Category — Assessments

I have talked about my Physiological Buffer Zone concept a few times (in THIS article about movement capacity, in THIS article regarding stress and allostasis, and in my lecture during the Strength in Motion Seminar).

The concept is centered around three components of performance:

1. Stress and Stress Resistance
2. Movement Competency
3. Fitness Level (both general and specific)

A recent study by Lisman and colleagues published in Medicine and Science in Sports and Exercise (Functional Movement Screen and Aerobic Fitness Predict Injuries in Military Training) looked at two components of the Physiological Buffer Zone – Movement Competency and Fitness Level – to help understand the association between injury risk, fitness level, exercise and injury history, and Functional Movement Screen (FMS) scores in Marine Recruits.

Subjects

Marine Corps Officer Candidates, ages 20-25, who were enrolled in either the six (n = 447) or ten (n = 427) week candidate training program. While both programs consist of similar training activities due to the shorter time frame the six week training program is considered to be the more intensive of the two.

Testing

The standardized Marine Corps Physical Fitness Test consists of (performed in this order):

• Pull ups to exhaustion
• Abdominal crunches completed in 2min
• 3 mile run for time

The seven test FMS was used to understand the candidates baseline movement competency:

1. Overhead Squat
2. Hurdle Step
3. Inline Lunge
4. Shoulder Mobility
5. Active Straight Leg Raise
6. Trunk Stability Push Up
7. Rotary Stability

Each test is scored on a 0-3 scale.  A “0″ is scored if the individual experiences pain during a movement. A “1″ is scored if the athlete is unable complete the movement properly. A score of a “2″ is awarded if the subject can complete the movement but has some level of compensation and a “3″ is scored if the subject performs the movement correctly without any compensation. The highest possible score an athlete can achieve is a “21″, which would be a “3″ on all seven tests.

Finally, a questionnaire was administered to the subjects to understand their previous injury history as well as their prior exercise routines (modalities and frequency) prior to entering candidate training school.

Some of the Key Findings

• Slower 3-mile run times (>/= 20.5min) indicated a higher risk of injury
• Lower FMS scores (</= 14) indicated a higher risk for injury
• The pull up test and abdominal crunch test were not significantly associated with injury risk
• Subjects where at a higher risk of injury if they reported a prior lower limb injury
• A lower general exercise frequency, as reported via the questionnaire, was associated with a higher risk of injury

Some Words on FMS Scoring

Kiesel and colleagues (2007) found that NFL athletes were 12 times more likely to suffer an injury when their scores were </= 14 compared to those who scored >14. Thus, it would appear that the cut off point on the FMS is a 14. However, Gray Cook and Lee Burton (two of the developers of the FMS) have stated that the number may not be as important as obtaining a score of symmetrical “2′s” on each of the 7 tests. Two of the FMS tests (Overhead Squat and Trunk Stability Push up) are performed bilaterally while the other 5 tests (Hurdle Step, Inline Lunge, Shoulder Mobility, Active Straight Leg Raise, and Rotary Stability) are performed in a unilateral fashion and the lower score between the two sides is factored into the overall score. An individual with movement asymmetry is often at a higher risk of injury (Note: The human body is inherently asymmetrical and several sports may have asymmetrical tendencies. That being said, there is a rather larger range of what a two can look like on the FMS tests allowing us to have some individual asymmetry but still have relatively symmetrical movement competency. In other words, it is very hard to score a “3″ and it is very hard to score a “1″ but it should not be that hard to score a “2″ if you have some basic levels of both mobility and stability). Therefore, an athlete may be able to score a “14″ by obtaining a “3″ on the trunk stability push up and a “1″ on one of the asymmetrical tests but this may still place that at a higher risk of injury. So, the goal should actually be to obtain at least a 14 with no asymmetries.

Practical Application

I think this study was a good first step at trying to understand the association between fitness and movement competency. When FMS scores were low (</= 14) and when 3-mile run times were slow (>/= 20.5min) the subjects were 4 times more likely to sustain an injury. These findings were similar to an earlier study by O’Connor and colleagues (2011) who also evaluated the FMS and fitness level as a model of injury prediction in officer candidates and found that those with a score of </= 14 were at higher risk of injury compared with those who scored >14 and that those with better physical fitness scores were significantly less likely to suffer injury compared to those who had poorer fitness scores.

Interestingly the pull up test and the abdominal crunch test were not associated with a higher risk of injury. I wonder how much this may have to do with the type of activity that the subjects participate in during officer candidate school? Obviously they use their upper body to do pull ups, push ups, and lift/carry things but the lower extremity seems to take the most punishment during this time period as the candidates would appear to always be running or on their feet (standing, lifting, or carrying things).

Together, some sort of fitness screen and some sort of movement screen appears to offer us, as fitness professionals and strength coaches, some valuable information to help not only understand our athletes but also program appropriately for them. A lower fitness score would indicate that our training program needs to focus more on general fitness and aerobic capacity. One of the difficult things about officer candidate school may be that there really isn’t time to develop an individual’s level of fitness. Everyone is supposed to show up fit, in shape, and ready to face whatever is thrown at them from a fitness standpoint. Unfortunately, this isn’t always the case, as evident by the fact that having a lower level of fitness and a lower frequency of general exercise training prior to officer candidate school led to a higher risk of injury. Essentially, the individual shows up unprepared to handle the stress that is placed upon them and they “break”.

Additionally, the FMS is not just a screen used to assess movement competency but it can also be used to influence program design and exercise selection. If you know what tests the individual is poor at or asymmetrical in and you understand the corrective exercise hierarchy (I talked a little bit about this in an article 3yrs ago on Developmental Kinesiology and Client Assessment and I encourage anyone interested in learning more about the FMS and the corrective hierarchy to attend one of the courses put on by Functional Movement Systems) then you can begin to develop a specific training program that not only meets that athlete’s needs but can also be re-tested and monitored to ensure you are moving in the right direction. Kiesel and colleagues (2009) found that a 7-week offseason training program, individualized for each athlete based on their FMS scores, improved the FMS scores of 62 NFL athletes with 41 of them being free from asymmetry at the end of the 7-weeks compared to 31 at the start of the study. Oftentimes people see the FMS and think it is a reason to be soft or not train hard. The FMS can tell you what not to do but it also can tell you what you can do and when you find things that the person can do you should be attacking those those things, loading them, and training hard while you concurrently improve upon their limitations (always keeping in mind that you must come back and re-test to ensure that you are improving the test and moving in the right direction).

Conclusion

When assessing individuals it is important to be holistic and take into account all aspects of the Physiological Buffer Zone. One part of the Physiological Buffer Zone is not more important than any other and I think, as professionals, we all have our biases towards subject areas we feel most comfortable – “I’m a movement guy” or “Fitness is the most important thing! Movement isn’t as important as getting guys fit” or “Strength is more important than anything. Just get them stronger and everything will be better.”

Rather than staying in our comfort zone (based on our previous experiences, education, etc) we should try and open up and be more aware of all things that may impact an athlete’s ability to appropriately adapt and tolerate the stresses that we, as coaches, apply to them in training (that stress resistance piece of the Physiological Buffer Zone is a really big piece and you can read more about it in my article on Allostasis and Physical Preparation).

Furthermore, the testing should in some way influence our training program. Don’t just test to test or do an FMS (or any other movement screen) just to say that you do it. Use these tests to provide you with information about the individual and then take that information and put together a program that reflects that individual’s needs and abilities. From their, the tests serve as a means of re-assessing to understand if your program is doing what you intend it to do or if you need to make some adjustments.

patrick
patrick@optimumsportsperformance.com

I recently had the opportunity to attend two courses from the Postural Restoration Institute – Myokinematic Restoration and Pelvis Restoration.

The basic premise of the system that is taught by the Postural Restoration Institute is that the body is asymmetrical and, in order to optimize human function, we need to try and restore as much symmetry needed in order to have balanced reciprocal function (while appreciating the asymmetries of the body and acknowledging that we will not change them). Basically, we have a liver on the right side, the crural attachments on the right lumbar vertebrae are thicker than on the left, the right lung has three lobes while the left lung has two, etc (we can go on and on with these sorts of asymmetries), thus we tend to orient ourselves over the right leg which places us in a pattern of right mid stance, referred to as a Left AIC.

Left AIC

The main pattern discussed and the backbone of their system is the Left AIC (short for Anterior Interior Chain). The Anterior Interior Chain is a chain of muscles which connect the torso to the knee and consists of the diaphragm, psoas, iliacus, TFL, vastus lateralis, and biceps femoris. We have two AICs in the body, one on both sides, however the Left AIC tends to be more dysfunctional than the right. Additionally, individuals may find themselves in other patterns but underneath those patterns is always a Left AIC due to the natural asymmetry of the human body as discussed above.

In this Left AIC pattern the main findings include things such as:

• Anterior pelvic rotation on the left
• Increased hamstring length, tension, and tone on the left
• Pelvis rotated to the right side
• Right ischial tuberosity sitting lower than the left
• Left femoral head is not received as well by the acetabulum as the right is
• Right side is more in a position of adduction, internal rotation, and extension
• Left side is more in a position of abduction, external rotation, and flexion
• Decreased trunk rotation to the right side
• Decreased right apical expansion and left diaphragm opposition
• Increased left rib flare (poor left zone of apposition)
• Decreased left mediastinum expansion

All of these things are actually “normal” and are due to the natural asymmetry we all posses; however, some people – with proper training – can control this position better than others and thus perform at a higher level. Other individuals may not control this position well and end up compensating in such a way that they themselves in a position of PEC – short for posterior exterior chain – where they exhibit many of the things above on both sides, bilaterally.

PEC

The Posterior Exterior Chain consists of our latissimus dorsi, QL, Posterior Intercostals, Serratus Posterior, and Ilicostalis Lumborum.

Being in a PEC position is characterized by attributes such as:

• Stiff looking gait mechanics
• Bilateral hyperlordosis
• Both hips in a position of flexion, external rotation, and abduction (people tend to walk with their toes out)
• Butt gripping (tight gluteus maximus bilaterally)
• Flat and stiff thoracic spine
• Bilateral compression of the SI-joints
• Sagital plane dominant individuals who have lost optimal function in the frontal and transverse planes
• Pelvic floor in a descended position, bilaterally, causing the muscles of the pelvic outlet to be stiff and inflexible leading to issues with constipation
• Poor zone of apposition bilaterally
• In a state of hyperinflation, lacking the ability to exhale and allow the diaphragm to dome up

Goal of PRI

The goal is to use a battery of tests to determine what sort of position the individual is in and then what type of control they actually have. To do this, the Postural Restoration Institute has a number of tests – some are tests of position while others are tests of function – to help understand the person in front of you and make informed decisions about exercise prescription. To take it a step further, the tests are also used, in an algorithmic sort of way, to differentiate between individuals displaying one of these patterns versus individuals displaying one of these patterns but considered to be “pathological” and displaying a certain amount of ligament laxity – referred to as a  Patho Left AIC or Patho PEC. This information further drives exercise choices as those that are pathological may need a different set of exercises or exercise regression to ensure they are performing the movements in the right position and feeling the correct muscles working.

PRI can get extensive with the exercises as they have over 100 in their catalog although there are a few exercises that would be considered “big money” exercises for each of the possible patterns one may be in. If you understand the patterns and use the testing approach effectively you will understand which structures/muscles you are looking to facilitate and which you are looking to inhibit and can pretty much use any permutation of the “big money” exercises as long as they achieve the intended goal and improve the testing when you go to re-test, which should be done frequently to know if what you are doing is working and if you are helping re-position the individual.

Similarities with other Approaches

Whether it is PRI or any other system (DNS, FMS/SFMA, Janda, Osteopathic approaches, etc) there should be some similarities in the message as all of the systems are dealing with the human body. It is the similarities between all these things that I care the most about because it helps me see the big picture and be aware of more things when I look at an individual.

One thing PRI does is go heavy into the anatomy of the body with regard to how muscles function and they do a good job of differentiating between which attachments are moving and which are stable. For example, we can have femoral acetabular rotation (a femur rotating on a pelvis) and we can have acetabular femoral rotation (a pelvis rotating over a femur). This is similar to the idea of punctum fixum and punctum mobile in the DNS methodology. While some may consider looking at things like this as being a bit excessive, I truly believe that understanding these concepts can be extremely helpful to understanding function and programming exercise.

PRI has a large focus on breathing and talks extensively about the “zone of apposition” (ZOA) – the aspect of the diaphragm that apposes the chest wall. The ZOA is influenced by the position of the rib cage. When the rib cage is flared upward, ribs in external rotation, the ZOA is not in a position to function and allow for proper diaphragmatic breathing. In DNS this same position is referred to as on “open scissor position” where the rib cage is angled upward and the pelvis is angled downward (anteriorly tilted), causing increased erector spinae tone and a lengthened abdominal wall which posses a high amount of tension. Individuals with an inefficient ZOA or the open scissor tend to be more upper chest breathers, stuck in a hyperinflated position, and recruit the neck musculature (SCM, Scalenes, Levator, Upper Trap) to assist with respiration.

I see a bit of an Osteopathic influence in the PRI system which is cool because I have read a lot of Osteopathic texts. The whole approach to re-positioning the pelvis in PRI is similar to self Muscle Energy Techniques where the individual is using muscular force to drive the pelvis into a certain position (which is great because you don’t have to put your hands on the person for these techniques to be useful and can allow the client to feel empowered by performing the activities on their own).  The interesting thing is that the common pattern in PRI, the Left AIC, is opposite that of the common pattern in Wolf Schamberger’s text, The Malalignment Syndrome, which states that everything is happening on the right side (right pelvis in anterior rotation rather than the left) and this is similar to some of the other Osteopathic things I have read in the past. The instructor gave some answers as to why this is and in the end it comes down to a visualization thing as most of the other approaches were looking at anatomical landmarks with the person either supine or prone on the table and because of this they can be flawed as anatomical landmarks can change when someone lies down on the table (Schamberger does talk about some of these changes in his book on pgs. 43-44). Thus, PRI recommends tests of position and function rather than static tests of anatomical landmarks. The instructor of the course also talked about how the Muscle Energy Techniques used in those Osteopathic approaches achieved a similar result a lot of the time, even though their understanding of the position was incorrect, because they were activating the correct muscles to drive the pelvis into the correction position. Who’s right? Who’s wrong? Does it really matter? At the end of the day the goal is to make a positive improvement and if you did something that had a positive influence, even if your explanation or thought process wasn’t 100% correct, I don’t know if it matters all that much. Another thing that I would add is that the Osteopaths discussed breathing and the autonomic nervous system pretty extensively so perhaps their holistic approach achieved many of the similar results that those using PRI achieve. Regardless, there are a lot of similarities between these two approaches to pelvic movement and correction which is interesting to look at and be aware of. The Osteopathic similarities with PRI also show up with regard to the discussion on the diaphragm and viscera as the Osteopathic techniques on visceral manual therapy/massage discuss similar relationships between the diaphragm and the liver on the right side and the diaphragm and the spleen on the left.

Finally, the PRI patterns, particularly the PEC, is where I see some similarities to Janda and Travell and Simons. This pattern is very similar in appearance and function to the Upper and Lower Crossed Patterns from Janda. Many of the muscles which are discussed as needing inhibition in PRI (and in Janda) are also those that are either needed to keep us upright throughout the day (anti-gravity muscles) or those that help assist with respiration when the diaphragm is not functioning properly. So, it makes sense that things you want to inhibit in some of these patterns are the lumbar erectors (we live in a world of extension) and the glutes (particularly in the PEC pattern). Additionally, the vastus lateralis is a muscle which is part of the Anterior Interior Chain and one that can function significantly in these patterns to help provide stability. It comes as no surprise that this muscle is also one that is frequently riddled with trigger points, particularly in the lateral side under the IT-band (which lies over the vastus lateralis, biceps femoris, and is influenced by the TFL – all three muscles which are part of the Anterior Interior Chain).

Integration & Conclusions

I have enjoyed the courses thus far and look forward to taking more of them. I think that they underpin things I already do in practice very nicely and can fit well within the FMS model as another tool that can positively impact the results in some of the tests. Also, I have found that when there are a number of things going wrong in the FMS using some of the PRI approach can be helpful to reposition the individual and then retest to see what sort of improvements have been made. I have been using some of the exercises in my own warm ups and in the warm ups of a few people I have been working with (based on what we have found in testing) and the results have been very positive.

I don’t think any one system has all the answers and I don’t think any system will ever have all the answers as there are so many things that influence the body and so many things we don’t quite know. What I will say is that I really enjoy when different philosophies line up and share many similarities. The PRI approach is one more tool in the toolbox to help understand human function and their courses are some of the most fun I have had during a con ed course in a pretty long time.

patrick
patrick@optimumsportsperformance.com

Soft tissue therapy and training of the shoulder has grown in leaps and bounds over the past decade.  While some may still be limiting their treatments to isolated soft tissue techniques at the site of pain and theraband exercises for internal and external rotation most have moved on to include a more holistic and full body approach.

The role of the scapula and thoracic spine are always discussed in the movement of the glenohumeral joint as limitations in movement here will translate to aberrant shoulder movement.  It is commonly talked about now that the thoracic spine needs to have its mobility restored so that the scapula can display optimal stability thus allowing the glenohumeral joint to produce safe and efficient mobility.

The Sternoclavicular Joint

One joint that seems to constantly get overlooked in the equation is the sternoclavicular (SC) joint.  The SC-joint is a true joint and is formed by the articulation between the sternum and the clavicle.  The distal end of the clavicle is where the acromioclavicular (AC) joint is formed, a union between the acromion process and the clavicle.  The AC-joint , while often discussed in the same sentence as shoulder impingement where structures are being compressed underneath the subacromial space, also is required to move during elevation of the upper extremity.  Thus, the movement at the distal end of the clavicle via the AC-joint during shoulder elevation causes a necessary movement of the clavicle and the SC-joint which, if not present can create issues with overall shoulder mobility.

Assessment of Clavicular Movement

The SC-joint should be assessed for both resisted abduction, which also produces a posterior rotation of the clavicle, and posterior movement during horizontal flexion of the shoulder.

Assessment of Abduction

With the client either seated or supine lying, place your index fingers on the superior aspect of the medial clavicle.  Ask the client to perform a shrugging movement while maintaining palpation of the clavicle and evaluate for caudad movement.  Failure of the SC-joint to move in a caudad direction during abduction would indicate a possible restriction.

Assessment of Horizontal Flexion

With the client supine lying, ask them to straighten their arms out toward the ceiling and place their palms together (like a prayer).  Again, palpate both SC-joints with your index fingers and ask the client to push their hands toward the ceiling simultaneously (shoulder protraction).  Assess the joint for movement in a posterior direction, moving toward the table.  Failure of the SC-joint to make this posterior movement during horizontal flexion would indicate a possible restriction.

Treatment of a restricted SC-joint

Depending on your level of training and scope of practice some therapists may choose to perform a high velocity maneuver to improve SC-joint function and shoulder function.  However, being a licensed massage therapist does not afford me this option however I have found the muscle energy techniques (post isometric relaxation) for this joint to be effective.  The client is asked to use their own muscular effort as we, the therapist, apply gentle stretching.  Another thing I like about these techniques is that they are pain free techniques and should not be performed if they produce any sort of pain or discomfort.

Restricted Abduction

• With the client seated stand to the side of the restricted SC-joint
• Place the thenar eminence of the hand closest to them on the superior aspect of the medial clavicle
• With your other arm, gasp the client’s elbow and abduct their arm to about 90 degrees with the shoulder externally rotated.
• Instruct the client to apply gentle adduction (approximately 20% effort) into your hand for 5-7seconds
• Upon relaxation of the muscular effort passively abduct their arm to the next barrier of resistance while simultaneously maintaining a firm (pain-free) pressure on the medial aspect of their clavicle with your thenar eminence
• Repeat this process until freedom of movement is attained at the SC-joint

Restricted Horizontal Flexion

• With the client supine lying stand to the side opposite that of the SC-joint you have to treat
• Place the hypothenar eminence of the hand furthest from the table over the medial end of their clavicle applying firm (pain-free) pressure towards the floor
• Place the hand closest to the table underneath their shoulder gently grasping their scapula
• Ask the client to place their arm around the back of your neck or shoulder
• With their arm behind your neck or shoulder gently lean back to take out the slack of their extended arm while simultaneously lifting the scapula gently from the table
• Ask the client to then attempt to pull you towards them – pulling against your neck or shoulder – with an effort of approximately 20% of muscular force and maintain that resistance for 5-7seconds
• Upon relaxation of the muscular effort, repeat the process of leaning back and lifting the scapula gently off the table to take out more of the slack while simultaneously maintaining pressure on the medial aspect of the scapula
• Repeat this process until freedom of movement is attained at the SC-joint

Patrick Ward
patrick@optimumsportsperformance.com

The lumbo-pelvic-hip complex is an extremely dynamic area of the body when it comes to sports performance.  Groin pain is something that plagues many athletes, especially those in sports that require a high amount of cutting, change of direction, and rapid acceleration and deceleration.

The topic of hip issues and groin pain has been a popular one as of late with my friend and colleague Dr. Jeff Cubos posting a great blog article last week on Femoroacetabular Impingement and offered some of his ideas for treatment.    Kevin Neeld, a strength coach who works with hockey athletes in New Jersey, wrote a blog about the same topic, Training Around Femoroacetabular Impingement, offering some of his training recommendations for his athletes suffering from this issue.  Additionally, Kevin also did a webinar for strengthandconditioningwebinars.com and talked more about the anatomy of this region and ways that he assesses the hip for his athletes to ensure that appropriate training recommendations are made.  Finally, two years ago, I wrote an article on groin pulls and talked a bit about training recommendations – Groin Pulls: Ouch!

Today, I’d like to touch on some of the things I look at when performing soft tissue therapy for athletes who have referral pain into the groin.  The groin and hip region can be very complex and many injuries can overlap each other with regard to how the symptoms present.  For this reason, it is essential that the athlete gets checked out by an appropriate medical professional to ensure that the proper course of action is taken.  Some of these referral patters can actually go into the testicles and making sure that the athlete is not dealing with something more dangerous (IE, testicular cancer) is a must in this situation.

Nerves that can refer to this region

There are a few nerves that can refer to the groin and testicular region.  Additionally, these nerves can be influenced/affected by various structures (soft tissue, boney, ligamentous, fascia, etc) along the way and after looking at the nerves themselves we will get into some of the structures that can influence and might be a target of our soft tissue treatment.

• Ilioinguinal (L1) – Supplies cutaneous distribution to the scrotum (labia for females).
• Iliohypogastric (T12-L1) - Supplies cutaneous innervation to the lower abdominal and groin region.
• Genitofemoral (L1-L2) - Supplies cutaneous distribution to the scrotum (labia for females).
• Pudendal (S2-S4) - Provides innervation to the external genital region in both males and females.
• Obturator nerve (L2-L4) - The obturator nerve is often cited as a reported source of groin pain (Morelli et al, 2005) and innervates the adductor muscle group as well as the obturator externus.
• Femoral nerve (L2-L4) - Aside from innervating the quadriceps muscle group, sartorious, pectineus, and iliopsoas, the femoral nerves anterior cutaneous branch supplies sensory innervation to the medial thigh and can have referral pain into the groin region.

Structures to check which can influence these nerves

All of these nerves, aside from the pudendal nerve which is arising from the sacral plexus, are coming from the lumbar plexus, so evaluating this region for any sort of abnormalities would be a wise decision: checking joint play, looking at muscles that can influence these vertebral segments, evaluating the skin over the paraspinals for any abnormal changes between the two sides, looking at muscle length and strength, looking at fascial connections, etc.  There are many ways to do all of these things and having your own system of evaluation to create a sort of “check list” would be a wise thing to do. 

The obturator nerve has been occasionally found to be entrapped in the obturator foramen by thickened fascia which surrounds the adductor muscles.  This region may be palpated for thickness, density, tenderness, as well as seeing if palpation creates referral symptoms that mimic the client’s complaint.

The psoas and iliacus should be evaluated for increased tone/tension as well, as they have influence over the femoral nerve.  The genitofemoral nerve also runs between the psoas and can receive a greater amount of pressure there.  Hip extension, tenderness just medial to the ASIS, and/or a positive tinnel’s sign over the inguinal ligament may reproduce the client’s symptoms and help guide your soft tissue strategy. 

The psoas major has a lot of influence over structures in this region and Chaitow and DeLany discuss this in Clinical Application of Neuromuscular Techniques Vol 2: The Lower Body.  They explain that the psoas communicates with the testicular/ovarian vessels, the genitofemoral nerve, the lumbar plexus, and the femoral nerve.  Thoroughly evaluating this muscle and muscles which connect with it and influence such as iliacus, diaphragm, and quadratus lumborum, is extremely important.

The pudendal nerve passes through the pudendal canal, which is partially formed by the obturator internus and increased tone in this tissue may influence the nerve.  Additionally, the nerve runs along the sacrotuberous ligament where it can receive a greater amount of pressure than normal and may warrant treatment.

Trigger Points (or peripheral nerve irritation or abnormal impulse generating sites or whatever people what to call it these days…)

• The oblique musculature has a referral pattern into the groin area and can also refer pain into the testicles.
• The quadratus lumborum has a referral pattern to the anterior side of the body into the lower abdominal and groin region (as well as a referral to the lateral hip).  As mentioned earlier, the quadratus lumborum has a fascial connection with the psoas and the diaphragm.  Not only should this muscle be checked for trigger points that mimic the referral pain, but this would also be a good time to stress the importance of breathing (breathing 101, breathing assessment, breathing corrections).  Stabilizing the thoracic-lumbar junction in this case, as Charlie Weingroff has talked about (Supine Sagital Stability and the T-L Junction), fits in well with this discussion.
• The iliolumbar ligament has a referral pattern into the groin as well as the outer hip.
• The adductor musculature can produce referral pain into the groin.  Evaluating the tissue healthy of the adductors, the muscle bellies and the attachment points, can be helpful. 

Conclusion

As you can tell, groin issues can get pretty extensive with regard to all the things you have to take into consideration.  I try and see the big picture as best I can and look at all the possible influences and gather a sense of all the anatomical connections, as Willem Kramer has talked about with his anatomy links concept.  Of course, this is only a small piece of the pie as I am only talking about the things that can refer into the groin.  We can certainly expand upon these connections and look even more globally at the structures that are influencing the structures referring to the groin.  This is where having a holistic approach and thought process will help you out the most.

Patrick
patrick@optimumsportsperformance.com

References

Morelli V, Weaver V. Groin Injuries and Groin Pain in Athletes: Part 1. Prim Care Clin Office Pract 2005; 35: 163-183.

Morelli V, Espinoza L. Groin injuries and groin pain in athletes: Part 2. Prim Care Clin Office Pract 2005; 32: 185-200.

Chaitow L, DeLany J. Clinical Application of Neuromuscular Techniques Vol 2: The Lower Body. Churchill Livingstone. 2002.

Gilroy AM, MacPherson BR, Ross LM. Atlast of Anatomy.Thieme. New York, NY. 2008.

Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual – The Lower Extremities. Lippincott, Williams, & Wilkins.

There has been, and always will be, much debate about why athletes get injured.  This is the holy grail question that keeps researchers busy in the lab, coaches scratching their heads, and athletes constantly frustrated.

Injuries are a complicated event and usually cannot be linked to one single variable (aside from a contact injury).  In my mind, I think of three main categories that influence the state of the athlete:

1. Stress Overload
2. Poor Fitness
3. Poor Movement

The first two have been discussed before in previous blog entries.  Obviously, we should be doing everything we can to try and monitor and manage the stress and fatigue of the athlete to ensure that they are in an optimal state of readiness for their competitive season.  Part of being able to tolerate the stresses of practice and the game is being in shape.  Plain and simple, being out of shape is huge problem!  An athlete can have an amazing movement capacity but if they are unfit the chances of them being able to sufficiently use their movement throughout the course of a game, as fatigue sets in, will drastically be reduced.  Additionally, athletes who do not possess a level of basic general strength (which is a component of fitness) will lack the ability to tolerate the stress of the season.

Poor movement is an interesting addition to the puzzle and one that has come under scrutiny lately as many want to take shots at the idea that having a decent movement base to draw from can potentially limit your chances of getting injured.

I tend to see many of these arguments being one-sided, with advocates arguing either for or against the issue.  I’d rather take the middle ground and say that (a) we probably don’t know exactly why most injuries happen and (b) it is probably a combination of all of the things above instead of just taking a myopic view and saying that one thing is the only thing or one thing is more important than anything else.  As stated earlier, if you have great movement but poor fitness, you are no more bullet proof than the guy with great fitness but less of a movement base.

Theory of Movement Reserve

With all of this in mind it led me to come up with my idea of what I call movement reserve.

What this basically means is that the athletes who do have a well-developed movement capacity appear to have a little bit larger physiological buffer zone when the circumstances are not perfect and the stars are not all aligned.

Obviously we do all we can to manage stress but no situation is 100% perfect.  If the team has to fly across country, the plane is delayed getting in, everyone misses dinner, and then they don’t get a good night sleep, the head coach cannot just go to the other head coach and say, “Our team is really exhausted.  Do you think we can put the game off until tomorrow so that we have another day to rest?”  It just doesn’t happen!  And, as an athlete, if a coach says “you have to play”…you have to play!  Even if that means you are a little bit tired, the HRV numbers are poor, and your level of stress is high.

In these instances, when there is more fatigue/stress than usual and when their body is not fully recovered/rested, it is the athlete with better movement capacity (and better general strength) that can get in the game and challenge their bodies knowing that their physiological buffer zone is a little bit greater than the guy who, when trying to push himself and operate under a high level of fatigue, doesn’t have the ability to manage his bodies ranges of motion and joint positions.

In a nut shell, when the chips are on the line, when the athlete starts to fatigue those with the greater movement capacity have some movement reserve to fall back on.  I believe that this may be one of the reasons why when looking at the research on the Functional Movement Screen it appears to be most valid in the NFL population.  This is a group of people who are trying to push their body to the max limit of its capacity and do so under some considerable amount of fatigue. 

If you take the time to do all of the things above:

• Manage stress with a good training and recovery program
• Develop fitness – work capacity, strength, power, etc – to adequately prepare for the season
• Enhance movement reserve – ensure that joint ranges of motion, mobility, joint stability, etc, are healthy - and then integrate of all of these things into systematic whole body movements to help increase the physiological buffer zone

you have a much better chance (in my opinion at least) to keep athletes as healthy as possible.

Look at all the factors of the athlete and try not to get stuck in the black & white arguments.  Nothing in the body is as simple as that.  Allow the body to express its complexity and embrace the grey area between the black & white by accepting the fact that no one has all of the answers (and maybe never will).

Patrick
patrick@optimumsportsperformance.com