tips, to follow in part 4. But first, we need to understand the biomechanics of an overhead athlete before we can treat. Continuing our assessment is Part 3: Biomechanics and Movement Patterns of the Overhead Athlete.


Reinold et al 2014 Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 2

Wilk et al 2009 Shoulder Injuries in the Overhead Athlete

Overhead Athlete series, Part 1: An Introduction to the Overhead Athlete

“Overhead athlete” is a broad term that encompasses many different sports including baseball, volleyball, tennis, javelin throwers, softball and more. While swimming could be grouped in this series because it is an overhead sport, it will have it’s own topic series in the future. Most research studies have been performed on baseball players, however, the mechanics of throwing, as well as the findings in the literature, can be extrapolated to the other aforementioned sports.

In order to effectively treat an overhead athlete, the therapist will need to understand the neural/mechanical relationships that exist in the shoulder joint and assess movement quality during an overhead throwing/hitting motion. I will not be listing treatments for specific diagnoses in this topic series – they will be addressed as separate topics in the future. Here I will outline the basics of the overhead athlete through anatomy and include clinical considerations that will be followed up with subsequent posts in much more detail.

The shoulder is a complicated joint due to its 3 degrees of freedom in ROM as well as its connections to the thorax and upper extremity. It is also the third most commonly injured joint. It plays an important role in stability and mobility. The glenohumeral joint is a ball and socket joint, a direct connection between the humerus and glenoid of the scapula. The scapula sits on the posterior aspect of the rib cage, and therefore is an indirect connection to the thoracic spine – indirect due to no true joint surface between the scapula and ribs/T-spine. The scapula is also connected to the clavicle, through the acromioclavicular joint. This connection as well as the thoracic spine’s relationship to the cervical spine warrants a deeper look into the shoulder’s mechanical relationship to the cervical spine – as well as its neurological relationship through the brachial plexus.

The above only lists the direct, bone-to-bone, articular connections. However, in order to produce movement, there are many, many muscular and ligamentous connections. The superficial back muscles including, but not limited to, the latissimius dorsi, all 3 aspects of the trapezius muscles, the rotator cuff muscle group and many more all control motion of the scapula and have a role in overhead movement.

Not only should the overhead athlete’s shoulder be considered during treatment, we should also be looking at the client’s core and lower extremity strength as well. Through many sources including Tom Meyer’s “Anatomy Trains” book, we know that there is a connection between the shoulder and the opposite hip through fascial lines, both anterior and posterior. We also know, through video analysis and understanding of each of the above sports, that power and speed are generated through the hips and core. Therefore the core and both lower extremities cannot be neglected when rehabbing an overhead athlete back to their sport.

This is basic anatomy, however, the application of this basic information and formulating treatment can be tricky because there are many things to consider. When treating an overhead athlete, there are a few physical characteristics to consider; TOTAL arc of motion between external and internal rotation and comparing them Right to Left, quality of scapular motion, visual positioning of scapula, visual spinal postural assessment, and overall strength including hips, RTC, lower traps, and core muscles. Stay tuned for Part 2 in the Overhead Athlete series: Physical Characteristics of the Overhead Athlete.

Reinold et al 2014 Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 1

Breaking Down the Initial Evaluation, Part 4: Movement Assessment


The previous posts discussed static postural assessment. I never solely conduct a static postural assessment and establish my diagnosis. We, as physical therapists, are movement experts and therefore, while I can utilize a static postural assessment to guide my clinical evaluation, I am more interested in seeing how my client moves. More importantly, I am interested in how they move in weight bearing positions because we often are required to do so in our daily lives. I utilize the SFMA primarily and add in other movement patterns depending on the client’s sport (running assessment if there is a running component to their sport/activity, for example). A basic run-down of the SFMA is that it uses 7 top-tier movement patterns starting with the cervical spine to the overhead deep squat and single leg balance. Each top-tier pattern can be broken down into its component tests to determine whether the dysfunction is soft tissue, joint, or stability/motor control related.

I won’t be going over the entire SFMA top-tier screen in detail– if you want to know more, please attend a live SFMA weekend course – but I will be picking some of the clinical highlights from select movement patterns to help guide your clinical decision making and localizing the source of the pain more efficiently in an evaluation.

A big “principle” in the SFMA is if the client can’t perform the movement in standing, change the stability requirements and re-assess. If reducing the stability requirements for that particular movement increases ROM, then the primary deficit is in motor control/motor recruitment. For example, for cervical flexion, if the client is unable to touch their chin to their chest in standing, but is able to in supine, there can’t be a joint mobility problem because they can perform the movement when their cervical musculature is on slack – therefore, it must be over recruitment of cervical musculature when in weight bearing. Since utilizing the SFMA, I’ve begun to realize that I need to further test to distinguish what is causing a ROM deficit – is it a true joint hypomobility or is it more of a stability motor control deficit. Many patients may appear to have a lack of ROM, but if tested further, you may find that they just don’t know how to control their range. If you’ve further tested by eliminating body parts or reducing stability requirements and the client still has decreased range, then biomechanical assessment is warranted to determine the cause of joint hypomobility.

The first movement I’d like to review is the multi-segmental flexion. The client essentially locks out their knees (feet together, for consistency in every position besides single leg balance and overhead squat) and bends forward and tries to touch their toes. Most people who can’t reach their toes automatically assume they have tight hamstrings. However, this may not be the case. When I see someone perform this movement and they can’t touch their toes, I re-assess them after they have activated their core – I place a foam roller in between their legs and ask them to squeeze it hard and repeat the motion. If they gain more range with this modification, it tells me they have a weak core and their hamstrings are, more or less, “holding on for dear life” for stability. If they don’t gain more range, then it’s a possibility that they have tight hamstrings. **A neat trick in the clinic is you can differentiate which side is tight by unweighting each side and repeating the motion – unweight by flexing the knee on the side you are trying to put on slack.

The second movement pattern is multi-segmental extension. One of the criteria for this movement to be scored “functional” is that the ASIS have to translate anteriorly and clear the toes. I’ve found that when it doesn’t, there is an extension deficit at the hip. I further assess this with a “step up with opposite knee march to 90°”. With this follow-up test, I can determine if the client achieves hip extension through lumbar compensation. Either way, I would assess joint mobility of the hip in prone and sitting to conclude if it is a joint/soft tissue dysfunction or stability/motor control dysfunction.

Single leg balance is something I work on with a majority of my clients with low back and lower extremity diagnoses. One point that the SFMA makes about this pattern is that difficulty with single leg balance is not always a proprioception deficit – in fact they make a point to say that until you have ruled out all other possibilities (ankle ROM, vestibular, visual, core, hip stability etc…) you can’t be certain it’s a proprioception deficit. I tend to agree, as I have found that hip and core weakness are more common culprits (again, hips and core….). In the breakouts, one that I have tended to gravitate towards automatically is differentiating hip weakness and core weakness. Half kneeling on an airex pad loads both the hips and the spine while quadruped “bird dog” loads only the hips. By performing these two quick assessments, you will be able to tease out if the hips or the core require more neuromuscular re-education. **Side bar – I know that the core is still required to activate in quadruped, however the differentiation is that the spine is not loaded in this position, and therefore the stability requirements are different. Half kneeling is more demanding and loads the spine more than quadruped.**

With athletes, in addition to the SFMA top tier tests and their breakout components, I always like to add a jumping and/or running component to the evaluation. Most sports will have a jumping or running aspect and watching a client jump on and off a box to see how they land as well as how they run and how their body is moving during dynamic movements is vital. Golf will be a special topic discussed later in the future because it does not fit this rule, it is rather an exception, of having a jump or run aspect – it is mostly rotation and there are separate tests you can do for golfers.

This concludes the first topic series on the initial evaluation. Everything from here on out will build off of the information presented in these previous 4 posts as well as provide new, additional insight. The next planned topic series will discuss the Overhead Athlete. I hope you guys enjoyed this first topic series. Please comment below if you have any suggestions of topics to cover. Thanks, again.

Breaking Down the Initial Evaluation, Part 3: Static Postural Assessment – LE

The previous post dissected the process of examining the upper extremity, particularly the relationship between the thoracic/cervical spine with the glenohumeral joint and scapula positioning. In today’s post, we will be continuing the discussion of static postural assessment with the lower extremity.

I believe that everything is connected to everything, and therefore neither of these examinations should be performed in isolation. It also means, that for me, everything comes back to the trunk, somehow. Just like how the shoulder was made to serve our hands and provide distal mobility, so were our hips made to serve our feet.

While I normally start with the spine and trunk when looking at the upper quarter, for the lower extremity, I tend to start with the feet, mostly out of habit. When I look at the athlete’s feet, I look to see what their resting position is – is it over pronated, is it over supinated (essentially what are their arches like in weight bearing). It’ll also help give me a sense of, are they weight bearing equally through both feet. With over pronation, it’ll be helpful to assess the peroneals for trigger points/myofascial restrictions or weakness of the posterior tibialis muscle – look for the opposite (posterior tibilais) in over supination. In either case, it’ll affect the subtalar joint and calcaneal mobility – so manual joint assessment of rear foot eversion/inversion will be on my list of items to check manually following a postural assessment. Over pronation and supination can affect the first metatarsal’s ability to participate in the windlass mechanism/push off phase of gait due to reduced ability to extend, therefore, first metatarsal extension mobilizations may need to be addressed. This last point will be important for any athlete due to the role of first ray extension in jumping and running – most sports have an element of at least one of the two. It can affect stability in single leg stance as well, further impacting hip activation.

Then I move up to the tibia to see where the tibial tuberosity – is it externally or internally rotated? At the knee, I also take a mental note of their Q ankle in weight bearing – this is the angle formed by the ASIS-mid patellar point-tibial tuberosity. Eighteen degrees is usually a cutoff for Q angle norms – that is anything higher than 18° can indicate poor patellar tracking and increased valgus at the tibiofemoral joint. Females, due to wider hips and increased laxity in their ligaments, will have a higher Q angle by about 4-5°. Increased Q angles (outside of the normative values) also increase an athlete’s risk in knee injuries including ACL tears due to knee injuries being caused in mostly the frontal and transverse planes. I will assess posture from all sides of the athlete – in the sagittal plane, it’ll be important to note if there is any hyperextension at the knees.

At the hips it’ll be important to note whether the femoral heads are in proper alignment inside the acetabulum or if they are retro/ante-verted. The femoral head normally sits in the acetabulum with about 12-15° from the frontal plane; and increase in this angle is termed anteversion and a decrease of this angle is termed retroversion. The positioning of the femur can influence positioning of the tibiofemoral joint at the knees, resulting in either genu valgum or varum (can also be influenced bottom up from the feet). Based on the information found at the tibia and foot/ankle complex, it’ll clue me in what I might find on a biomechanical assessment of the hip joint.

If an athlete does not weight bear equally through both lower extremities, I will note their hip positioning as well as lumbar spinal curvature. If there is an increase in lumbar lordosis, it can anteriorly tilt the pelvis, either unilaterally or bilaterally, affecting leg length in a resting weight bearing position. It can also indicate that the athlete’s core is under active (TrA and multifidi, though if these are under active, the rest of the core including pelvic floor and diaphragm will also be affected) and that the athlete is relying primarily on the erector spinae to support the spine.

While this is a truncated version of my postural assessment for athletes, by this point in the evaluation, I will have made a mental note of all of the items that require further dynamic movement and biomechanical testing to properly determine the source of the dysfunction. In some cases, the deficit identified could be anatomical and would require preservation of their current range/mobility and proper strengthening and neuromuscular control around the joint. In others, it may be hypomobility and poor motor control that is limiting them and causing a poor resting posture. In either case, I always want to see the athlete move, and I utilize the SFMA for that component. The above is only a mental check list that I use – I always verify with the SFMA because I want to see how the client moves within their own anatomical means. I am by no means diagnosing them based solely on static posture. Stay tuned for some highlights in Part 4: Movement Assessment, based on the SFMA.



Nguyen, A et al Relationship between lower extremity aligment and quadriceps angle. Clin J Sport Med. Author manuscript; available in PMC 2010 Jun 7.’Q’_Angle#Normative_Values.C2.A0

Breaking Down the Initial Evaluation, Part 2: Static Postural Assessment – UE

Postural assessment should be a staple in every therapist’s initial evaluation, no matter the diagnosis. How else are you supposed to know the relationship between the spine and the rest of the body? And yes, this means for guys, asking them to take their shirts off, and for females too (as long as they have a tank top or sports bra underneath). A lot times the client does not wear the proper clothing to their first visit, and you may have to make do with what you have, but at some time during their POC, it is important to visually see their posture.

The scapula sits on the posterior aspect of the rib cage; therefore their relationship is vital in the assessment of an athlete’s shoulder. What should we look for when assessing posture? First, I look at the spinal curvature, or lack thereof. I want to make sure that there is a normal cervical and lumbar lordosis and thoracic kyphosis. A lot of times, the overhead athlete will have a decreased thoracic kyphosis – a flattened T spine. This can cause a lot of problems because the athlete is now “stuck” in spinal extension; the first being that spinal extension is important to shoulder flexion, and the second being that this now puts the scapula in relative anterior tilt when compared to the rest of the thoracic spine and rib cage (with extension the rib cage will be posteriorly rotated). The second problem listed can also lead to RTC tendinitis and impingement, with the worst-case scenario being a tear later in the athlete’s career.

Once I’ve looked at the spinal curvature, I then look at scapular positioning on the rib cage. Normally, the medial border of the scapula should be about 2-3 inches away from the vertebral column (I tend to eyeball about 2-3 finger widths). Many times I will look to see if both of the scapula are positioned equidistant to the vertebral column instead, as well as if they are excessively abducted. Other dysfunctions that can be detected in scapular positioning include anterior tipping, upwardly or downwardly rotated, and winging. An abducted scapula could be due to lengthened (and weak) lower trapezius or rhomboids, both of which can be caused due to a shortened serratus anterior.

An anteriorly tipped scapula can be assessed best in supine; looking from the head down in the axial direction, assess if both shoulders rise off of the treatment table or if one is higher than the other. Due to the scapula being an attachment for multiple muscles, scapular dysfunction can lead to many shoulder problems. The pectoralis minor muscle attaches from the ribs (2-5) to the coracoid process off of the scapula, and when shortened, can lead to an anteriorly tipped scapula. In standing posture, this can also be seen as rounded shoulders. With rounded shoulders, the therapist will typically want to look at the cervical spine due to the risk of the client being in upper crossed syndrome – would be picked up on the spinal assessment. Subscapularis and serratus anterior can be the culprit to an upwardly rotated scapula (assessed by measuring the posture of the inferior angle) and a shortened levator scapulae or rhomboid major/minor can lead to a downwardly rotated scapula.

As you can see, a lot can happen with scapular dysfunction to lead to shoulder pain. Seventeen muscles insert or attach on the scapula, and if any of them are lengthened or shortened, the scapula will be positioned poorly. If you are overwhelmed with performing a thorough postural assessment, a good place to start treatment would be on the scapula.

Following a scapular assessment, I will look at cervical spine and humeral head position. Cervical spine is important because forward head posture plagues a majority of Americans and consists of hyperflexion of the lower cervical spine and hyperextension of the upper cervical spine and lead to upper crossed syndrome. Humeral head positioning can tell you if the clients humerus is internally rotated – in standing posture, the therapist should not be able to see the backs of the clients hands in the frontal plane, and the olecranon process should be pointed in the sagittal plane more than the frontal plane.

Now, what does this all mean for the athlete? There are huge implications on how posture will affect how the athlete throws or hits. If the athlete’s thoracic spine is “stuck” in extension and the athlete does not have full GH flexion, during their acceleration phase, the athlete may bring their arm into more horizontal abduction to complete the throwing or hitting motion due to inability to throw or hit form above their head, leading to increased stress on the ulnohumeral joint, increased activation of the pectoralis muscle group for stability, and probably a lengthened lower trapezius muscle (typically seen as unintentional “side arming” a pitch in baseball).

If the lower trapezius muscle fibers are weak due to an overactive serratus anterior or subscapularis, this will lead to scapular dyskinesia – where the athlete will be unable to control his or her shoulder mobility in the scapular plane. This can be seen with shaking during the lowering phase of “scaption”. Due to the complexity of the upper quarter, a thorough assessment is needed to find the source of the client’s pain/dysfunction. The lower extremity postural assessment is just as important due to it’s involvement in power generation and will be discussed in Part 3.

Breaking Down the Initial Evaluation, Part 1: The Subjective

I’ve decided to address the initial evaluation in my first topic series because I think it will serve as a good foundation for future posts to come. In this series, I will highlight how I perform an evaluation – I am not saying that everyone has to do it this way, nor am I saying this is a complete guide to an evaluation; it is simply parts of what I ask my athletes.

Much of what we do as therapists relies on what the client tells us. Many clients don’t know what is pertinent and don’t have the knowledge background to know what pieces of information are useful to us. In an effort to not be too long-winded and not too brief, many times, the client ends up leaving out pieces of information unintentionally. It’s our job as therapists to obtain the information we need through well-phrased questions. For a sports physical therapist, this means understanding each sport and the demands of the sport. I watch a lot of sports and was an athlete my entire life (I continue to coach volleyball following a collegiate career), and I tend to analyze every little movement made by the athletes. I also read articles on biomechanics of various sports. In this topic series, I won’t be breaking down the specifics of each sport – I will follow up with more specific questions to ask in those future upcoming topic series. For those who have a more limited knowledge base or are just unfamiliar with most sports (the list will be a select list of sports because this post would be very long if I tried to address all sports), I will touch on a few highlight questions that I will always ask in my evaluations.

For baseball players the first thing to ask is, are they a positional player or a pitcher or a catcher. For pitchers, it’s important to know their pitch count in practice and in games – this is extremely important for youth baseball pitchers, as they should not be exceeding a certain pitch count each day to prevent injury. Catchers, most commonly, present with knee pain, however it is important to know what their pitcher’s pitch count is as well because the catcher will be throwing a ball that many times in a game and practice as well – not at the same intensity, but it still stresses the shoulder/upper extremity. This goes for volleyball, tennis, and any other overhead athlete – how many repetitions are they performing in practice, in competition? While there isn’t a limit in these other overhead sports on repetitions like there is in baseball, high repetitions will continue to stress the glenohumeral joint and it is important to know how many swings/throws, ball park average, the athlete is undergoing – this is also important depending on the age of the athlete (i.e. pediatric athlete vs. collegiate vs. professional).

Track and field athletes commonly present with non-contact/traumatic injuries. Due to the variety of events, there are a variety of injuries that can surface. Therefore, the first question to ask is what event they participate in – most athletes will participate in up to 3 events in high school and 2-3 specialized events in college. Depending on state regulations at the high school level, the type of event is regulated – in Massachusetts an athlete can participate up to 3 events, but 1 has to be a field event, if only entering in 2 events they can both be track, both field events, or one of each.

For golfers, tennis players, and long distance (5K and higher) runners (should be asked for all athletes, actually), I tend to ask about nutrition and hydration prior to competition due to the duration of competition and being primarily outdoors. Nutrition a few days prior and the hours leading up to competition are important. In most competitive athletes, you want your last “meal” to be about 3-4 hours before competition. Right before and during competition, the athlete should be taking fast carbohydrates to provide energy throughout the duration of the match/game, nothing that will “sit in the gut” and make the athlete feel sluggish (the myth that eating a banana prior to competing has been debunked – it will only make you feel slow and behind).

For the initial evaluation, while it’s important to ask questions specific to their sport, you, as the therapist, may not be familiar with all sports, maybe only a select few. Therefore, it is paramount to do your homework and read-up and learn more about a specific sport that you may not be familiar with. In the meantime, it’ll be essential to understand the athlete’s training schedule/periodization of training. These are just some of the basic questions I would ask on an evaluation – I will get to more sport specific ones in future posts. In the mean time, stay tuned for Part 2: Static Postural Assessment – UE.