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.

 

References:

Nguyen, A et al Relationship between lower extremity aligment and quadriceps angle. Clin J Sport Med. Author manuscript; available in PMC 2010 Jun 7.

http://www.physio-pedia.com/’Q’_Angle#Normative_Values.C2.A0

http://www.humankinetics.com/acucustom/sitename/Documents/DocumentItem/7088.pdf

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.

 

Not your average physio

Welcome! This blog is meant to provide literature review and clinical insight into treatment of athletic injuries. The format of the blog will include topic series determined by population and diagnosis and organized into introduction/basic anatomy and always ending with treatment interventions for the athlete. Between these topic series there will be literature reviews as well as stand alone posts. Topic series will be posted once a week. The intended audience of this blog is aimed at practicing therapists and students who are in DPT school and want to learn more about treating the athletic population. If you have an suggestions for topics to cover, please leave a comment, otherwise stay tuned to the first topic series… Breaking Down the Initial Evaluation – This is meant to serve as a foundation for everything else that is posted in the future. Hope you all enjoy! #firstpost #notyouraveragephysio #DPT #movementtherapy #athletes #sportsphysio #injuryprevention