10 ‘Secrets’ In 10 Years

It’s been a little over 10 years since I finished PT school and I’ve learned a few things since then.
Hopefully more than just ten, but these were some of the best to come to mind. Most of what you will
read here has come from conversations and working with other therapists, athletic trainers, and
strength coaches who have been in the trenches working with athletes. Do I have loads of evidence-
based research to back up every claim I make? No, I do not. What I do have is clinical evidence from
years of working with athletes as a physical therapist and on the performance side as a strength coach.

So here we go. If you have objections, please let me know. If you agree, but have found a way
to tweak things and improve upon them, please let me know that as well. I am doing this to learn as
well. joe@sportsrehabexpert.com

1. You Need a System

In PT school you learn to test everything from posture to ROM to strength to sensation. Every
joint and every muscle was tested. But then what? I still didn’t have a good place to start. That’s were
a system like the Selective Functional Movement Assessment (SFMA) and Functional Movement Screen
(FMS) come into play. The SFMA tests movement patterns involving multiple joints and muscle groups
versus using a shotgun approach. Here is how the patterns are scored:

Functional, non-painful

Functional, painful

Dysfunctional, non-painful

Dysfunctional, painful

Addressing movements that are dysfunctional and non-painful are where you start. Now you
can move forward breaking down the pattern(s) in question, and narrow it down to individual muscles
and joints that are directly responsible for the problem. Once you have treated the problem in
isolation, you then work back into the pattern with corrective exercises (integration). One nice thing
about this system is the instant feedback. Once you correct something, then go back and test the
movement pattern again. It may not be perfect yet but should be improved. You know immediately if
you are on the right track.

Using the FMS, we are again looking at patterns but in an athlete without pain. Now we can
rate as follows:

Movement performed without compensation (3)

Movement is completed with compensation (2)

Based on this rating system, and/or the presence of any right to left asymmetries, you know which
patterns to attack first. Corrective exercises for the FMS strictly address the dysfunctional patterns,
never isolating specific muscles or joints. This system also allows you to go back and immediately re-test
the faulty pattern to see improvements.

These are very brief overviews of much more complex systems but I hope you get the idea. I
have become a much better clinician now that I have a system to guide me from evaluation through the
entire rehab process. ”Functional Movement Screen Introduction” can be found at in the ‘Sample
Articles’ section at http://www.sportsrehabexpert.com/members/106.cfm. Case studies using the
SFMA can be found in the ‘Members Only’ section.

2. A Lack of Ankle Dorsiflexion =Anterior Knee Pain

An ankle lacking dorsiflexion is going to place more stress on the anterior and medial structures
of the knee with every step, every time you stand up/sit down, go up or down stairs, etc, etc. Check
your athletes who have chronic knee issues, such as maltracking and patellar tendinitis. Very often they
are significantly limited. In the subjective portion of the exam I always ask them about previous ankle
injuries. We all know how easy it is to lose DF following a fracture or severe sprain.

I just got done telling you about my systematic approach in #1. An overhead squat test, which is
part of the SFMA, will lead me right to what I suspected all along. Often you will see the heel on the
affected side come off the ground resulting in the knee diving over the foot and going into valgus. With
the FMS you will catch it during the Overhead Deep Squat and In-line Lunge tests.

Mobilize the ankle to gain dorsiflexion. Personally I like Mulligan’s Mobilization With Movement
(WMW) technique. It’s quick and easy, and I see measureable results right away. The goniometer will
tell me DF is improved but now I want to see the athlete squat or lunge again. It may not be perfect yet
but they will get deeper with less knee pain.

Self mobilization into dorsiflexion – the stick is positioned against the fifth toe, the knee is guided
around the stick to maintain a supinated foot position.
3. Lower Crossed Syndrome and the Achilles

Read the Janda article in the ‘Featured Resources’ box to fully understand the lower crossed
syndrome. It basically goes like this: overactive and tight hip flexors and lumbar paraspinals will
inhibit/weaken the abdominals and glutes. We’ve all heard this in one form or another, the result being
an anteriorly tilted pelvis.

So what does increased anterior tilt have to do with the Achilles? Feel this for yourself. Stand
as you normally would. Where is the pressure through your feet? Is it more toward the balls of the feet
or more posterior? Now tilt your pelvis forward. Feel the weight shift with more pressure toward the
balls of the feet? Guess what muscles are working overtime in this position to keep you from falling
over? Gastroc, soleus, and plantaris, all of which insert into the Achilles. We’ve all seen people with
enormous calves. Hypertrophy as a result of chronic overuse. Imagine the load on that tendon in an
athlete who naturally assumes this position. Over time it can create a significant problem.

This is not normally addressed either in PT school or in the standard PT practice. I don’t want to
turn this into a tutorial on using the SFMA or FMS but they will lead you in the right direction on this one
as well. It’s a case of looking for the pain source versus treating just the site of the pain. The latter may
be relatively successful in the short term until previous activity levels are resumed. The former will be
the more successful approach long term.

4. Increasing Thoracic Spine Mobility Increases Shoulder ROM

This is another area I know we didn’t spend enough time on back in PT school. Maybe things
have changed now but back then thoracic spine mobility was an afterthought. What we know now is
that the t-spine is of great significance when it comes to shoulder mechanics.

Appropriate t-spine extension and rotation is critical for positioning and stability of the scapula
on the thorax. If the scapula is not positioned correctly and stabilized, the rotator cuff will not work
effectively thus altering mechanics and bad things happen.

Do I need loads of research to know this? No. Take someone with limited shoulder flexion and
work strictly on the t-spine. Mobilize into extension or use a foam roller, and work t-spine rotation.
Then re-check the patient’s motion. Often times it will increase as much as 10-15 degrees now that the
scapula is seated appropriately and can upwardly rotate throughout flexion.

This little trick works nicely with internal and external rotation as well. Any of you that have
used the Functional Movement Screen, the shoulder mobility test is basically one arm over the top and
the other arm coming behind the back and measuring the distance apart. If the screen calls for
shoulder mobility to be addressed then t-spine rotation is the first corrective exercise. I’ve seen
patients close the gap by as much as three inches following this one exercise.
Thoracic Spine Rotation – knee is pressing into a medicine ball to engage the core and lock up the
lumbar spine. Reach and pull the upper body over.

5. Posture, Posture, Posture

Now we did spend a lot of time on this back in school so I’ll take responsibility on this one. I
guess I never fully understood the power of posture and the ability to apply force while preserving
proper joint mechanics. I should know with my weight lifting background. Perfect posture with stability
allows for big numbers in the squat and deadlift. You lose any of that and you get crushed. Sometimes
you just don’t put 2 and 2 together even when it’s staring you right in the face.

Here is another one of those examples I like so much. Shake hands with someone and have that
person slump. Ask them to squeeze as hard as possible. Now have that same person squeeze your hand
again but have them stand tall, grip the ground with their feet, squeeze the glutes, retract the shoulder
blades, and clench the teeth. The difference can be amazing.

I love the instant feedback so I use this demonstration with my patients and the athletes I’m
training. Sure beats trying to explain length-tension relationships and force generation. Besides, they
can see fairly quickly how important it is to set their posture prior to lifting, pushing, pulling, throwing,
etc. Great posture = great performance whether it’s athletics or in the game of life.

6. Hip Abductor/External Rotator Strength Prevents Patella-Femoral Pain, not the VMO

I might take some heat for this one, but I’ll bet anyone out there that I can get an athlete
moving better and faster using a hip based approach to patella-femoral pain vs the old VMO stand-by. It
comes back to pain site versus pain source. Is it really the patella gliding laterally that is the the cause of
PFPS? Or is it the femur internally rotating and adducting?

More and more research is coming out encouraging a serious look at what the hip is doing in
those with anterior knee pain. Clinical experience also tells me the hip is the way to go. I’ve worked
with all kinds of patients with PFPS and never once did anything to address VMO strength. Somehow
they got better. I tend to think it was a steady dose of activating the glutes, esp glute medius, and
addressing faulty movement patterns such as the squat, step, and lunge. Top it off with some core
stability and ankle mobility/stability and there you have it. No quad sets, straight leg raises with the leg
externally rotated, and no open chain knee extension (which only increases patellar compression).

Correction of the Squat Pattern in a Patient with Bilateral PFPS – the patient’s squat is limited with
considerable valgus. Forcing the athlete to resist valgus collapse allows him to drop well below parallel
without pain. Activate his glutes and look what happens. Didn’t need to strengthen that VMO after all.

Here is another great point from a buddy of mine, Charlie Weingroff, who has spent quite of bit
of time in the NBA where knee pain is rampant:

“Prophylactic taping and bracing are very successful at improving stability at joints that are supposed to
be stable, but often improve stability at joints that are supposed to be mobile in a functional pattern.
This off-setting of the kinetic chain while decreasing injury at one joint will then increase injury at
another joint. I'm of the practice patterns that proximal stability will always begat distal stability, and
prophylactic corrections don't correct but rather change the problem. These techniques are often used
in young and athletic individuals, so the painful patterns elsewhere are not often identified or chalked
up to "normal" injuries.”

“I think that particularly when it comes to corrective taping of the knee, the patella taping is taping the
wrong thing. There is nothing wrong with the patella that needs to be fixed. Powers in 2004 identified
through Stanford's weight bearing upright MRI, females with PFS diagnosis showed no patella motion
during closed chain activities. Through Powers and others' work, the illusion of lateral patella tracking is
a function of femoral internal rotation. While there is still retro-patella pathology, there is also equal
and opposite peri-femoral pathology. But it is the femur that is "tracking" aberrantly, not the patella.
That is why there is debate, controversy, and inconclusive research in the patella taping literature. We
are taping something in the open chain when it is not bound by the quad tendon into the kinetic chain,
and expecting it to participate with the rest of the uncorrected chain.”

“I think pain is relieved via the patella taping because a medial patella has efficient facet contact with an
internally rotated femur. However, force generation is still aberrant, and issues elsewhere abound.”

“Correcting mechanics or using a Mulligan knee taping strategy where there is influence towards tibial
internal rotation and femoral external rotation also eliminates pain but also facilitates optimal glute
activation, which in turn checks gravity's regular vector to bring the femur into internal rotation.”

“Lateral glide is all an illusion from excessive hip internal rotation. Powers weight bearing MRI is the
evidence basis.”

7. Emphasize Core Stability vs. Core Strength

Core stability and core strength are terms that are often used interchangeably when speaking
about training the trunk musculature and spinal stabilization. The fact is that they are quite different.
Training for core stability requires resisting motion at the lumbar spine through activation of the
abdominal musculature as a whole. Training for core strength allows for motions to occur through the
lumbar spine in an attempt to work the abdominal or back musculature, often in an isolated fashion. I
realize depending on the definition of “core” we could be discussing any number of muscle groups, but
for now I will keep it to the abdominals and paraspinals.

Looking at the functional anatomy of the lumbar spine, it does allow for movement in all three
planes of motion but overall it is quite limited.

The lumbar spine can move quite a bit through flexion and extension but we know from
experience to avoid repetition going the extremes, hanging out at one extreme or the other for
prolonged periods, and to avoid high loads while trying to move through the lumbar spine.
Rotation at the lumbar spine is only supposed to contribute 13% of total spine rotation
(Sahrmann, 2002), hence limiting rotation with training might be a good idea.
Lateral flexion occurs as well but limited. The total amount of lateral flexion allowed from L1-S1
is 27 degrees, while the thoracic spine is capable of contributing up to 75 degrees (Sahrmann,
2002). This also has a degree of rotation to it which again is not really designed to happen in the
lumbar spine.

Think of the sports that require tremendous amounts of rotation. Golf and baseball (pitchers) come
to mind. Two populations we see quite often with back pain. They get more than enough rotation and
lateral flexion with every swing or throw so why add more? Throw out the stability ball crunches,
superman exercise, crunches with a twist, side bending, etc. Teach them to resist these motions against
a load, and how to maintain a stable spine through a golf swing or a pitch. Work on bird dogs, front and
side planks, chops and lifts in tall kneeling and half kneeling, and don’t forget to deadlift.
Bird Dog with Band Resistance

Side Plank

Romanian Deadlift – I’ve fielded a lot of questions in regards to this exercise over the years so here is
the quickie tutorial. Knees are bent approximately 20 degrees throughout. Tall posture with scapulae
retracted. Hip hinge to initiate the lift. Depth is determined by the point at which the spine ‘breaks’
(loss of neutral). Drive forward with the hips to return to standing. There may not be a better exercise
to strengthen the hips while sparing the spine and the knees.

8. Scapular Stability/Strengthening

I’ve touched on this a bit already in #4 discussing the role of the thoracic spine but let’s get into
it a little deeper. It still goes back to length – tension relationships. If the scapulae are seated properly
with sufficient stability from the surrounding muscles then proper glenohumeral rhythm is maintained
during a pitch, a spike in volleyball, or a serve in tennis.

I talked a bit about the lower crossed syndrome earlier. The upper crossed syndrome is very
real as well. Basically, we’re looking at tight and overactive pec minor, levator, and upper trap resulting
in stretch weakness and under utilization of serratus, lower trap, and rhomboids. It’s a common
imbalance that pulls the scapula into an elevated and protracted position, often times with winging. I
keep going back to simple demonstrations but they really work with your patients and athletes. Stand
slumped so that the scapulae are protracted and raise your arm into flexion. You will probably run out
of motion somewhere around 140-150 degrees depending on the person. Now stand tall and
retract/depress the scapulae and you’ll flex the final 30-40 degrees without a problem. By improving
posture and activating the appropriate muscles the scapula can now upwardly rotate and maintain the
joint space.

Using this approach, it’s not uncommon to see someone gain 20 degrees of flexion and
abduction on day one without any range of motion or stretching. It’s all posture and activating the
correct musculature.

To start with the rotator cuff, in my opinion, is crazy. It’s like trying to teach a baby to walk
when he or she hasn’t even pulled to standing yet. There are just certain pieces that need to be in place
first. Personally I start out looking at the hips, trunk stability, t-spine mobility, and the scapulae before I
ever touch the rotator cuff. I know this is only from clinical experience, but I have seen many patients
with shoulder pain diagnosed with impingement, rotator cuff tear, biceps tendonitis, etc who have
improved significantly and returned to athletics without a single direct rotator cuff exercise in their
program. No band internal or external rotation. Just ‘core’ strengthening, t-spine mobility, and
exercises aimed at stabilizing the scapulae.

9. I Can Think of About 10 Different Causes of Hamstring Pulls and ‘Tight Hamstrings’ Is Not One of
Them

This sounds like the dumbest thing I could possibly say, but I can’t remember that last time I saw
someone with an acute hamstring injury that I thought occurred because they were ‘tight’. ‘Over
active’ is more like it. Might sound like I’m splitting hairs but follow my logic for a minute. In Shirley
Sahrmann’s book, “Diagnosis and Treatment of Musculoskeletal Impairment Syndromes”, she
introduces a concept known as synergistic dominance. Basically, a synergist (hamstings) becomes
dominant over the prime mover (glutes) for a specific motion (hip extension). So the hamstrings are
always ‘on’ and are chronically overworked. At some point, usually during a high stress activity, they
give out and a tear can occur.

Here is the first test. Have the patient lie prone. Palpate the glutes and hamstrings. Ask the
patient to keep the leg straight and lift off the table. Feel what fires first. It should be the glutes first
and hamstrings second. Many athletes will be just the opposite.

The second test is to have the athlete bridge and extend the hips. Again, palpate hamstrings
and glutes on each side. The athlete should be able to complete the bridge using the glutes only.

What you will also notice in many of these hamstring dominant athletes is that they can touch
their toes during a sit and reach test, but cannot do it standing. The hamstrings are working overtime to
stabilize the pelvis during the standing toe touch versus the preferred glutes. Makes it kind of hard to
stretch something that is always firing.

Correct the firing pattern first to reduce hamstring tone, teach the athlete to use the glutes to
stabilize and extend the hips, and then see what kind of flexibility is really there.

10. Pain Site Versus Pain Source

I know I mentioned this earlier and almost every suggestion I have made to this point has
revolved around this idea, but it is so important that I am going to finish with it as well. We have been
trained to find the source of pain through ROM and strength testing, special tests for specific joints, and
palpation skills, and we as physical therapists, athletic trainers, physicians, etc are very good at it. So
good in fact, that I think we get caught up in chasing the pain and focusing our treatments on that one
area. That was me 10+ years ago.

I like to think that in addition to being older, I’m a little wiser as well. I tend to do a little more
investigative work now and look what is directly above and below the joint or muscle in question. Is
there some loss of mobility below that is forcing excessive motion up the chain to that painful joint? Is
there a lack of stability in the joint above or below? Are there muscles that are dominant and others
that are more or less inactive when needed the most?

Here is one final example in the form of a case study (at the time of this writing she is ¾ of the
way through her physical therapy program). A 16 year old female injures her knee falling directly on it
during a ski competition. X-rays and MRI are negative. The patient participated in PT for 4 weeks, 3 x
per week, and spent the entire time doing quad sets, SLR, knee extensions, and band resisted hip
flexion, extension, abduction, and adduction. Electrical stimulation and ice were used each visit as well.
The patient was discharged 75% improved (her subjective report) and returned to skiing and then tennis
but still with anterior knee pain.

Obviously, it continued to get worse over the next 6 months until she could no longer
participate and was limited to walking about a ½ mile. She decided to give PT another try. At the first
visit, the following things stood out:
 Ankle dorsiflexion was limited to 5 degrees bilaterally and the patient was pronating significantly
during gait. 10 degrees is needed to walk normally, 20 – 30 degrees to run (amount depends
greatly on speed, surface, incline)

Hamstring dominance over glutes with hip extension activities.

Poor single leg balance with noticeable hip abduction weakness and internally rotated femurs
bilaterally.

Squat pattern with significant valgus bilaterally, heels coming off the floor, and lumbar flexion;
pain limits her to a ½ squat.

Visit 1:

1) Ankle dorsiflexion mobilizations followed up with self mobilization with the foot/ankle complex in
neutral and maximally supinated. Ankle DF ROM increased to 14 and 15 degrees R and L
respectively.

Self Mobilization into ankle dorsiflexion

2) Double leg bridging emphasizing glute contraction and hamstring relaxation.

3) Single leg stance + band pull to engage the core. Emphasis is on maintaining supination of the
foot, firing the glutes on the stance leg, and maintaining perfect posture. The non weight bearing
leg is flexed to 90 degrees at the hip.

**All exercises were practiced at home throughout the course of therapy 1-2 x per day depending
on the exercise**

Visit 2: (Day 4)

1) The patient had 15 degrees of active ankle DF bilaterally. Performed mobilization again and
increased to 18 degrees. The patient continued with self mobs at home.
2) The patient could also bridge without hamstring contraction so the intensity was increased to a
bridge with marching. The goal is to keep hips high and level while maintaining glute activation and
no hamstrings.

3) Posture and stability with single leg balance were excellent upon return so the next step was a
single leg reach. The goal again is to maintain a supinated foot with maximal glute activation.

4) Added the X-band walk for glute activation and strengthening

X Band Walk

Visit 3: (Day 8)

1) The patient demonstrates 18 and 17 degrees of DF R and L ankles respectively and will continue
with self mobs as a warm-up.

2) Bridge with marching is progressed to a single leg bride.

Single Leg Bridge

3) Continues X-band walk.

4) The single leg reach is progressed to a single leg deadlift with 10 pounds.
Single Leg Deadlift – The knee flexion angle is maintained at approximately 20 degrees throughout
the movement. Normally the weight would be held only in the R hand (when on the L leg) to
increase demands on the glutes to maintain a neutral trunk position.

5) Kaiser pull-through is added to strengthen the glutes and reinforce the hip hinge pattern.

Pull Through Start – The picture is of a full range of motion pull through. For purposes of protecting
the knee and learning the hip hinge, knee flexion is limited to 20 degrees. Exercise depth is then
determined by how long the athlete can maintain a neutral spine.

Pull Through Finish

6) Squats to a bench with a band around the knees (nearly to femur parallel depth). The band
forces a valgus moment at the knees that the patient must resist by pulling the band apart. This was
the first ‘knee dominant’ activity we had done to that point. At evaluation, the squat pattern was
painful with an obvious increase in knee valgus and pronation. On day 3, the patient had no pain
with the corrected squat.

Visit 4: (Day 10) No L knee pain the past two days.

1) Single leg bridging and x band walks to warm-up and activate the glutes.

2) Ankle DF self mobs.

3) Single Leg Deadlifts with an 8kg kettlebell (approx 17 lbs).

4) Squats to a box (femur parallel for this individual) with band around the knees.

5) Kaiser pull-through as above.

6) Begin addressing the lunge pattern. The patient performs ½ range of motion split squats with a
band around the lead knee attempting to pull into valgus. The patient must resist this to correct
alignment. There is no pain with a ½ range of motion.

Visit 5: (Day 14) The patient continues to have no pain but has not returning to running or tennis.

1) Continues with exercise 1-5 from Visit 4.

2) Split squats with a full range of motion and band around the lead knee attempting to pull into
valgus. Patient has no pain as she corrects alignment.

3) Walking lunges forward with a full range of motion are added. No band for feedback but the
patient maintains alignment and has no pain.

4) Lateral squats (technically it is a squat if the feet are stationary throughout the exercise. It is a
lunge if a step is taken). The goal with the lateral squat is to sit the hips back to increase glute
contribution, and get the ankle, knee, hip, and shoulder to align vertically.

Lateral Squat
 Visit 6: (Day 18) The patient continues to have no pain and is now jogging a couple miles daily.
1) She continues with exercises 1-5 from visits 4 and 5. She is now squatting well below parallel
without pain.

2) Walking lunges are progressed to lunges.

3) Lateral squats are progressed to lateral lunges to simulate deceleration and cutting during tennis.

4) Single leg squats

5) Core work added – front and side planks

Single Leg Squats

This is as far as I have gotten with this individual to date. We are on target for a return to tennis
instruction in one week, and she is going to ski camp in two weeks. The plan for the next two weeks is
to strengthen within the perfected movement patterns of the squat and lunge, maximize ankle
dorsiflexion ROM and core stability, and train the patient to integrate the physical therapy program into
her sports programs.

Hopefully this partial case study gives a good idea of where I am coming from with my rehab
philosophy: attack the ankle , hip, and core to allow the knee structures to fully heal, and then address
more knee dominant patterns when pain free.

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Joe Heiler PT, CSCS

joe@sportsrehabexpert.com

231 590-1364